Mini-ReviewRecurrent Vaginal Discharge in Children
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)
- et al.
Premenarchal vaginal discharge: findings of procedures to rule out foreign bodies
J Pediatr Adolesc Gynecol
(2002) - et al.
Prepubertal vaginal discharge
Obstet Gynaecol
(2007) - et al.
Vaginal discharge
Cited by (28)
Vaginal discharge caused by lymphatic malformation identified by lymphoscintigraphy combined with T2-weighted magnetic resonance imaging
2020, Journal of Vascular Surgery Cases and Innovative TechniquesOccult foreign body: A rare cause of recurrent vulvovaginitis
2020, Anales de PediatriaClinical and Microbiological Findings of Vulvovaginitis in Prepubertal Girls
2019, Journal of Pediatric and Adolescent GynecologyCitation 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 UrologyCitation 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 GynaecologyCitation 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.
Vulvovaginal infections in girls – prevention and treatment
2017, Pediatria Polska
PLW is currently Chair of the British Society for Paediatric and Adolescent Gynaecology.