Causes of Vaginitis in Pre-Pubescent Girls

February 2, 2015 admin 0 Comments

The pre-pubescent vagina: an overview

Unsurprisingly, the vagina of a prepubescent girl is quite different from that of the adolescent or adult, though that is not initially the case. For four to six weeks after birth, an infant’s vaginal tissues are strongly influenced by maternal estrogens still present within their body. These estrogens cause the infant’s vagina to resemble that of an adult, both microbiologically and morphologically. As a result, an infant female’s vagina will have relatively thick vaginal mucosa as well as a colony of Lactobacillus, the bacterium that is responsible for protecting the vagina against the overgrowth of pathogenic bacteria.

However, once the estrogens are metabolized, the characteristics of the vagina change considerably. Now lacking the protection of maternal estrogens, the normal characteristics of the prepubescent vagina, including a thin epithelium, the absence of a Lactobacillus colony and a non-acidic pH level, lack of pubic hair and labial fat pads, small labia minora, and the rectum’s close proximity to the vagina, make it vulnerable to vaginitis1)Mayoclinic.org (2014) Vaginitis: Definition. Available from: http://www.mayoclinic.org/diseases-conditions/vaginitis/basics/definition/con-20022645 . and vulvovaginitis.

Nonspecific vaginitis

Nonspecific vaginitis is the most common form of vaginitis found in prepubescent patients, accounting for up to 75% of cases. The term encompasses a wide variety of symptoms that are typically mild and common and that have no discernible cause. Nonspecific vaginitis is characterized by dysuria, itchiness, discharge, and genital discomfort in a patient whose vulva and vagina appear normal and healthy, or only slightly inflamed. Causes of nonspecific vaginitis include:

  • Poor hygiene

Failing to wash hands, wiping incompletely or wiping from back to front (this is especially risky for prepubescent girls, as their anus and vagina are already located so closely together), and urinating with the legs closed are just a few examples of poor hygiene habits that could cause vaginitis. It is important to note that poor hygiene can be a contributing factor to more serious forms of vaginitis (such as those caused by pathogens) because it is incredibly easy to transfer harmful organisms via hand to the vagina.

  • Too-tight clothing and non-cotton bottoms

Tight-fitting clothing and synthetic fiber and nonabsorbent underwear cause direct irritation to the vulva. Switching to breathable cotton underwear and wearing looser bottoms (or switching to dresses, skirts, and nightgowns for a little while) are all favorable alternatives.

  • Chemical vulvovaginitis

Over-exposure to perfumed soaps, bubble bath, laundry detergent and other similar products can cause inflammation, itching, discharge, and dysuria. The symptoms that present are typically mild, but persistent.

Contact dermatitis and allergic vulvitis

Contact dermatitis and allergic vulvitis occurs due to skin irritation caused by contact with a material or surface. This is especially common in children with sensitive skin who tend to break out a lot elsewhere on their body. Allergic vulvitis is characterized mainly by itching, which may cause dysuria and burning, depending on the ferocity with which the individual scratches. Scratch marks may be evident and examination of the labia will reveal a microvesicular papular eruption; chronic conditions may cause the skin to have an eczema-toid appearance.

Foreign body

Foreign bodies lodged inside the vagina are frequently the cause of vaginitis, with tissue and toilet paper being the worst offenders. Presentation of a vaginal foreign body varies—sometimes it appears as an odorous brown or blood-streaked discharge, but in other cases it will appear as yellow discharge that is mildly purulent. Though toilet paper and tissues are perhaps the most common foreign bodies, because children have a tendency to stick random objects into various orifices, the possibilities are fairly limitless—crayons, small toys, paper, and cotton are examples of items that have been found. It should be noted that the insertion of foreign objects into a vagina may be a sign of sexual abuse or disturbed behavior, so care should be taken to obtain additional information regarding the patient’s psychosocial history.

Vaginitis with a pathogenic cause

Sexually transmitted pathogens

  • Chlamydia trachomatis and Neisseria gonorrhea

Chlamydia trachomatis and Neisseria gonorrhea are both sexually transmitted (in most cases) infections that can cause vaginitis. Symptoms include labial swelling, genital pruritus, dysuria, and copious amounts of green or yellow discharge. The vagina may also be inflamed, as well. It is exceedingly rare that the acquisition of both infections is nonsexual and a diagnosis of either in a prepubescent child warrants suspicion of child abuse and requires a call to Child Protective Services.

Gastrointestinal pathogenic causes

  • Shigella

Shigella flexneri, Shigella sonnei, Shigella boydii, and Shigella dysenteriae are all known causes of vaginitis in infants and children, characterized by a white to yellowish discharge that is bloody 75% of the time. The vulvar mucosa is often inflamed and in some cases, diarrhea and dysuria may occur. The Shigella form of vulvovaginitis is fairly uncommon.

  • Pinworm infection (Enterobius vernicularis)

Pinworms are a type of roundworm that measure less than 1cm in length. They are one of the most common infections, particularly for children, who often harbor a multitude of worms in their intestinal tract. Pinworms are acquired from ingesting worm eggs; they then hatch in the duodenum and travel to and settle in the colon. Females often travel through the anus (usually at night when the child is asleep) to lay their eggs in the perianal skin. Symptoms of a pinworm infection include intense anal and perianal itching; a quick at-home test to check for pinworms is to apply a piece of clear tape to the affected area, pull it up and attach it to glass slide, then examine it for evidence of pinworm eggs.

  • Escherichia coli

Respiratory and skin pathogens

  • Strains of Streptococcus

Three types of streptococcus infections are known to cause vaginitis—Streptococcus pyogenes (also known as Group A streptococcus), Streptococcus agalactiae (Group B streptococcus), and Streptococcus pneumoniae. Streptococcus pyogenes is the causal factor in 21% of vaginitis cases involving prepubescent girls2)Maniatis, AN et al (1996) “Streptococcus agalactiae: a vaginal pathogen?” Journal of Medical Microbiology March 44(3): 199-202., but is rarely seen in adult women.

  • Haemophilus influenza
  • Staphylococcus aureus3)Meltzer, Micelle C. and Jane R. Schwebke (2008) “Lactational Amenorrhea as a Risk Factor for Group A Streptococcal Vaginits.” In Clinical Infectious Diseases 46 (10), pp. 112-115.

Rare forms of vaginitis in prepubescent girls

Bacterial vaginosis (not to be confused with bacterial vaginitis)

(Note: Vaginosis is not always included in discussions on vaginitis, as it presents slightly differently and is typically not considered an infection. Some authors place bacterial vaginosis with nonspecific vaginitis in their work, others make a clear distinction—there is not really a consensus on how to handle its categorization.)

Bacterial vaginosis results from an imbalance in the flora that naturally exist in the vagina4)Red Book Atlas of Pediatric Infectious Diseases. Typically, the dominant bacteria is that of the Lactobacillus species, a “good” bacteria which maintains the pH level of the vagina and inhibits the overgrowth of other types of organisms. In cases of bacterial vaginosis, however, the level of Lactobaciluus decreases and concentrations of Gardnerella vaginalis, genital mycoplasmas, species of Ureaplasma and Mycoplasma, and anaerobic bacteria like those of the Mobiluncus and Prevotella species increase. Bacterial vaginosis is the leading cause of vaginal discharge5)Turovskiy, Yevgeniy et al (2011) “The Etiology of Bacterial Vaginosis.” In Journal of Applied Microbiology May 110(5): 1105-1128. in sexually active adolescents and adults, but occurrences in prepubescent females are very rare. Unlike forms of vaginitis, bacterial vaginosis usually does not present with inflammation.

Candidal Vulvovaginits

Candida albicans is typically only seen after the onset of puberty because estrogen is an important fuel for fungal growth. Additionally, the pH balance of the prepubescent vagina is not conducive to the development of a yeast infection. Candidal vulvovaginitis may develop in prepubescent girls if they have either recently been on antibiotics or have been wearing diapers.

Sources

Aghababian, Richard V. ed. (2011) Essentials of Emergency Medicine. Sudbury, MA: Jones & Bartlett Learning.

Baker, Carol J. MD, ed. (2013) Red Book Atlas of Pediatric Infectious Diseases 2nd Edition. Elk Grove Village, IL: American Academy of Pediatrics.

Crain, Ellen F. and Jeffrey C. Gershel (2010) Clinical Manual of Emergency Pediatrics Fifth Edition. Cambridge: Cambridge University Press.

Crowley, Leonard V. MD (2013) An Introduction to Human Disease: Pathology and Pathophysiology Correlations. Burlington, MA: Jones & Bartlett Learning.

Fleisher, Gary R. and Stephen Ludwig, eds. (2002) Synopsis of Pediatric Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins.

Fleisher, Gary R. and Stephen Ludwig, eds. (2010) Textbook of Pediatric Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins.

Leppert, Phyllis C. and Jeffrey F. Peipert, eds. (2004) Primary Care for Women. Philadelphia, PA: Lippincott Williams & Wilkins.

Sanfilippo, Joseph, ed. et al (2009) Clinical Pediatric and Adolescent Gynecology. New York: Informa Healthcare USA, Inc.

Schlossberg, David, ed. (2008) Clinical Infectious Diseases. Cambridge: Cambridge University Press.

Smith, Tara C. PhD (2010) Streptococcus (Group A). New York: Infobase Publishing.

Sultan, C. ed. (2012) Pediatric and Adolescent Gynecology. Basel, Switzerland: S. Karger AG.

Zitelli, Basil J. ed. Et al (2012) Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis. Philadelphia, PA: Elsevier Saunders.

References   [ + ]

1. Mayoclinic.org (2014) Vaginitis: Definition. Available from: http://www.mayoclinic.org/diseases-conditions/vaginitis/basics/definition/con-20022645 .
2. Maniatis, AN et al (1996) “Streptococcus agalactiae: a vaginal pathogen?” Journal of Medical Microbiology March 44(3): 199-202.
3. Meltzer, Micelle C. and Jane R. Schwebke (2008) “Lactational Amenorrhea as a Risk Factor for Group A Streptococcal Vaginits.” In Clinical Infectious Diseases 46 (10), pp. 112-115.
4. Red Book Atlas of Pediatric Infectious Diseases
5. Turovskiy, Yevgeniy et al (2011) “The Etiology of Bacterial Vaginosis.” In Journal of Applied Microbiology May 110(5): 1105-1128.

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