Curr Treat Options Peds (2016) 2:209–215

DOI 10.1007/s40746-016-0062-8

Pediatric Gynecology (L Breech and K Stambough, Section Editors)

Vulvovaginal Complaints
Chelsea Bayer, MD
Laura Parks, MD*
Address
*
Washington University School of Medicine, St. Louis, MO, USA
Email: [email protected]

Published online: 26 July 2016

* Springer International Publishing AG 2016

This article is part of the Topical Collection on Pediatric Gynecology

Keywords Vulvar care I Pediatrics I Vulvovaginitis I Hygiene I Treatment

Opinion statement
Teaching patients the proper vulvar care is the first, and arguably the most important,
aspect of treating vulvovaginal complaints in the pediatric population. Other treatments,
which will be discussed in this chapter, will be less effective with a high risk of recurring
symptoms if the patient and her parents do not adopt good vulvar care habits. Vulvovag-
initis usually can be managed with conservative measures, including proper hygiene and
education on vulvar care guidelines. These include avoiding chemical irritants and exces-
sive hygiene, wearing white cotton underwear, avoiding dryer sheets, wiping from front to
back, and limiting tight-fitting clothing. Additionally, it is important to discuss bathing,
including recommending showers or baths without soaps and bubble products. If both the
child and the parents follow these simple rules, the vast majority of vulvovaginal com-
plaints will dramatically improve. Consistently following the vulvar care guidelines will not
only help relieve the symptoms of itching and irritation but will also aid in the healing and
treatment of vulvovaginitis. If the girl is infected with a specific organism, the treatment
should be directed at that organism, and the girl should be educated on proper vulvar care.
Finally, any condition that requires topical steroid ointment or simple barrier creams will
be treated more quickly and effectively when good vulvar hygiene is added to the
treatment regimen.

Introduction
Vulvovaginal complaints are the most common reasons hygiene. In addition to a tendency towards poor perine-
for a young girl to see a pediatric gynecologist [1]. Vul- al hygiene, young girls are also more susceptible to
vovaginitis describes conditions in which either the ex- generic vulvovaginal complaints than their post-
ternal genitalia, the vagina, or both are inflamed, irritat- pubertal counterparts. This is because pre-pubertal girls
ed, pruritic, or erythematous [2]. Such conditions are have a nonestrogenized vaginal mucosa with a more
commonly caused by irritation from chemicals such as alkaline pH, lack labial development, and lack pubic
scented soaps or detergents, poor hygiene, or excessive hair, which provide a protective barrier [3].
210 Pediatric Gynecology (L Breech and K Stambough, Section Editors)

A complete history is essential to treating

vulvovaginal complaints and can help the physician
decide whether more extensive treatment or interven-
tion is necessary. In addition to helping the physician
develop a differential diagnosis, a history is important as
children may misinterpret urinary or bowel complaints
as vulvovaginal complaints. The patient and her parents
should be asked questions about hygiene, possible ex-
posures to irritating chemicals, timing of itching, and
possible foreign bodies that may have been inserted into
the vagina, most commonly toilet paper. Chronic self-
stimulatory habits can lead to thickening of the clitoral
hood and, consequently, to non-specific vulvovaginal
complaints in pre-pubertal children. Finally, the physi-
cian should always keep in mind that sexual abuse can
lead to vulvovaginitis. Taking the time to obtain a thor-
ough history can help identify common triggers or
causes of the vulvovaginitis and prevent unnecessary
tests or treatments.
The two most common causes of vulvovaginitis are
local irritants and foreign bodies; infection is a distant Fig. 2. Lichen Sclerosus (Photo by Diane F. Merritt MD)
third [4]. Most common causes of infection include
streptococcus pyogenes [5], pinworms, candida, or sex- specific causes of vulvovaginitis and some less common
ually transmitted infections. Non-sexually transmitted causes are outlined in Table 1 below.
vulvar ulcers or aphthous ulcers (Fig. 1) are unique in Because local irritation is the most common cause of
that they are generally quite painful and often paired vulvovaginitis, treatment is commonly conservative
with systemic symptoms such as fever, fatigue, and mal- with a behavioral component to improve symptoms.
aise [6]. Cutaneous vulvar disorders, such as lichen scle- Treatment is based almost entirely on education and
rosis (Fig. 2) or labial adhesions (Fig. 3), are a less
common cause of vulvovaginal complaints but need to
remain on the differential, especially in the setting of
refractory symptoms. Diagnosis and treatment of these

Fig. 1. Aphthous ulcers (Photo by Diane F. Merritt MD) Fig. 3. Labial adhesions (Photo by Laura A. Parks MD)
 Vulvovaginal Complaints Bayer and Parks 211

Table 1. Vulvovaginal complaints and treatment

Cause Presentation Diagnosis Treatment
Atopic Itching, skin dryness, Clinical diagnosis based on Vulvar care guidelines,
dermatitis erythema, oozing history and morphology topical steroids for
and crusting, and of lesions flare-ups
lichenification
Candida Uncommon in prepubertal Candida seen on wet Fluconazole or miconazole
girls, usually with recent prep, fungal culture
antibiotic use or who are
immunosuppressed. Itching
and discharge [7].
Condyloma Skin-colored flattened Visual inspection, HPV Observation and trichloroacetic
acuminata papules often with testing not helpful. acid. Imiquimod therapy may help.
cauliflower or smooth Biopsy only if diagnosis Surgical management with laser or
appearance is questionable [8]. cryotherapy is an option [9].
Contact Erythematous and edematous, Localized irritation Vulvar care guidelines, topical steroids
dermatitis rarely with vesicles or pustules. with exposure to irritant
Foreign Body Chronic discharge, occasional Visual inspection and history. If specimen is visualized, may
vaginal bleeding, foul- May require exam under remove in office with swab or
smelling odor anesthesia. irrigation with warm water. Exam
under anesthesia may be necessary.
Herpes Simplex Vesicular ulcers or blisters Culture from lesion Acyclovir
that tend to break open
Labial Can have partial or full fusion, Visual inspection No treatment necessary if
Adhesions may have difficultly urinating, asymptomatic. Vulvar care guidelines.
(Agglutination) recurrent UTIs/infections, Topical estrogen +/− topical steroids.
pulling sensation. Surgical correction is RARELY necessary [10]
Lichen Sclerosis White lesion, typically Visual inspection, biopsy Super-potent topical steroid daily for
in a butterfly configuration confirmation not required 6 weeks, with taper [11]. May need
with whitened skin in pediatric patients. maintenance therapy.
circumscribing the vulvar and
perianal areas
Non-sexually One or more painful ulcers Rule out sexually transmitted origin. Treat symptomatically with topical
transmitted with raised edges and Viral etiology often not determined, anesthetics and pain control; may
ulcers purulent bases, often can test for EBV, CMV, or influenza A require antibiotics if appears
(Baphthous accompanied by systemic super-infected. Generally
ulcers^) symptoms self-resolve in 2–3 weeks.
Pinworms Pruritis ani or perianal Scotch tape test or visual inspection Single 100 mg dose Mebendazole
itching, classically or Albendazole. Repeat in 2
at night. weeks if needed.
Seborrheic Erythematous and greasy, Visual inspection Topical clotrimazole with 1 %
dermatosis yellowish scaling on vulva and hydrocortisone if needed
labia-crural folds associated
with dandruff-type folds
behind ears/face
Streptococcus Flare of vulvovaginal Vaginal cultures should be obtained Penicillin or similar
pyogenes complaints with if discharge is purulent or antibiotic
respiratory infections persistent
212 Pediatric Gynecology (L Breech and K Stambough, Section Editors)

adoption of proper vulvar care by the patient and her adherence to the vulvar care guidelines outlined in
parents, with the caveat that some specific causes may the lifestyle section below will lead to relief of symp-
require antibiotics, topical steroids, topical hormones, toms in most children in 2–3 weeks. If symptoms
or other pharmacologic intervention. If, after a thor- persist after this amount of time, other causes of the
ough history is obtained and physical examination of vulvovaginitis should be explored and the child
the vulva is performed, the physician is unable to should be reevaluated. Even if a specific pathogen is
identify a cause of the child’s symptoms, conservative identified, the child will likely get more relief from
therapy should be started for non-specific vulvovagi- her symptoms if medical treatment is combined with
nitis. For non-specific vulvovaginal complaints, strict behavioral support.

Treatment
Lifestyle

& Daily warm baths

– Allow child to soak in plain warm water for 10–15 min

– Clean other areas with mild, unscented soap
– Avoid scented soaps, cleansers, and bubble baths
– Finally, clean the vulva, limiting soap use, and rinse well
– Pat dry the vulva after bath or use hair dryer on low/cool heat setting
& Laundry

– Double rinse underwear

– Line-dry underwear or avoid dryer sheets or as dryer sheets leave
potentially irritating chemicals in the dryer
& Clothing

– Wear white cotton underwear

– Avoid leggings, tights, and leotards
– Change quickly out of wet swim wear, or sweaty or soiled
underwear
& Toileting hygiene

– Wipe front to back—have child demonstrate their understanding

– Wet wipes may be less irritating and more thorough than toilet paper
for wiping after bowel movements
– Encourage child to sit with knees apart when urinating to pre-
vent reflux back into vagina—parents may need to purchase a
smaller seat or have the child face backward if she is too small
to sit with her knees apart on a regular toilet
– Parents should supervise toileting until child can consistently demon-
strate proper hygiene
& Do not scratch
 Vulvovaginal Complaints Bayer and Parks 213

– Take sitz baths in warm water for relief of itching

– Cool compresses may relieve discomfort
& Sleeping

– Do not wear underwear while sleeping

– Choose nightgowns or shorts instead of pajama pants to allow air
circulation
Pharmacologic treatment

Antibiotics

Amoxicillin (oral)[12]
Dosing 25 to 50 mg/kg/day in divided doses every 8 h
Contraindications hypersensitivity
Interactions BCG, Probenecid, tetracyclines, typhoid vaccine
Main side effects diarrhea
Cost very inexpensive
Antifungals

Clotrimazole (topical)[12]
Dosing 1 % ointment applied once or twice daily
Contraindications hypersensitivity
Interactions rare, possibly Xanax
Main side effects skin irritation or rash, edema
Cost inexpensive
Corticosteroids

Clobetasol (topical)[12]
Dosing 0.05 % ointment applied daily to weekly
Contraindications hypersensitivity
Interactions Aldesleukin, Hyaluronidase
Main side effects Atrophic striae, local irritation, hyperglycemia, or adrenal suppression
Cost inexpensive
Dosing 1 % ointment applied two to three times daily, up to four times daily

Hydrocortisone (topical) [12]

Contraindications hypersensitivity
Interactions Aldesleukin, Hyaluronidase
Main side effects Atrophic striae, local irritation, hyperglycemia, glucosuria, or adrenal
suppression
Cost inexpensive
214 Pediatric Gynecology (L Breech and K Stambough, Section Editors)

Estrogens

Topical estrogen or estradiol cream[12]

Dosing 0.01 % ointment applied twice daily
Contraindications hypersensitivity, estrogen dependent tumor
Interactions BCG, Probenecid, tetracyclines, typhoid vaccine
Main side effects irritation, redness, vulvar hyperpigmentation, minimal vaginal bleeding, and
breast bud formation
Cost inexpensive
Surgery

Surgical separation of labial adhesions (Fig. 2)

Standard procedure Application of topical anesthetic and mild sedation, as needed, is followed by
insertion of a lubricated Q-tip behind the labia minora. The Q-tip is then gently
pulled forward along the midline raphe formed by the fused labia minora.
Surgery should be followed by topical estrogen cream for 1 to 2 weeks and then
application of a bland emollient for 6 to 12 months.
Contraindications Unable to tolerate in office or unable to tolerate anesthesia
Complications Can cause further scarring and should therefore only be performed in those for
whom medical management has failed or who have serious symptoms such as
complete urinary obstruction

Conclusion

Vulvovaginitis is a disruptive problem that is by definition irritating or

painful but can also be distracting or embarrassing for a young child.
The overwhelming majority of vulvovaginal complaints are due to
local irritants and behaviors that can be modified. Thus, most cases
can be treated conservatively and most of the patient should see
improvement in their symptoms in 2–3 weeks after adopting the
vulvar care guidelines outlined in this chapter. For the remaining cases
that have a specific cause, treatment is dependent on accurate diagno-
sis. Therefore, any child without improving symptoms after behavioral
modifications should be reevaluated.
Vulvovaginitis is the most common reason for a young girl to
visit a pediatric gynecologist, but fortunately, this complaint can
almost always be treated without complex medical or surgical
intervention; just a few simple changes to the child’s habits can
have an enormous impact on their symptoms and how they feel
on a day-to-day basis.
 Vulvovaginal Complaints Bayer and Parks 215

Compliance with Ethical Standards

Conflict of Interest
Chelsea Bayer and Laura Parks declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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