Comparison of Short-Duration and Chronic Premenarchal Vulvar Complaints

Abstract

Study Objective

To compare clinical characteristics, treatment histories, and microbiology of premenarchal girls who presented to a pediatric gynecology specialty clinic with short-duration and chronic vulvar symptoms.

Design

Retrospective cohort study.

Setting

Pediatric and adolescent gynecology clinic at a tertiary care children's hospital.

Participants

One hundred eighty-two premenarchal patients ages 2-14 years who presented to a pediatric gynecology specialty clinic with vulvar complaints and who were evaluated with a yeast and/or bacterial culture.

Interventions

None.

Main Outcome Measures

Chronic and short-duration vulvar symptoms, microbiology, and diagnosis.

Results

Patients with chronic symptoms were more likely to present with itching (59/102 (57.8%) vs 34/80 (42.5%); P = .04), redness or rash (53/102 (52.0%) vs 22/80 (27.5%); P = .0009), and discomfort (59/102 (57.8%) vs 30/80 (37.5%); P = .006), compared with patients with short-duration symptoms. Overall, 44.5% of patients had a history of antifungal treatment, with a greater proportion of patients with chronic symptoms having received antifungal treatment compared with those with short-duration symptoms (53/102 (52.0%) vs 28/80 (35.0%); P = .02). Despite a history of antifungal treatment in nearly half of the patients, Candida albicans was isolated in only 3/144 (2.1%) yeast cultures. Bacterial vulvar cultures were positive in 75/159 (47.2%), and there was no difference among the symptom duration groups (38/71 (53.5%) vs 37/88 (42.1%); P = .15).

Conclusion

Vulvovaginitis is a common gynecological diagnosis among premenarchal girls with short-duration and chronic vulvar symptoms. Regardless of symptom duration, yeast cultures are rarely positive. Antifungal treatment should be avoided in toilet-trained prepubertal girls.

Introduction

Because of low levels of endogenous estrogen, prepubertal genitalia are quite different from those in adolescents and young women.¹ The labia majora, labia minora, and prepuce (clitoral hood) are small, not yet developed, and provide little coverage for the vestibule. The hymen tends to be thin and translucent and the vaginal tissues are atrophic.1, 2, 3 Young girls are susceptible to specific and nonspecific vulvovaginitis because of various factors including unestrogenized tissue and a neutral vaginal pH, as opposed to the acidic environment the postpubertal vagina. Additionally, they lack fat pads and pubic hair, which protect the vulva. Poor hygiene and proximity of the vulva to the rectum also contribute to a favorable environment for microorganisms. Additionally, genital tissues are easily irritated by harsh soaps, chemicals, and clothing.3, 4, 5, 6, 7

Urogenital symptoms in the prepubertal child include genital discomfort, vulvar redness, itching, vaginal discharge, dysuria, and less commonly, vaginal bleeding.^2,8 These symptoms are quite common and in a study of 191 parent/female child dyads, 33% of parents and 48% of girls reported a history of urogenital symptoms that were not related to a urinary tract infection.⁹ Gynecological problems seen in prepubertal girls include vulvovaginitis, labial adhesions, and vulvar dermatoses such as eczema or lichen sclerosus (LS).^3,4 Of these, vulvovaginitis is generally considered the most common and in most cases the etiology is nonspecific.⁸ Previous studies have identified an infectious culprit in 20%-36% of cases.^2,8,10 Those with a bacterial etiology tend to have vulvar erythema and more visible discharge.⁸ Isolated bacteria are often enteric or respiratory in origin such as group A β-hemolytic Streptococcus, Hemophilus influenzae, Klebsiella pneumoniae, Shigella flexneri, Staphylococcus aureus, Escherichia coli, Enterococcus faecalis.^2,6,11 Among patients with group A β-hemolytic Streptococcus vulvovaginitis, 41% had a recent history of sore throat.² Candida is rare in the hypoestrogenic vagina.^2,8,11,12

Presentation can be variable in duration and patients can present with acute or chronic symptoms, however, vulvar complaints and microbiological differences have not been recently studied according to duration of symptoms. The purpose of this study was to compare clinical characteristics, treatment histories, and microbiology among premenarchal girls who presented to a pediatric gynecology specialty clinic with short-duration and chronic vulvar symptoms.