Vulvovaginal itching (pruritus) and/or vaginal discharge in children result from infectious or noninfectious inflammation of the skin or mucosa. Symptoms may also include irritation and burning.
The etiology, diagnosis, and treatment of vulvovaginal pruritus or discharge vary by reproductive phase or status: premenarche, reproductive age, pregnancy, or menopause. Vulvovaginal symptoms in premenarchal children are discussed here. (For a discussion of symptoms in nonpregnant reproductive-aged and postmenopausal women, see Vulvovaginal Itching or Vaginal Discharge.)
Etiology of Vulvovaginal Pruritus or Vaginal Discharge in Children
The most common causes of vulvovaginal pruritus and vaginal discharge in children are external irritants or infection (see table Some Causes of Vulvovaginal Pruritus and Vaginal Discharge in Children).
Nonspecific vulvovaginitis is common, usually due to infection with gastrointestinal or respiratory tract flora. A common contributing factor in girls aged 2 to 6 years is poor perineal hygiene (eg, wiping from back to front after bowel movements, not washing their hands after bowel movements).
Vulvovaginal candidiasis is uncommon in children (except following recent antibiotic therapy or in immunocompromised patients), and tends to be overdiagnosed and treated (1).
Chemicals in bubble baths or soaps may cause inflammation and pruritus of the vulva, which often recur.
Foreign bodies (eg, child's toy or another item in the vagina) may cause nonspecific vaginitis, often with a scant bloody discharge.
Less commonly, a vaginal discharge in children results from sexual abuse. If abuse is suspected, measures to ensure the child’s safety must be taken, and a report must be made to state authorities.
Etiology reference
1. Banerjee K, Curtis E, de San Lazaro C, Graham JC: Low prevalence of genital candidiasis in children. Eur J Clin Microbiol Infect Dis. 2004;23(9):696-698. doi:10.1007/s10096-004-1189-2
Evaluation of Vulvovaginal Pruritus or Vaginal Discharge in Children
History
General medical history is obtained; for infants, birth history and mother's obstetric history are included. Family history of cancer is important. The medical history is obtained from the parent (or caregiver) and the child, if age appropriate.
History of present illness includes nature of symptoms (eg, pruritus, burning, pain, discharge, bleeding), duration, and intensity. If vaginal discharge is present, questions should elicit any exacerbating and remitting factors, including exposure to soaps or laundry products.
Review of systems should seek symptoms suggesting possible causes, including the following:
Fever or chills and abdominal pain: Pelvic inflammatory disease
Vaginal bleeding: Foreign object or sexual abuse
If sexual abuse of a child is suspected, a structured forensic interview based on the National Institute of Child Health and Human Development (NICHD) Protocol can be used. It helps the child report information about the experienced event and improves the quality of information obtained.
Physical examination
A general physical examination is done.
If a pelvic examination is required, it should be performed by an experienced clinician. The parent and child should be educated regarding the examination so they know what to expect and to build trust between the child and clinician. The goal of the examination should be to obtain necessary information without causing fear or unnecessary discomfort to the child.
Examination of the external genitals and perineal and groin area should note any bleeding, discharge, bruising, or injury.
In children, internal pelvic examination is typically performed under anesthesia. The vagina and cervix may be examined using Killian nasal speculum, a fiberoptic vaginoscope, cystoscope, or flexible hysteroscope with saline lavage.
Red flags
The following findings are of particular concern:
Vaginal discharge, fever, chills, lower abdominal tenderness, and/or signs of genital injury: Possible pelvic infection, with possible tubo-ovarian abscess and/or sexual abuse
Interpretation of findings
In children, vaginal discharge is usually a symptom of inflammation or infection, and discharge that is persistent, bloody, or accompanied by other symptoms (eg, fever or severe vulvar erythema, edema, or pruritus) requires evaluation. The exceptions to this are times when it is normal for a child to have a physiologic vaginal discharge (clear or white, small volume per day) because serum estrogen levels are elevated. This includes the first 2 weeks of life, when estrogen levels are high because of exposure to maternal estrogen, which crosses the placenta. Sometimes slight vaginal bleeding often occurs in infants as estrogen levels abruptly decrease because exposure to maternal estrogen ceases. A discharge may also be present and during the few months before menarche, as estrogen production increases.
Vaginal discharge without fever or chills and without other findings on pelvic examination is likely to be vaginitis or a foreign body.
Signs of systemic infection or suspected sexual abuse require immediate medical attention.
Testing
If there is a vaginal discharge, a sample can be collected for culture without a speculum examination, using methods appropriate for children. The sample is tested for common vaginal bacterial infections or candidiasis. If sexual abuse is suspected, testing for sexually transmitted infection is done with blood tests and urine or vaginal specimens (cervical specimens should be taken only with the child under anesthesia) (1).
A complete blood count (CBC) is done if signs and symptoms are consistent with pelvic infection.
If a pelvic infection with an abscess is suspected, imaging is done. Transabdominal ultrasound is preferred over transvaginal ultrasound in young children and prepubertal adolescents. If ultrasound does not clearly delineate size, location, and consistency of a mass, another imaging test (typically MRI) may be needed. If there is an ovarian mass and a nonepithelial neoplasm is suspected, tumor markers (eg, alpha-fetoprotein, lactate dehydrogenase, inhibin) are measured.
Evaluation reference
1. Chiesa A, Goldson E. Child Sexual Abuse. Pediatr Rev. 2017;38(3):105-118. doi:10.1542/pir.2016-0113
Treatment of Vulvovaginal Pruritus or Vaginal Discharge in Children
Any specific cause of the pruritus or discharge is treated.
Soaps and unnecessary topical preparations should be avoided. If a soap is needed, a hypoallergenic soap should be used. Intermittent use of ice packs or warm sitz baths may reduce soreness and pruritus. Flushing the genital area with lukewarm water may also provide relief.
Prepubertal girls should be taught good vulvar hygiene (eg, wiping front to back after bowel movements and voiding).
Key Points
Causes of vulvovaginal pruritus and vaginal discharge vary depending on the patient’s age.
Vaginitis, a foreign body in the vagina, and poor hygiene are common causes of vulvovaginal irritation or vaginal discharge in children.
Evaluate with external examination of the vulva and vaginal opening; internal examination, if required, is typically performed under anesthesia.
Treat based on etiology, if identified, or with general hygiene and comfort measures (eg, sitz baths) of nonspecific vulvovaginitis.
