You are in: eMedicine Specialties > Pediatrics: Surgery > Gynecology Genital Complaints in Prepubertal GirlsArticle Last Updated: Mar 6, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Joyce Adams, MD, Professor of Clinical Pediatrics, Department of Pediatrics, Division of General Academic Pediatrics and Adolescent Medicine, University of California at San Diego School of Medicine Joyce Adams is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine Editors: Elizabeth Alderman, MD, Director of Fellowship Training Program, Director, Adolescent Ambulatory Service, Clinical Professor, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati; Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System; Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center Author and Editor Disclosure Synonyms and related keywords: genital complaints, vaginitis, genital skin conditions, vaginal bleeding, suspected sexual abuse, vaginal itching, vaginal discharge, vaginal bleeding, genital pain, genital complaints in girls, genital redness, genital irritation, genital discharge, genital bleeding, genital itching, child sexual abuse, child molestation, sexually transmitted disease, sexually transmitted infection, vulvitis, allergic rhinitis, eczema, upper respiratory infection, gonorrhea, chlamydia, erythema of the genital tissues, streptococcus cellulitis, pinworms, lichen sclerosus, lichen sclerosus et atrophicus, cervicitis BACKGROUNDSection 2 of 12
  Complaints of genital redness, itching, discharge, or bleeding are relatively common in young girls before the onset of puberty. Most of these problems have benign causes and respond to the removal of irritants.1 However, because a genital complaint such as discharge or bleeding may be caused by trauma to the area or a sexually transmitted infection, assessment of each patient requires the clinician to be sensitive to possible unspoken concerns of parents regarding suspicions of molestation.2 When a child makes a statement or a disclosure of abuse and describes sexual touching, all 50 US states mandate that the clinician make a report of suspected child sexual abuse to the local child protective services agency, law enforcement, or both. However, if the concern of possible abuse is based only on a physical sign or symptom, the child must be examined by a health care provider who is familiar with the nonabusive causes of the symptoms or signs. Understanding the wide variations in the appearance of the hymen and other genital tissues in prepubertal girls is also necessary. The American Academy of Pediatrics has recently published a clinical report on the subject of suspected child sexual abuse with guidance for the clinician in deciding when a report to protective services is necessary.3 History The following questions are helpful in determining the possible causes of genital redness, itching, discharge, or irritation:
Physical examination To perform a careful genital inspection, the following are necessary:
If vaginal discharge is evident upon examination, obtain cultures using small urethral swabs (calcium alginate, Dacron, or cotton) moistened with sterile saline. A wet mount slide, routine vaginal culture, and cultures for gonorrhea and Chlamydia can be obtained. A nucleic acid amplification test may also be used to detect gonorrhea and Chlamydia, either from a urine sample or a vaginal swab. These tests are very sensitive and generally have a low false positive rate; however, if the urine nucleic acid amplification test findings are positive for either gonorrhea or Chlamydia, the child should be asked to return for a repeat test with a different type of nuclear acid amplification if Chlamydia cultures are not available. See the recommendations from the Centers for Disease Control and Prevention. If the hymen fails to open up with labial traction to reveal the hymenal opening, or if vaginal cultures need to be taken, the child can be turned over and placed in the prone knee-chest position. In this position, cultures can be taken with a urethral swab from the vagina without touching the hymen and causing pain and without the child being alarmed by the sight of the swab. NORMAL VARIATIONS AND CONGENITAL ANOMALIESSection 3 of 12
In infants, the hymen is thickened, pale in color, folded upon itself, or redundant. This is due to the effects of maternal estrogen (see Media file 1). As the child begins to enter puberty, sometimes before the onset of breast development, estrogen again causes the hymen to become thicker, paler, and folded (see Media file 2). In the intervening years, the hymen is usually thinner, more translucent, and pink-red. The most common hymenal configuration is the crescentic hymen (see Media file 3), in which the anterior attachments of the hymen are at the 9- to 11-o'clock or 1- to 3-o'clock position, with no hymenal tissue anteriorly. The posterior rim of the hymen may appear very narrow in some children, but if no tears or breaks appear in the tissue in the posterior half of the hymen, it is probably normal. Hymens can also be septate, as shown in Media file 4. This is a normal congenital variation that requires no treatment. If the hymenal septum appears very thick, referring the child to a gynecologist to determine whether a septate vagina is also present may be necessary. Two other common variants include the fossa groove in a child who is nearing puberty (see Media file 5) and the perineal groove, which appears as a mucosal defect extending from the fossa to the anus, usually observed in infants or toddlers. This defect spontaneously heals without treatment, but healing may take several years. ERYTHEMA OF THE GENITAL TISSUESSection 4 of 12
The skin of the labia majora and labia minora is subject to the same conditions as skin elsewhere on the body. Therefore, childhood eczema, seborrhea, and psoriasis can cause redness, irritation, scaling, and itching in the genital area. However, most often, genital redness (with or without vaginal discharge) is caused by local irritants. The most common of these include bubble bath, shampoo, and scented soaps. Bleach used to clean underclothing can also cause irritation, as can strong detergents. Occlusive clothing, such as nylon panties, leotards and tights, pantyhose, swimsuits, and Lycra shorts or exercise pants, can cause irritant vulvitis in some children. The standard recommendations for treatment of presumed irritant vulvitis are as follows:
In a child who is toilet trained, vulvitis or vaginitis caused by Candida albicans is quite unusual. If the child has the typical thick white vaginal discharge, obtain a culture for fungus. However, most girls in whom a yeast infection is diagnosed probably have irritant vulvitis (see Media file 6). In infants and girls who have had repeated episodes of vulvitis, labial adhesions may develop. These occur because of the lack of estrogen effect on the skin of the labia majora, and irritation then leads to a stickiness of the skin, which fuses or adheres. Labial adhesions can be extensive (see Media file 7), causing urinary retention, or minor. If the child has no complaints and is able to urinate normally, no treatment is needed. If irritation or recurrent urinary or vaginal infections occur, the adhesions can be treated with topical estrogen cream. The cream must be applied directly to the adhesion several times daily for 3-4 weeks. Once the adhesions resolve, daily use of a lubricant, such as petroleum jelly, is necessary to prevent their recurrence (see the eMedicine article Labial Adhesions).4 VAGINAL ITCHINGSection 5 of 12
Pinworms can hatch in the anus, travel to the vagina, and cause genital itching. The child may be noted to scratch at either the genital or the anal area, especially at night. Occasionally, the parent may be able to see pinworms in the anal area if the child is checked when asleep (see Media file 8). If genital or perianal itching is particularly intense, a trial of oral medication to eliminate pinworms is warranted. Irritant vulvitis can also cause itching, and the measures mentioned above usually relieve this symptom.Another skin condition that can present with intense genital itching is lichen sclerosus. The frequency of this disorder seems to be increasing in prepubertal girls, and it is sometimes difficult to diagnose. The full name of the condition is lichen sclerosus et atrophicus because it eventually causes atrophy of the skin of the affected areas. The skin then becomes easily traumatized and bleeds with normal activities, such as genital wiping, or with rubbing of clothing against the labia. The characteristic appearance that leads to diagnosis is the sharply demarcated area of hypopigmentation, often in a figure-8 pattern, around the vulva and the perianal area (see Media file 9). Low-potency topical steroid ointments are often effective in controlling the itching; however, higher-potency formulations used for a shorter time are occasionally necessary (see the eMedicine article VAGINAL DISCHARGESection 6 of 12
Most cases of vaginal discharge are caused by primary irritants or poor hygiene. Measures recommended above often eliminate the discharge as well as the genital redness and irritation. Obtain cultures if discharge persists, has a foul odor, or is sometimes bloody. Respiratory pathogens, such as group A beta-hemolytic Streptococcus and Branhamella catarrhalis, or enteric pathogens, such as Escherichia coli or Shigella organisms, can cause vaginitis with discharge and genital erythema; therefore, obtain a routine culture from the vagina. Sexually transmitted organisms can also cause vaginitis in prepubertal girls, even though they cause cervicitis in adolescent and adult women. Obtain cultures in a child with a purulent vaginal discharge upon examination to determine the presence of Neisseria gonorrhoeae and Chlamydia trachomatis. However, do not use the rapid antigen tests for Chlamydia in prepubertal girls in whom vaginal infection is suspected because of a very high rate of false-positive results for these tests. Instead, use the Chlamydia culture or possibly nucleic acid amplification tests, such as the ligase chain reaction or the polymerase chain reaction tests. Foreign bodies in the vagina are another relatively common cause of vaginal discharge, especially recurrent discharge with a foul odor or with intermittent bleeding. The most common types of foreign body are small pieces of toilet tissue, which the child usually inserts herself (see Media file 10). Small toys, crayons, pen caps, erasers, and other small objects have been removed from young children's vaginas. Most often, these objects are inserted by the child as she explores the vaginal opening in a manner similar to young children who insert objects into their noses or ears. In girls with relatively large hymenal openings, less of a barrier is available to block foreign materials, and bits of tissue may be found inside the vagina from wiping, even if the child has denied inserting anything. If a child has persistent vaginal discharge with negative culture results, an examination by a gynecologist with the patient under anesthesia is indicated. The vagina can be irrigated with saline and explored using the smallest Pedersen speculum or sometimes a hysteroscope or cystoscope. Additional cultures can be obtained in this manner, and the vagina can be thoroughly explored for the presence of a small foreign body. VAGINAL BLEEDINGSection 7 of 12
In addition to foreign bodies, bacterial vaginitis, and lichen sclerosus, other conditions must be considered in the child who presents with blood on the diaper or panties that seems to originate from the vaginal area Condyloma acuminatum, or genital warts, often present with bleeding because they are friable and easily abraded. These lesions, caused by human papillomavirus, can be present in infants as a result of perinatal transmission from the mother's birth canal, even if the mother has no active lesions at the time of delivery. The appearance of the condyloma varies. They can present as large pedunculated lesions (see Media file 11) or as fleshy hypervascular lesions in mucosal areas such as the vaginal vestibule. Another cause of vaginal bleeding is urethral prolapse. The cause of this condition is unknown, and it can occur with no known precipitating factor. It is said to occur sometimes with excessive straining and, for unknown reasons, is much more common in African American girls than in white girls. When the urethra prolapses, it causes discomfort and bleeding. When a child presents with a history of blood in the diaper or on the panties, perform an examination on an urgent basis. If trauma to the genital or anal tissues has occurred, the possibility of sexual abuse must always be considered. Acute lacerations of the posterior fourchette, hymen, or anus are readily seen by even an inexperienced examiner. Media file 14 shows a laceration of the posterior fourchette and a complete tear through the hymen in a 9-year-old girl who was raped by her stepfather and bled for 5 days. When children have injuries such as these, even if the history of sexual assault is not forthcoming, the child needs to be referred to the closest center where forensic medical examinations of children are conducted. Collect and preserve trace evidence for law enforcement, and carefully document the injuries, preferably with photographs. GENITAL PAINSection 8 of 12
Young girls with urinary tract infections, vaginal infections, vaginal irritation, vulvar skin conditions, or other skin lesions may complain of pain in the genital area. If inspection reveals the presence of genital ulcers, the following are differential diagnoses:
Because only herpes simplex and syphilis raise the suspicion of sexual abuse, culture the vesicular lesions for virus and obtain serum for syphilis serology if the child gives no history of sexual contact before any report is made to protective services. Obtain a routine bacterial culture and carefully examine the oral mucosa, eyes, and perianal area for other signs of systemic illness. Media file 15 shows vesicular lesions on the labia of a 6-year-old girl who described being sexually abused. One lesion was swabbed and sent for viral culture, and herpes simplex type 2 was identified. The adolescent girl in Media file 16 presented with a painful genital ulcer, which was cultured for herpes. Her case was reported as probable abuse to child protective services, despite the fact that she denied any type of sexual contact. The culture of the lesion subsequently was negative for herpes. A bacterial culture revealed E coli, and the lesion resolved with improved hygiene and oral antibiotics. This child had no oral lesions at the time but several months later developed another genital ulcer along with an oral ulcer; she was thought to have Behçet disease. CONCLUSIONSection 9 of 12
Genital complaints in prepubertal girls are not rare, and all clinicians who examine children need to be familiar with the conditions that can cause genital redness, itching, discharge, bleeding, and pain. Physicians, nurse practitioners, nurses, and physician assistants who examine children must know the wide variations of normal in the appearance of the genital tissues so as not to unnecessarily raise the suspicion of sexual abuse if the child gives no disclosure. Clinicians who wish to learn more about the specific examination for child sexual abuse can review the eMedicine article Pediatrics, Child Sexual Abuse or the articles on the medical evaluation of sexual abuse listed in the References.3, 9 For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's patient education article Foreign Body, Vagina. FURTHER READINGSection 10 of 12
Heger A, Emans J, Muram D. Evaluation of the Sexually Abused Child. A Medical Textbook and Photographic Atlas. 2nd ed. New York, NY: Oxford University Press; 2000. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Genital Complaints in Prepubertal Girls excerpt Article Last Updated: Mar 6, 2008 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
