Pediatric emergency medicine trisk 392

CHAPTER 80 ■ VAGINAL DISCHARGE
JENNIFER H. CHUANG, KAREN J. DI PASQUALE, ARCHANA VERMA, DANIELLE
MASCARO

INTRODUCTION
Vaginal discharge among children and adolescents is a common complaint,
and the differential diagnosis can be very broad. Discharge may be
physiologic as a normal part of development, or it may be infectious and
require further testing and treatment. Physiologic leukorrhea, a clear or
whitish discharge is caused by circulating estrogen that stimulates the
vaginal epithelium. This can be seen in newborns up to 3 weeks of age, the
discharge resolves spontaneously as the effects of maternal estrogen wane.
It also occurs before menarche, due to an increase in circulating estrogen
levels.
Vaginal discharge beyond the newborn period and prior to puberty is an
abnormal finding. Appropriate treatment is guided by history, physical
examination, laboratory testing, and imaging if needed. The possibility of
sexual abuse must always be considered in any girl presenting with vaginal
complaints.
Postpubertal females presenting with vaginal discharge usually have a
specific cause, including sexually transmitted infections, candidiasis,
bacterial vaginosis, or physiologic leukorrhea (see Chapter 92 Gynecology
Emergencies ). Pregnancy screening should also be considered in this age
group.

EVALUATION OF VAGINAL DISCHARGE IN THE
PREPUBERTAL CHILD
Differential Diagnosis
The etiology of vaginal discharge in the prepubertal child differs from that
of the adolescent ( Fig. 80.1 ). Normal vaginal flora in this age group may
contain Staphylococcus epidermidis, Streptococcus viridans, diphtheroids,

mixed anaerobes, enterococci, lactobacillus, and Escherichia coli. Lack of


estrogen in the prepubertal child results in thinner, atrophic labia and an
alkaline pH, making the vaginal mucosa more susceptible to irritation and
infections. In this age group, this is potentiated by the higher prevalence of
poor local hygiene, the close proximity to the rectum, more frequent use of
bubble baths and other harsh soaps, the use of tight, nonabsorbent clothing,
and exploratory behaviors including insertion of foreign bodies.
Vaginitis is the most common gynecologic problem in prepubertal girls,
and the differential diagnosis can be quite extensive ( Table 80.1 ). In
addition to vaginal discharge, other symptoms can include dysuria, itching,
soreness, erythema, and bleeding.
Nonspecific vaginitis occurs in 25% to 75% of girls presenting with
symptoms of irritation and vaginal discharge. In these cases, no specific
pathogen is isolated. The etiology is most likely the result of poor perineal
hygiene or mechanical or chemical irritation. Symptoms resolve within 2 to
3 weeks with vaginitis treatment.
Children with infection caused by respiratory and enteric pathogens can
present with a purulent, bloody, or mucoid discharge. The most common
respiratory pathogen associated with this infection is Streptococcus pyogene
s. A recent history of sore throat is sometimes obtained. The vulva and
perianal areas have a distinctive beefy red appearance. Other bacteria found
less commonly include Staphylococcus aureus, nontypable Haemophilus
influenzae, Streptococcus pneumoniae, Neisseria meningitides, and
Moraxella catarrhalis. These usually cause self-limited symptoms. Enteric
pathogens that may or may not be associated with diarrhea include Shigella
flexneri and Yersinia enterocolitica.
The possibility of sexual abuse must always be considered in a
prepubertal child who presents with vaginal complaints. Sexually

transmitted infections as a result of sexual abuse in this age group include
Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis,
human papilloma virus, and herpes simplex virus.
N. gonorrhoeae infection causes a purulent vaginal discharge. C.
trachomatis may produce a scant, mucoid discharge, but is often
asymptomatic. Chlamydia may be transmitted perinatally and may persist
for several months up to 2 to 3 years of age. However, the possibility of
sexual abuse must be thoroughly investigated as it is more common after
toddlerhood. T. vaginalis infection beyond the newborn period is most


commonly transmitted through sexual contact and very rarely through
washcloths or towels. Vaginal discharge and other vaginal symptoms are
often mistakenly diagnosed as candidal infections in prepubertal girls. In
contrast to the postpubertal adolescent, candidal infection in the prepubertal
child typically causes perineal dermatitis, often in diapered areas, rather
than vaginal discharge and vulvar inflammation. Candidal vulvovaginitis
infections are not common in the prepubertal child. If present, these candida
infections most often occur in children who are immunosuppressed, have
diabetes mellitus, or who have had recent antibiotic treatment.
Foreign bodies in the vagina usually present with a foul-smelling
discharge and/or bleeding. Other presenting symptoms may include dysuria
and vaginal, pelvic, or abdominal pain. The most common items retained
are toilet paper, hair accessories, toys, and paper clips, although any object
that is small enough to pass through the introitus has the potential to be an
intravaginal foreign body.
An ectopic ureter, which can originate from a duplex collecting system or
from a dysplastic kidney, and can insert into or near the vagina, can cause
chronic symptoms of vulvar irritation, wetness, and a purulent discharge in
prepubertal girls. A history of chronic vaginal discharge and recurrent

urinary tract infections should increase the examiner’s index of suspicion
for this diagnosis.


FIGURE 80.1 Diagnostic approach to vaginal discharge.