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. 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.

Understanding the wide variations in the appearance of the hymen and other genital tissues in prepubertal girls also is necessary.

History

The following questions are helpful in determining the possible causes of genital redness, itching, discharge, or irritation:

·         If out of diapers, how is the child bathed? Does she take showers or baths? Does she play in a tub with bubble bath or shampoo suds? What kind of soap is used? Does the mother or caregiver scrub the genital area with soap or a washcloth? Bubble bath, shampoo, perfumed soaps, and vigorous scrubbing can cause irritant vulvitis.

·         Does the child wear cotton or nylon panties? Does she often wear Lycra clothing or other types of clothing that restrict air circulation to the genital area? Does she like to wear her wet bathing suit all day? Nylon, Lycra, and other occlusive materials can cause genital irritation after prolonged wear.

·         Is the child recently toilet trained? If so, does mother or other caregiver still help her with hygiene after a bowel movement? If the child cares for her own toilet needs, does the mother or caregiver frequently find streaks of stool on the child's underwear? Fecal soiling can cause irritant vulvitis.

·         Has the caregiver noticed a bad odor from the genital area or seen dark discharge on the panties?

·         Does the child frequently complain of itching in the genital and anal area, or does the caregiver observe her to be constantly scratching or rubbing herself in that area?

·         Does the child have eczema, allergic rhinitis, or diarrhea, or has she had recent upper respiratory infections? These could explain itching, irritation, or discharge.

·         Has the caregiver ever noticed the child trying to insert objects into her own vagina?

·         Has the caregiver ever noticed blood on the child's underwear or after wiping?

·         Does the caregiver have any concerns about possible sexual abuse, based on the child's statements or sexualized behaviors?

Physical examination

To perform a careful genital inspection, the following are necessary:

·         A relaxed or distracted child (Books read by the mother or caregiver are great sources of distraction.)

·         A good light source

If vaginal discharge is evident on the 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 taken.

The best position for the patient while the physician is conducting the examination is lying on her back on the examination table in the supine frog-leg position with her knees bent and the soles of her feet touching. The labia majora are then gently spread laterally using separation or grasped and pulled forward toward the examiner using labial traction. In this way, the hymen and vestibular tissues are clearly identified.

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.

In infants, the hymen is thickened, pale in color, and folded upon itself, or redundant. This is due to the effects of maternal estrogen. 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. In the intervening years, the hymen is usually thinner, more translucent, and pink-red. The most common hymenal configuration is the crescentic hymen, 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,. 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 also exists may be necessary.

Two other common variants are the fossa groove in a child who is nearing puberty and the perineal groove, which appears as a mucosal defect extending from the fossa to the anus, observed usually in infants or toddlers. This defect heals spontaneously without treatment, but healing may take several years.

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 are bubble bath, shampoo, and scented soaps. Bleach used to clean underclothing also can 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:

·         Use only white cotton underwear and white unscented toilet tissue.

·         Stop all bubble baths, do not allow the child to play in the tub after shampooing her hair, and do not use shampoo or dishwashing detergent as a bubble bath substitute.

·         If proper hygiene is a problem after the child has a bowel movement, have her use a squirt bottle of warm water to rinse afterwards and pat dry with toilet tissue. If marked redness of the genital tissues is present, also involving the perianal area, consider streptococcal cellulitis. A culture can be taken from the affected area, and if test results are positive for group A beta-hemolytic Streptococcus, infection can be treated with penicillin or amoxicillin.

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.

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, 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.

Irritant vulvitis also can cause itching, and the measures mentioned previously usually relieve this symptom. Another skin condition that can present with intense genital itching is lichen sclerosus. 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. Low-potency topical steroid ointments are often effective in controlling the itching, but, occasionally, higher-potency formulations, used for a shorter length of time, are necessary.

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. The parent sometimes may be able to see pinworms in the anal area if the child is checked while asleep. If genital/perianal itching is particularly intense, a trial of oral medication to eliminate pinworms is warranted.

Most cases of vaginal discharge are caused by primary irritants or poor hygiene. Measures recommended in Erythema of the Genital Tissues often eliminate the discharge as well as the genital redness and irritation. Take 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 also can cause vaginitis in prepubertal girls, even though they cause cervicitis in adolescent and adult women. A child with a purulent vaginal discharge on examination also needs to have cultures taken for 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. Small toys, crayons, pen caps, erasers, and other small objects have been removed from young children's vaginas. Most of the time, 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 exists 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.

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, since 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 condyloma is varied. They can present as large pedunculated lesions 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 the inexperienced examiner.

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.

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:

·         Primary varicella or varicella zoster lesions

·         Syphilis

·         Ulcerative vulvitis of bacterial origin

·         Aphthous ulcers

·         Behçet disease

·         Crohn disease

·         Bacterial infection (especially Streptococcus)

Because only herpes simplex and syphilis raise the suspicion of sexual abuse, culture the vesicular lesions for virus and draw serum for syphilis serology 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.

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. It is also important for physicians, nurse practitioners, nurses, and physician assistants who examine children to 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.