All of us, at one time or another, will be presented with a frantic mother, seeking treatment for her young daughter’s chronic itching “down there” or discharge in her underwear. Usually the girl will have been treated multiple times by her pediatrician with antifungal creams as well as with various home remedies. We are called upon to help with the diagnosis, as well as to help sooth the nerves of both mother and daughter who have been worried and uncomfortable, often for months.
When evaluating these children, we have to always keep in mind the possibility of abuse, though this is not a common reason for referral to an office setting. Generally, if the pediatrician suspects abuse, referral will have been made to the appropriate authorities for intervention. Nonetheless, I am always careful to ask both mother and daughter, separately, about the possibility of abuse.
When asking children about abuse, it is vital to remember that it may be the abuser who has brought her to the visit and, whenever possible, the child should be question without her parent or guardian present. It has been estimated that 5% of girls presenting with chronic prepubertal vaginal discharge do so as a result of abuse.1 This will, of course, vary with the population served and the location of the clinic.
Most commonly, the discharge and itching is a hygiene issue. While one would think that the primary care provider would address this, often they do not. Neither can we assume that parents know about proper hygiene for little girls, despite their best intentions.
I recently had a mother very earnestly tell me that she taught her daughter to wipe “the front first and then the back” after defecation. When I asked the girl (then 6) to show me (while clothed) exactly what she does when she wipes using a tissue, she very carefully wiped her vulva from back to front, then took another tissue and wiped the anal area from front to back. The same mother had been bathing her daughter in vinegar because she had read that it was good for vaginal hygiene. This girl had been itching with intermittent green discharge for more than a year. The pediatrician had told them that everything looked normal.
On my exam, the labia looked normal. However, with separation of and traction on the labia, the (intact) hymen was revealed to be bright red with a small amount of mucoid discharge present. Culture showed Escherichia coli. After antibiotic treatment and behavioral changes, her symptoms resolved.
Before we ever go into an exam room, I spend time discussing and demonstrating proper wiping from front to back. I address myself to the girl as much as to the parent, using simple words. Then I ask the girl to mime back to me good wiping technique. We also discuss other common irritants in young girls lives, including scented detergents/soaps, bubble bath, prolonged sitting in wet bathing suits or sweaty ballet leotards, nylon panties, and tight pajamas. About 90% of the time, we find the offending agent via our discussion.
During the exam, I try to involve the child as much as possible, and I do much of the exam on the parent’s lap. A gentle and reassuring approach is essential. This is a girl’s first interaction with a gynecologist; if it goes badly, she will remember for years to come. Promise not to hurt her and keep that promise.
On exam, it is crucial to visualize the labia minora, the hymen, the vaginal orifice, and the perianal area. Culture is also an important part of the workup. The most frequently grown organisms are anaerobes, making up about half (51%) of all positive swabs.1 The next most common include group B streptococcus (12%), Haemophilus influenzae (10%), mixed growth (4%), and coliforms (4%).1
The treatment plan will be a combination of behavioral modification, antibiotics if necessary, and antipruritic/emollient agents if needed. I find that my patients achieve significant symptom relief from warm soaks with Aveeno colloidal oatmeal.
If you think that adequate treatment has been given but symptoms persist, it is important to check for foreign bodies in the vagina. The object most often found is rolled bits of toilet paper, which are easily flushed out with warm water and a small foley catheter.1 A foreign body might also be suspected with bloody or foul smelling discharge. In these cases, referral for vaginoscopy may be appropriate.
Less common causes of itching and discharge in prepubertal girls, such as tumors, skin conditions, malformations, and trauma, must be kept in mind as well.
Vulvovaginitis will be diagnosed in upwards of 80% of prepubertal girls referred to a gynecologist for itching and discharge. Poor hygiene is one of the key causes of this and must be addressed with both the child and her parents. The key to diagnosis is a good exam and cultures.
As the examiners, we must be mindful of the fact that our encounter with our young patients will leave a lasting impression and must be conducted with patience and sensitivity.
McGreal S, Wood P. Recurrent vaginal discharge in children. J Pediatr Adolesc Gynecol. 2013;26:205-208.