Although vulvar condyloma presenting before age 2 to 3 years can be transmitted during vaginal delivery from the mother or from warts on caretakers’ hands, the possibility of abuse should be considered in all children with genital warts (44,45). Condyloma in older girls may be spread in a nonsexual manner, but was classified as “indeterminant” in classification findings that may be associated with sexual abuse (44). Sensitive, but direct, questioning of the parent or caretaker and the child should be a part of the evaluation; if sexual abuse is suspected, the incident must be reported to the appropriate social services agency.
Nonsexually transmitted vulvar ulcers can occur in peripubertal and adolescent girls, often in association with systemic symptoms suggestive of a viral illness (46). Herpes simplex virus, syphilis, and Behcet’s disease can cause vulvar ulcers, and they may occur as a form of genital aphthosis (Fig. 14.10).
Figure 14.10 Vulvar aphthosis in prepubertal girl.
The symptom of vaginal discharge in the prepubertal age group is almost always caused by inﬂammation and irritation. In prepubertal girls, the primary site typically is the vulva, with vaginitis following secondarily, whereas in adolescents and adults, vaginitis typically is the primary finding with vulvitis occurring secondarily. Sexual abuse should always be considered in prepubertal children with vaginal discharge or a foreign body (47). Although the routine use of cultures to detect sexually transmitted diseases (STDs) in girls with a history of sexual abuse was questioned, vaginal culture for gonorrhea and chlamydia should be performed in girls who have symptoms that include vaginal discharge (48). In prepubertal girls, vulvovaginitis is usually caused by multiple organisms that are present in the perineal area, although a single organism such as Streptococcus, or even rarely Shigella, may be causative (49). When the cause is related to poor perineal hygiene, cultures often reveal a mixture of bacterial organisms. In this situation, the typical history is intermittent symptoms of irritation, itching, discharge, and odor over many months to years. Treatment should be initiated with a focus on hygiene and cleansing measures (40). A short-term (less than 4 weeks) course of treatment with topical estrogens and broad-spectrum antibiotics may be necessary. The problem is frequently recurrent. In girls who have a relatively acute onset of vaginal discharge and vulvovaginal symptoms, a single bacterial organism is more likely to be the cause of their symptoms.
Pokorny and Stormer described a technique for obtaining vaginal cultures and for performing vaginal irrigation (50). A catheter within a catheter can be fashioned using the tubing from an intravenous butterﬂy setup within a sterile urethral catheter. Nonbacteriostatic saline (1–3 mL) can be injected, aspirated, and sent for culture (Fig. 14.11). Cultures taken in this manner are almost always better tolerated than cultures obtained using a cotton-tipped applicator. A larger quantity of saline can be used to irrigate the vagina while the catheter is still within the vagina. Small foreign bodies can often be ﬂushed from the vagina in this manner. The most common foreign body is a small piece of toilet paper, although children will place other objects (toys, beans, coins) within their vaginas (Fig. 14.5). A persistent vaginal discharge after treatment or a discharge that is bloody or brown in color without other obvious external lesions should prompt vaginal irrigation or vaginoscopy to rule out a foreign body (12).
Figure 14.11 Catheter technique for obtaining vaginal culture and irrigation.