Mini-Review
Recurrent Vaginal Discharge in Children

https://doi.org/10.1016/j.jpag.2011.12.065Get rights and content

Abstract

Background

Childhood vaginal discharge remains a frequent reason for referral from primary to secondary care. The Pediatric and Adolescent Gynecology (PAG) service at Kettering General Hospital was established in 1993 and provides a specialized service that meets the needs of children with gynaecological conditions.

Aim

To investigate recurrent vaginal discharge noting symptomatology, defining pathogens, common and rarer causes, exploring management regimes, and any changes in practice over time.

Method

Retrospective review spanning 15 years identifying prepubertal children attending the outpatient PAG clinic with recurrent vaginal discharge. We reviewed the medical notes individually.

Results

110 patients were identified; 85% were referred from primary care. The age distribution was bimodal at four and eight years. Thirty-five percent of our patients were discharged after the initial consultation. The commonest cause of discharge was vulvovaginitis (82%). Other important causes included suspected sexual abuse (5%), foreign body (3%), labial adhesions (3%), vaginal agenesis (2%). 35% of patients were admitted for vaginoscopy.

Conclusion

Vaginal discharge is the most common gynecological symptom in prepubertal girls and can cause repeated clinical episodes. Vulvovaginitis is the most common cause and often responds to simple hygiene measures. Awareness of the less common causes of vaginal discharge is essential.

Introduction

Vaginal discharge remains the most common gynecological complaint in young girls1, 2 and the majority of cases are diagnosed and treated by primary care physicians. Referral to secondary care for specialist review tends to occur when symptoms are recurrent or resistant to treatment. When treating young children with vaginal discharge it is important to understand the causes so that the condition can be adequately investigated and treated.4 Gynecological examination and assessment of prepubertal girls can be challenging. Sensitivity, understanding, and compassion are essential to achieve a successful examination. Vaginal discharge can be distressing to a child and cause alarm in her family, especially if the symptoms have been present for many months. Parental anxiety is also often heightened due to the associations of vaginal discharge in adults with pelvic inflammatory disease, poor hygiene, and sexual abuse.3

The aims of our study were to investigate recurrent prepubertal vaginal discharge with the objectives of noting symptomatology, defining pathogens, classifying common and rarer causes, exploring management regimes and any changes in practice over time in a secondary care setting. Our cohort was identified from the Paediatric and Adolescent Gynaecology (PAG) service at Kettering General Hospital which was first established in 1993 as a defined service to meet the needs of children and adolescents with gynecological disorders.

Section snippets

Methods

We identified a retrospective cohort of patients attending the monthly PAG clinic between1994 and 2009. There were 124 children out of 800 referrals during this time period who presented with vaginal discharge as the primary complaint. Each set of the notes was reviewed on an individual basis by the authors using a standard form, noting the patient demographics, source, and letter of referral, presenting complaint, examination findings, investigations, management, and outcomes. From this group

Results

Of the 110 patients identified 85% were referred from a primary care source and the remaining 15% were referred by hospital or community-based consultant pediatricians, consultant gynaecologists, or from the child protection team. The age of presentation was clearly bimodal with peaks at four years and eight years although the age range ranged from 15 weeks to 12 years. The average age was six years (Fig. 1).

During the study period and after initial outpatient assessment and investigations we

Vulvovaginitis

The peak age of presentation was bimodal at four and eight years old, with fewer cases noted under the age of three years.

Of this cohort, 29% were treated with simple hygiene advice and information leaflets alone with no further intervention required. Twenty-nine percent were formally admitted for a day case procedure, undergoing an examination under anesthesia and vaginoscopy, with some cases receiving a further form of treatment such as antibiotic therapy, topical hormonal cream, topical

Suspected/Alleged Sexual Abuse

Of all patients presenting with recurrent prepubertal vaginal discharge, 5% were referred for suspected or alleged sexual and physical abuse. The age group ranged from six to nine years old with the peak age being seven years. In addition to vaginal discharge, other symptoms at presentation in this group included offensive discharge, vaginal soreness, blood staining, urinary symptoms, and persistent green discharge. The most frequently isolated bacteria on vaginal swabs were anaerobic organisms

Discussion

Obtaining an adequate history from a prepubertal girl can be both challenging and stressful. While the majority of the history is obtained from the child’s parent or guardian it is also wise to engage the girl in general conversation and ask questions about her condition depending on her age and maturity. In this way she can be involved in the consultation and can appreciate the need for an examination.4 The history should contain details of the frequency, duration, impact, and extent of

Conclusions

Vaginal discharge is the most common gynecological symptom in prepubertal girls and can often be the cause of repeated visits to the general practitioner. Obtaining a history and physical examination of the girl can often be awkward, stressful, and embarrassing; and sensitivity and patience are essential to a successful consultation. Vulvovaginitis is the commonest cause of vaginal discharge and often responds adequately with simple hygiene advice, emollients, and antibiotics. It is essential

Summary

Most cases of recurrent vaginal discharge are caused by vulvovaginitis and the first line management should include a review of hygiene behavior and appropriate behavioral advice unless there are concerns of other underlying pathology or sexual abuse.

In patients with more significant symptoms such as vaginal blood staining, offensive discharge or recurrent symptoms despite adequate treatment; referral to secondary care should be considered.

All cases of suspected foreign body should be referred

References (6)

There are more references available in the full text version of this article.

Cited by (28)

  • Clinical and Microbiological Findings of Vulvovaginitis in Prepubertal Girls

    2019, Journal of Pediatric and Adolescent Gynecology
    Citation Excerpt :

    Candida albicans is a rare finding in the genitalia of prepubertal girls2,5,12 and was detected only once in the study group and twice among control participants with low growth intensity. Because many clinicians still believe in a fungal origin of vulvovaginitis among prepubertal girls, there remains excessive use of antifungal agents, increasing the risk of resistance.6,15 The causal relationship between Staphylococcus aureus and vulvovaginitis remains controversial, in accord with our findings and other studies2,5,13 (Table 4).

  • Parental experiences of their child's vulvovaginitis: a qualitative interview study

    2019, Journal of Pediatric Urology
    Citation Excerpt :

    Recurrent non-specific infections can be difficult to manage, and symptoms can re-occur frequently. The lack of effective treatment for this condition results in the main emphasis being on the prevention of future infections through regular and rigorous handwashing, perineal hygiene and good dietary habits [11,13,14]. If the recommended hygiene advice is not followed, then evidence suggests that there is a higher incidence of re-occurrence and the need for antibiotic administration [5].

  • Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology

    2018, Best Practice and Research: Clinical Obstetrics and Gynaecology
    Citation Excerpt :

    Chronic vaginal discharge is the most common presentation of retained foreign body [23]. In a study of 110 pediatric gynecology patients with vaginal discharge, 5% had a retained foreign body [24]. Intermittent bleeding or spotting, brown colored discharge, and/or a foul smelling odor are clinical manifestations of retained foreign body.

View all citing articles on Scopus

PLW is currently Chair of the British Society for Paediatric and Adolescent Gynaecology.

View full text