Vulval and vaginal problems in prepubertal females

Introduction

Vulval and vaginal problems in young girls often result in pruritus vulvae (itch affecting the female genital area). Causes and treatments differ slightly between prepubertal females and mature women.

The prepubertal vulva is thin, delicate, and has a neutral pH, meaning it is easily irritated. Older women are somewhat protected by oestrogen-induced labial fat pads, thickening of the skin, and pubic hair.

What causes pruritus vulvae in prepubertal girls?

The main cause of pruritus vulvae in prepubertal females is contact irritant dermatitis due to the presence of chemical and/or mechanical irritants.

• Urinating or bowel movement may contaminate the vulva with urine and faeces.
• Soaps, bubble baths, laundry detergents, shampoo, and chlorinated pool water are potential chemical irritants.
• Mechanical irritation may occur from scratching, wiping with toilet paper, or tight-fitting underwear.

Prepubertal pruritus vulvae may also be a symptom of other vulvar or vaginal problems. These include:

• Primary skin disease such as atopic dermatitis, seborrhoeic dermatitis, psoriasis, lichen simplex, and lichen sclerosus may affect the vulva. Lesions elsewhere on the body are often present.
• A foreign body in the vagina such as toilet paper may result in vaginal discharge – this irritates vulval skin.
• Primary infection
  • Skin pathogens (Streptococcus pyogenes, Staphylococcus aureus) may cause impetigo or folliculitis.
  • Non-sexually transmitted bacterial pathogens include Str. pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Shigella, Yersinia entercolitica and Escherichia coli. Mixed bacterial cultures may indicate poor hygiene.
  • Sexually transmitted bacterial causes include trichomoniasis, chlamydia and gonorrhoea.
  • Infestations with pinworms, lice and scabies. Pinworms are common in children; they may move from the anus to the vagina where they cause itching especially at night time. Lice are however rarely seen in prepubertal girls who lack pubic hair.
  • Viral causes may include molluscum contagiosum, genital herpes and genital warts.
  • In infants still in napkins, candidiasis may cause napkin dermatitis but older prepubertal children are not prone to candida infections.
  • Fungal infections such as and tinea are rarely the cause of pruritus vulvae in prepubertal females.

Often several factors are present, and it can be difficult to determine the exact cause.

How is a diagnosis made in a prepubertal girl with vulval or vaginal problems?

Mostly the diagnosis is made by careful history and clinical examination by an experienced doctor. The doctor will need to examine the affected area and take swabs for microbiological examination. Other areas of the skin will be examined to determine the likelihood of a more widespread skin disorder being the cause.

Sometimes, a skin biopsy is necessary to determine the exact nature of the skin condition.

Patch tests are sometimes performed to see whether any contact allergy is present such as to a fragrance, preservative, medicament or another allergen.

What treatment is available for prepubertal vulval and vaginal problems?

Prepubertal vulval and vaginal problems can be treated and prevented by instituting good hygiene measures and by avoiding things that may cause irritation or infection. Some basic practices include:

• Using a front to back motion when wiping the vulva after urination or bowel movement.
• Separate legs when passing urine to reduce vaginal retention of urine.
• Change underpants frequently if soiled.
• Wear loose-fitting comfortable underwear and outer clothing.
• Avoid tight-fitting nylon clothing such as leotards and pants that restrict airflow and promote sweating.
• Avoid using bubble baths or allowing the child to sit in soapy bath water for long periods. However, a soap-free bath can be very soothing and will improve hygiene. The child should gently use her fingers to separate the folds of the vulva but should try not to rub or scratch.
• Avoid harsh soaps; try a soap-free cleanser instead of conventional soap.
• Pat dry the vulva with a clean towel after bathing rather than rubbing vigorously.

Bland emollients such as sorbolene and glycerine cream or petrolatum can be used. Hydrocortisone cream is generally safe, but if it seems to irritate, discontinue its use and seek advice. Dermatological or infectious causes may be treated with medicines prescribed by a doctor.