Pediatric emergency medicine trisk 393

TABLE 80.1
DIFFERENTIAL DIAGNOSIS OF VAGINITIS IN THE
PREPUBERTAL CHILD


1. VAGINITIS ASSOCIATED WITH VAGINAL DISCHARGE
(a) Nonspecific vaginitis
(b) Specific etiology
(i) Respiratory and enteric flora
(1) Streptococcus pyogenes
(2) Staphylococcus aureus
(3) Nontypable Haemophilus influenza
(4) Streptococcus pneumonia
(5) Neisseria meningitides
(6) Moraxella catarrhalis
(7) Shigella flexneri
(8) Yersinia enterocolitica
(ii) Sexually transmitted infections
(1) Neisseria gonorrhoeae
(2) Chlamydia trachomatis
(3) Trichomonas vaginalis
(iii) Foreign body
(iv) Congenital Abnormalities
(1) Ectopic ureter
(2) Urethral prolapse
2. OTHER VULVOVAGINITIS WITH OR WITHOUT
DISCHARGE
(a) Sexually transmitted infections
(i) Herpes simplex
(ii) Condyloma acuminate
(b) Pinworms and other helminths

(c) Tumors, polyps
(d) Trauma
(e) Systemic illnesses
(i) Kawasaki disease
(ii) Crohn disease


(iii) Stevens–Johnson syndrome
(iv) Scarlet fever
(v) Viral infections
(f) Skin conditions
(i) Atopic dermatitis
(ii) Contact dermatitis
(iii) Lichen sclerosis
Other causes of vaginal complaints in the prepubertal child include
cervical polyps and tumors, systemic illnesses such as Kawasaki disease,
Stevens–Johnson syndrome, and Crohn’s, certain infectious diseases
including scarlet fever and some viral illnesses, parasitic diseases such as
pinworms, and skin diseases such as atopic dermatitis, contact dermatitis,
and lichen sclerosis.

Examination
In the prepubertal patient, examination begins with a general physical
examination. Examination of the prepubertal patient should be performed in
the presence of a parent or caregiver. Explaining what will occur during the
examination helps to alleviate anxiety surrounding the exam in some
children. Provide a gown or drape when possible. Examination of the
external genitalia is often best accomplished by having the infant or child
lie supine in the frog-leg position. The child’s parent or caregiver can assist
by placing the child on his or her lap or between the parent’s legs on the

examining table. If the patient is unable to tolerate this position, an alternate
position for examination can be obtained by having the patient lie prone in
the knee to chest position. The examination should include inspection of the
perineal area, vulva, and vaginal introitus. Specimen testing can be obtained
by using a cotton-tipped swab moistened with sterile nonbacteriostatic
saline or swabs provided in PCR testing kits.

Diagnostic Testing and Treatment
In the majority of prepubertal girls who present with vaginal discharge, no
specific etiology can be found. Treatment of nonspecific vaginitis includes


practicing good perineal hygiene and removing any mechanical and
chemical sources of irritation.
Nonspecific Vaginitis Treatment
Avoid bubble baths and harsh soaps
Bathe daily for 10 to 15 minutes in warm water
Supervise children under 5 years and assist with toilet hygiene, including
front to back wiping and proper positioning during urination
Allow for air circulation with sleepwear; nightgowns are preferred over
pajama bottoms
Wear cotton underpants
Avoid the use of fabric softeners and other dryer additives
Launder clothing with hypoallergenic detergents
Avoid tight-fitting clothes
Change into dry clothing as soon as possible after swimming
Protect the vulvar skin with a barrier ointment, such as A&D or zinc oxide
Antibiotic treatment for infectious causes of vaginal discharge is guided by
clinical index of suspicion, vaginal culture, and sensitivities (see Chapter 92
Gynecology Emergencies ).

If sexual abuse is suspected, test for sexually transmitted diseases.
Vaginal swabs or urine specimens using nucleic acid amplification tests
(NAATs) are most sensitive and specific in initial testing for C. trachomatis
, N. gonorrhea , and T. vaginalis genital infection in prepubertal children
(with high sensitivity and specificity). Be familiar with local requirements
for forensic evidence as some states still require culture confirmation.
Treatment for a retained intravaginal foreign body is removal of the
foreign body. Treat the hymen with topical lidocaine jelly and remove by
irrigation with warmed saline is usually tolerated well. Palpation and
removal of small round objects can also be accomplished by a digital rectal
exam by palpation and application of gentle outward pressure. In rare cases,
if the patient is unable to cooperate for the procedure or the foreign body is
sharp or too large, exam by a gynecologist or pediatric surgeon under
sedation or general anesthesia may be necessary. Identification of certain