Vulvar and vaginal symptoms, such as burning, dysuria, itching, or a rash, are common initial symptoms among children that are reported to gynecologists. It may be difficult for a young child to describe vulvar sensations. Parents may notice the child crying during urination, scratching herself repeatedly, or complaining of vague symptoms. Often, the child’s pediatrician will have evaluated the child for urinary tract infection. Evaluation for pinworms is warranted, because pinworms can cause severe itching in the vulvar as well as perianal area. Vulvovaginitis is the most common gynecologic problem of childhood. Prepubertally, the vulva, vestibule, and vagina are anatomically and histologically vulnerable to bacterial infection, with the bacteria typically present in the perianal area. The physical proximity of the vagina and vestibule to the anus can result in overgrowth of bacteria that can cause primary vulvitis and secondary vaginitis. Yeast infections are rare in prepubertal children who are toilet trained and out of diapers (37).
Figure 14.9 A: Labial adhesions B: Cotton-tipped applicator placed inside the labial adhesions shown in (A).
The clinician should be familiar with normal prepubertal genital anatomy and hymenal configuration (38,39). The unestrogenized vulvar vestibule is mildly erythematous and can be confused with infection. In addition, smegma around and beneath the prepuce may resemble patches of candida vulvitis. In prepubertal girls, the vulvar area is quite susceptible to chemical irritants.
Chronic skin conditions such as lichen sclerosus, psoriasis, seborrheic dermatitis, and atopic vulvitis may occur in children (40). Lichen sclerosus, the cause of which is not well established, has a characteristic “cigarette paper” appearance in a keyhole distribution (around the vulva and anus) (Fig. 14.4). Lichen sclerosus should be treated in pediatric patients as it is in adults; there is some evidence that the condition may regress as the child progresses through adrenarche and menarche, although this appears to be infrequent. The use of ultrapotent steroids topically has been successful in children and adults (41).
Labial agglutination or adhesions may occur as a result of chronic vulvar inﬂammation from any cause (Fig. 14.9A). The treatment of labial adhesions consists of a brief course (2 to 6 weeks) of externally applied estrogen cream. The area of agglutination (adhesion) will become thin as a result, and separation can usually be performed in the office with the use of a topical anesthetic (e.g., lidocaine jelly) (Fig. 14.9B). Manual separation in the office without pretreatment with topical estrogen and without anesthesia is discouraged, as this practice may be so traumatic to the child that she will not allow subsequent examination. In the absence of a previously traumatic examination or previous surgical separation with recurrence, surgical separation frequently is not required (42). Treatment with a topical emollient (such as petrolatum) is indicated after lysis to prevent recurrent adhesions. Urethral prolapse may cause acute pain or bleeding, or the presence of a mass may be noted (Fig. 14.2).
Vulvovaginal symptoms of any sort in a young child should prompt the consideration of possible sexual abuse. Sexually transmitted infections may occur in prepubertal children (43).