Vaginal organisms in prepubertal children with and without vulvovaginitis. A vaginoscopic study

Identification of shared bacterial strains in the vaginal microbiota of related and unrelated reproductive-age mothers and daughters using genome-resolved metagenomics

It has been suggested that the human microbiome might be vertically transmitted from mother to offspring and that early colonizers may play a critical role in development of the immune system. Studies have shown limited support for the vertical transmission of the intestinal microbiota but the derivation of the vaginal microbiota remains largely unknown. Although the vaginal microbiota of children and reproductive age women differ in composition, the vaginal microbiota could be vertically transmitted. To determine whether there was any support for this hypothesis, we examined the vaginal microbiota of daughter-mother pairs from the Baltimore metropolitan area (ages 14-27, 32-51; n = 39). We assessed whether the daughter's microbiota was similar in composition to their mother's using metataxonomics. Permutation tests revealed that while some pairs did have similar vaginal microbiota, the degree of similarity did not exceed that expected by chance. Genome-resolved metagenomics was used to identify shared bacterial strains in a subset of the families (n = 22). We found a small number of bacterial strains that were shared between mother-daughter pairs but identified more shared strains between individuals from different families, indicating that vaginal bacteria may display biogeographic patterns. Earlier-in-life studies are needed to demonstrate vertical transmission of the vaginal microbiota.

Host and Microbiome Interplay Shapes the Vaginal Microenvironment

The female reproductive tract harbors a unique microbiome, especially the vagina. The human vaginal microbiome exhibits a low diversity and is dominated by Lactobacillus species, compared to the microbiome of other organs. The host and vaginal microbiome mutually coexist in the vaginal microenvironment. Host cells provide Lactobacillus glycogen as an energy source, and Lactobacillus produce lactic acid, which lowers vaginal pH thereby preventing growth of other bacteria. Bacterial vaginosis can modulate host immune systems, and is frequently associated with various aspects of disease, including sexually transmitted infection, gynecologic cancer, and poor pregnancy outcomes. Because of this, numerous studies focused on the impact of the vaginal microbiome on women`s health and disease. Furthermore, numerous epidemiologic studies also have demonstrated various host factors regulate the vaginal microbiome. The female reproductive tract undergoes constant fluctuations due to hormonal cycle, pregnancy, and other extrinsic factors. Depending on these fluctuations, the vaginal microbiome composition can shift temporally and dynamically. In this review, we highlight the current knowledge of how host factors modulate vaginal microbiome composition and how the vaginal microbiome contributes to maintaining homeostasis or inducing pathogenesis. A better understanding of relationship between host and vaginal microbiome could identify novel targets for diagnosis, prognosis, or treatment of microbiome-related diseases.

Healthy Vaginal Microbiota and Influence of Probiotics Across the Female Life Span

Vaginal microbiota plays a central role in women’s health and reproduction. Vaginal microbiota is dynamic and shaped by hormonal shifts in each stage of a woman’s life from pre-puberty to postmenopause. Current research has mainly focused on vaginal bacterial and fungal members of the community and emphasized their role in disease. However, the impact of balanced vaginal microbiota on health and its interaction with the host is yet poorly understood. High abundance of vaginal lactobacilli is most strongly associated with health, but the concept of health may vary as vaginal dysbiosis may be asymptomatic. Furthermore, there is a lot of variation between ethnic groups in terms of dominating vaginal bacteria. Probiotic lactobacilli could be a safe and natural means to balance and maintain healthy vaginal microbiota. Research evidence is accumulating on their role in supporting women’s health throughout life. This review describes the current literature on vaginal microbiota, the major factors affecting its composition, and how the communities change in different life stages. Furthermore, we focused on reviewing available literature on probiotics and their impact on vaginal microbiota and health.

Finding a Balance in the Vaginal Microbiome: How Do We Treat and Prevent the Occurrence of Bacterial Vaginosis?

Bacterial vaginosis (BV) has been reported in one-third of women worldwide at different life stages, due to the complex balance in the ecology of the vaginal microbiota. It is a common cause of abnormal vaginal discharge and is associated with other health issues. Since the first description of anaerobic microbes associated with BV like Gardnerella vaginalis in the 1950s, researchers have stepped up the game by incorporating advanced molecular tools to monitor and evaluate the extent of dysbiosis within the vaginal microbiome, particularly on how specific microbial population changes compared to a healthy state. Moreover, treatment failure and BV recurrence rate remain high despite the standard antibiotic treatment. Consequently, researchers have been probing into alternative or adjunct treatments, including probiotics or even vaginal microbiota transplants, to ensure successful treatment outcomes and reduce the colonization by pathogenic microbes of the female reproductive tract. The current review summarizes the latest findings in probiotics use for BV and explores the potential of vaginal microbiota transplants in restoring vaginal health.

STROBE-sequencing analysis of the vaginal microecology of 4- to 6-year-old girls in Southwest China

We investigated the vaginal flora diversity of preschool-aged (ie, 4-6-year-old) girls in southwest China.Fourteen preschool-aged girls were enrolled in this study. The statuses and differences in their vaginal flora were evaluated by Gram staining, bacterial culturing, and sequencing analysis.Gram staining and microbial culturing showed that the main vaginal flora of the preschool-aged girls were Gram-negative bacilli, whereas the main vaginal flora of healthy adult controls were large Gram-positive bacilli such as Lactobacillus crispatus. Shannon and Simpson indexes indicated that the bacterial diversity tended to decrease with age. The species abundance heat map showed that the vaginal microecology of the girls differed slightly at different ages but mainly comprised Pseudomonas, Methylobacterium, Sphingomona,s and Escherichia. The functional abundance heat map indicated that the bacterial functions increased with age.The vaginal microecology of preschool-aged girls differs from that of adults. A comprehensive understanding of the vaginal flora diversity of preschool-aged girls will aid in clinically diagnosing vulvovaginitis in preschool-aged girls.

The relationship between sex hormones, the vaginal microbiome and immunity in HIV-1 susceptibility in women

The role of sex hormones in regulating immune responses in the female genital tract has been recognized for decades. More recently, it has become increasingly clear that sex hormones regulate susceptibility to sexually transmitted infections through direct and indirect mechanisms involving inflammation and immune responses. The reproductive cycle can influence simian/human immunodeficiency virus (SHIV) infections in primates and HIV-1 infection in ex vivo cervical tissues from women. Exogenous hormones, such as those found in hormonal contraceptives, have come under intense scrutiny because of the increased susceptibility to sexually transmitted infections seen in women using medroxyprogesterone acetate, a synthetic progestin-based contraceptive. Recent meta-analyses concluded that medroxyprogesterone acetate enhanced HIV-1 susceptibility in women by 40%. In contrast, estradiol-containing hormonal contraceptives were not associated with increased susceptibility and some studies reported a protective effect of estrogen on HIV/SIV infection, although the underlying mechanisms remain incompletely understood. Recent studies describe a key role for the vaginal microbiota in determining susceptibility to sexually transmitted infections, including HIV-1. While Lactobacillus spp.-dominated vaginal microbiota is associated with decreased susceptibility, complex microbiota, such as those seen in bacterial vaginosis, correlates with increased susceptibility to HIV-1. Interestingly, sex hormones are inherently linked to microbiota regulation in the vaginal tract. Estrogen has been postulated to play a key role in establishing a Lactobacillus-dominated microenvironment, whereas medroxyprogesterone acetate is linked to hypo-estrogenic effects. The aim of this Review is to contribute to a better understanding of the sex-hormone-microbiome-immunity axis, which can provide key information on the determinants of HIV-1 susceptibility in the female genital tract and, consequently, inform HIV-1 prevention strategies.

Psychosocial Stress, Cortisol Levels, and Maintenance of Vaginal Health

Stress stimuli are ubiquitous and women do not enjoy any exemptions. The physiologic "fight-or-flight" response may be deleterious to the female lower genital tract microbiome if the stress stimuli persist for longer than necessary. Persistent exposure to psychosocial stress and stimulation of the hypothalamic-pituitary-adrenal (HPA) and sympathetic-adrenal-medullary (SAM) axes, and associated hormones are risk factors for several infections including genitourinary tract infections. Though this could be due to a dysregulated immune response, a cortisol-induced inhibition of vaginal glycogen deposition may be involved especially in the instance of vaginal infection. The estrogen-related increased vaginal glycogen and epithelial maturation are required for the maintenance of a healthy vaginal ecosystem (eubiosis). The ability of cortisol to disrupt this process as indicated in animal models is important in the pathogenesis of vaginal dysbiosis and the subsequent development of infection and inflammation. This phenomenon may be more crucial in pregnancy where a healthy Lactobacillus-dominated vaginal microbiota is sacrosanct, and there is local production of more corticotropin-releasing hormone (CRH) from the decidua, fetal membranes and placenta. To highlight the relationship between the stress hormone cortisol and the vaginal microbiomial architecture and function, the potential role of cortisol in the maintenance of vaginal health is examined.

Association of Sexual Debut in Adolescents With Microbiota and Inflammatory Markers

OBJECTIVE

To investigate the association of sexual debut and vaginal, anorectal, and oral microbiota and vaginal inflammatory markers in female adolescents.

METHODS

We conducted a school-based study in adolescents in Antwerp, Belgium. During three visits over 8 months, participants answered questionnaires and self-collected vaginal, anorectal, and oral swabs. Five Lactobacillus species, Lactobacillus genus, Gardnerella vaginalis, and Atopobium vaginae were quantified; and seven inflammatory markers were measured in the vaginal specimens. In the oral and anorectal specimens, Lactobacillus genus, G vaginalis, and A vaginae were ascertained.

RESULTS

Of the 93 adolescents (mean age 16.2 years) at the first visit, 41 (44.1%) had passed sexual debut (penile-vaginal intercourse) and five (5.4%) had sexual experience without passing sexual debut. Having sexual experience at the first visit was not found to be associated with species presence or concentrations (acknowledging an underpowered study because the required sample size was not attained). Modeling the longitudinal data on all girls showed that sexual debut was associated with increased odds of vaginal and anorectal G vaginalis (P=.021; P=.030) and A vaginae (P=.041; P=.012) with increments of interleukins (interleukin [IL]-1α P<.001, IL-1β P=.046, IL-8 P=.033) and chemokines (regulated on activation, normal T cell expressed and secreted P<.001; macrophage inflammatory protein-1β P=.040), whereas no difference was seen when modeling (before-after) the girls initiating and girls staying without sexual intercourse. The association of sexual intercourse with IL-1α (P<.001), IL-1β (P=.030), and IL-8 (P=.002) at the first visit was (greater than 70%) mediated by vaginal G vaginalis and A vaginae concentrations.

CONCLUSION

Sexual debut in adolescents is associated with an inflammatory vaginal reaction and with the presence of bacterial vaginosis-related species. Strategies preventing the colonization of bacterial vaginosis-related organisms during early sexual debut are urgently needed and may prevent acquisition of sexually transmitted infections including human immunodeficiency virus in early life.

Flushing of the vagina and the prepuce-a cause for contaminated urine cultures in children

OBJECTIVE

An uncontaminated urine culture is a prerequisite for the diagnosis of a urinary tract infection. However, this may be difficult to obtain in small children. We have studied the frequency of ballooning of the prepuce in non-circumcised boys and vaginal reflux in girls during voiding as a possible cause of contaminated urine cultures.

METHODS

All micturating cystourethrograms (MCUG) performed in our institution over the last 5 years in children aged 0-15 years were reviewed retrospectively for ballooning of the foreskin or vaginal reflux as a potential source of bacterial contamination. The voiding pictures were routinely done with the catheter present for the first voiding cycle and then removed on the second void.

RESULTS

A total of 526 children (77.4 % boys, 22.6 % girls) were eligible for the study. Ballooning of the foreskin was identified on the micturition pictures of 115 (38 %) boys, with the frequency significantly higher in boys aged <12 months [odds ratio (OR) 4.1; 95 % confidence interval (CI) 2.1-7.3)] and boys with vesicoureteral reflux (OR 1.6; 95 % CI 1.06-2.4). Seventeen girls (14.3 %) showed vaginal reflux. No correlation with age or vesicoureteral reflux was found in the girls.

CONCLUSION

Ballooning of the prepuce or vaginal reflux was seen on a fluoroscopic MCUG in a large proportion of children during their voiding. This normal phenomenon might cause contaminated urine cultures when the urine is obtained by bag or clean catch.

Clinical and microbiologic characteristics of vulvovaginitis in Korean prepubertal girls, 2009-2014: a single center experience

OBJECTIVE

To update information on the clinical and microbiologic characteristics of pediatric vulvovaginitis in Korean prepubertal girls.

METHODS

A total of 120 girls (aged 0 to 9 years) with culture-confirmed pediatric vulvovaginitis, diagnosed between 2009 and 2014, were enrolled in the study. The epidemiologic and microbiologic characteristics, and clinical outcomes were assessed. Patients with sexual precocity, as well as those who were referred for suspected sexual abuse, were excluded.

RESULTS

Girls aged 4 to 6 years were at the highest risk of pediatric vulvovaginitis. Seasonal distribution indicated obvious peaks in summer and winter. Of the 120 subjects, specific pathogens were identified in the genital specimens in only 20 cases (16.7%). Streptococcus pyogenes (n=12, 60%) was the leading cause of specific vulvovaginitis. Haemophilus influenzae was isolated in one patient. No cases presented with enteric pathogens, such as Shigella or Yersinia. A history of recent upper respiratory tract infection, swimming, and bubble bath use was reported in 37.5%, 15.8%, and 10.0% of patients, respectively. Recent upper respiratory tract infection was not significantly correlated with the detection of respiratory pathogens in genital specimens (P>0.05). Of 104 patients who underwent perineal hygienic care, 80 (76.9%) showed improvement of symptoms without antibiotic treatment. Furthermore, the efficacy of hygienic care was not significantly different between patients with or without specific pathogens (P>0.05).

CONCLUSION

Specific pathogens were only found in 16.7% of pediatric vulvovaginitis cases. Our results indicate an excellent outcome with hygienic care, irrespective of the presence of specific pathogens.

The vaginal microbiome is stable in prepubertal and sexually mature Ellegaard Göttingen Minipigs throughout an estrous cycle

Although the pig has been introduced as an advanced animal model of genital tract infections in women, almost no knowledge exists on the porcine vaginal microbiota, especially in barrier-raised Göttingen Minipigs. In women, the vaginal microbiota plays a crucial role for a healthy vaginal environment and the fate of sexually transmitted infections such as Chlamydia trachomatis infections. Therefore, knowledge on the vaginal microbiota is urgently needed for the minipig model. The aim of this study was to characterize the microbiota of the anterior vagina by 16 s rRNA gene sequencing in prepubertal and sexually mature Göttingen Minipigs during an estrous cycle. The dominating phyla in the vaginal microbiota consisted of Firmicutes, Proteobacteria, Actinobacteria, Bacteriodetes and Tenericutes. The most abundant bacterial families were Enterobacteriaceae, unclassified families from Gammaproteobacteria, Clostridiales Family XI Incertae Sedis, Paenibacillaceae, Lactobacillaceae, Ruminococcaceae and Syntrophaceae. We found a higher abundance of Lactobacillaceae in the prepubertal Göttingen Minipigs compared to sexually mature non-pregnant Göttingen Minipigs. However, correlation tests and diversity parameters revealed a very stable vaginal microbiota in the Göttingen Minipigs, both before and after sexual maturity and on different days throughout an estrous cycle. The vaginal microbiota in Göttingen Minipigs was not dominated by lactobacilli, as it is in women and according to our results the minipig vaginal microbiota is very stable, in opposite to women. These differences should be considered when using the minipig as a model of the genital tract in women.

Vaginal microbiota of adolescent girls prior to the onset of menarche resemble those of reproductive-age women

Puberty is an important developmental stage wherein hormonal shifts mediate the physical and physiological changes that lead to menarche, but until now, the bacterial composition of vaginal microbiota during this period has been poorly characterized. We performed a prospective longitudinal study of perimenarcheal girls to gain insight into the timing and sequence of changes that occur in the vaginal and vulvar microbiota during puberty. The study enrolled 31 healthy, premenarcheal girls between the ages of 10 and 12 years and collected vaginal and vulvar swabs quarterly for up to 3 years. Bacterial composition was characterized by Roche 454 pyrosequencing and classification of regions V1 to V3 of 16S rRNA genes. Contrary to expectations, lactic acid bacteria, primarily Lactobacillus spp., were dominant in the microbiota of most girls well before the onset of menarche in the early to middle stages of puberty. Gardnerella vaginalis was detected at appreciable levels in approximately one-third of subjects, a notable finding considering that this organism is commonly associated with bacterial vaginosis in adults. Vulvar microbiota closely resembled vaginal microbiota but often exhibited additional taxa typically associated with skin microbiota. Our findings suggest that the vaginal microbiota of girls begin to resemble those of adults well before the onset of menarche.

IMPORTANCE

This study addresses longitudinal changes in vaginal and vulvar microbial communities prior to and immediately following menarche. The research is significant because microbial ecology of the vagina is an integral aspect of health, including resistance to infections. The physiologic changes of puberty and initiation of cyclic menstruation are likely to have profound effects on vaginal microbiota, but almost nothing is known about changes that normally occur during this time. Our understanding has been especially hampered by the lack of thorough characterization of microbial communities using techniques that do not rely on the cultivation of fastidious bacteria, as well as a dearth of studies on girls in the early to middle stages of puberty. This study improves our understanding of the normal development of vaginal microbiota during puberty and onset of menarche and may better inform clinical approaches to vulvovaginal care of adolescent girls.

Altered perineal microbiome is associated with vulvovaginitis and urinary tract infection in preadolescent girls

BACKGROUND

Vulvovaginitis has a known association with urinary tract infections (UTIs) in girls. We hypothesize that vulvovaginitis is a major contributor to UTIs in prepubertal girls by increasing periurethral colonization with uropathogens.

METHODS

Periurethral swabs and urine specimens were obtained from a total of 101 girls (58 with vulvovaginitis and 43 without vulvovaginitis). Specimens were cultured for bacterial growth. The dominant organism in the periurethral swabs and urine cultures was recorded and antibiotic sensitivity profiles were compared.

RESULTS

Periurethral swabs from children with vulvovaginitis were associated with a statistically significant increase in uropathogenic bacteria (79% Enterococcus species or Escherichia coli) as the dominant culture compared with swabs from girls without vaginitis (18%) (p < 0.05). In children with vulvovaginitis, 52% of the urine cultures were positive for UTIs, and the dominant organism in the urine cultures matched the species and antibiotic sensitivity profile of the corresponding periurethral swab. Only 11% of the urine cultures from girls without vulvovaginitis were positive for UTIs.

CONCLUSIONS

Vulvovaginitis may cause UTIs by altering the perineal biome such that there is increased colonization of uropathogens.

Urogenital symptoms after sexual abuse vs irritant contact in premenarchal girls

OBJECTIVES

Sexually abused (SA) girls report urogenital symptoms temporally related to inappropriate genital contact. Since girls also experience symptoms following genital irritant exposure and mostly all girls are exposed to genital irritants, we describe overall symptoms reported by girls that disclosed SA compared to those that did not and we compare how girls describe symptoms following a specific episode of contact SA vs a genital irritant exposure.

DESIGN

Cross-sectional study. Parents/girls interviewed; medical records reviewed.

PARTICIPANTS

Five to 12-year-old premenarchal girls/parents.

SETTING

An urban and a suburban pediatric practice; a regional treatment center for child abuse.

OUTCOME MEASURES

Prevalence of histories of urogenital symptoms in SA girls compared to girls attending well-child exams (controls); girls' description of urogenital symptoms following specific episodes of contact SA compared to specific episodes of genital irritant exposure.

RESULTS

More parents/girls in SA group reported prior urogenital symptoms. Most SA girls said past symptoms were caused by inappropriate genital touching; most control girls could not identify causes for prior symptoms. Girls' responses following specific irritant exposures: 76% SA vs 24% control girls used negative terms to describe how it felt, 69% SA vs 6% control girls said it bothered her body and her feelings, and 33% SA vs 12% control girls described experiencing dysuria afterwards (all ps < 0.05).

CONCLUSIONS

Girls can relate urogenital symptoms to specific genital contacts; more SA girls reported unpleasant symptoms with an emotional component. A skilled medical history can help differentiate these conditions and diagnose sexual abuse with greater certainty.

Urogenital symptoms in premenarchal girls: parents' and girls' perceptions and associations with irritants

OBJECTIVES

Premenarchal girls commonly seek care for urogenital symptoms, yet little is published about parents' and girls' perceived causes of symptoms or associations with irritant exposures. We sought to describe urogenital symptoms, perceived causes, and associations between symptoms and genital irritant exposures.

DESIGN

Descriptive study. Parents/girls interviewed; medical records reviewed.

PARTICIPANTS

Five- to 12-year-old well, premenarchal girls and their parents.

SETTING

One urban and 1 suburban pediatric practice.

OUTCOME MEASURES

Prevalence of histories of urogenital symptoms and perceived causes; association between symptoms and exposure to genital irritants in a well population.

RESULTS

Of 191 parent/girl dyads, 33% of parents and 48% of girls reported girls' histories of urogenital symptoms not attributed to urinary tract infections or trauma. Perceived causes: poor hygiene (29% of parents vs 14% of girls); soap products (20% of parents and girls); none identified (24% of parents vs 53% of girls). Analysis of symptoms versus irritant exposures demonstrated these associations: dysuria and genital soreness with poor genital hygiene, tight garments, or exposure to soap products; genital pruritus with poor hygiene (all P < .05). No symptoms were associated with nylon underwear, tights, or bike or horseback riding. Vaginal discharge was not associated with any irritants.

CONCLUSION

Almost half the girls had histories of urogenital symptoms. Poor hygiene and soap exposure were perceived causes of most symptoms. When no cause for urogenital symptoms is identified, treatment should be focused on hygiene, soap exposure, and tight-fitting clothes, not on bike or horseback riding or wearing nylon underwear or tights. Vaginal discharge warrants further evaluation.

What the paediatrician should know about paediatric and adolescent gynecology: The perspective of a gynecologist

Gynecological problems are common in children but training in this subject is rare during paediatric postgraduate education. Knowledge in this area is important for providing comprehensive health care to children. The article explores the gynecological examination of the child and common gynecological disorders in the paediatric and adolescent age groups. Routine examination of the external genitalia as part of a well-child physical normalizes the examination for the child and helps to inform the physician about the large variations in normal genitals. Many complaints can be dealt with by reassurance, while most others respond to medical therapy and can be dealt with easily by paediatricians. Both young children and adolescents respond positively when allowed to have control over the tempo of the interview and the examination. A positive experience associated with a genital examination will help to open lines of trust. This along with nonjudgmental, open communication, will create educational opportunities to enhance a responsible transition from child to young adult.

The aetiology of bacterial vaginosis

Bacterial vaginosis (BV) is the most common vaginal infection among women of childbearing age. This condition is notorious for causing severe complications related to the reproductive health of women. Five decades of intense research established many risk factors for acquisition of BV; however, because of the complexity of BV and lack of a reliable animal model for this condition, its exact aetiology remains elusive. In this manuscript, we use a historical perspective to critically review the development of major theories on the aetiology of BV, ultimately implicating BV-related pathogens, healthy vaginal microbiota, bacteriophages and the immune response of the host. None of these theories on their own can reliably explain the epidemiological data. Instead, BV is caused by a complex interaction of multiple factors, which include the numerous components of the vaginal microbial ecosystem and their human host. Many of these factors are yet to be characterized because a clear understanding of their relative contribution to the aetiology of BV is pivotal to the formulation of an effective treatment for and prophylaxis of this condition.

Vaginal microbiocoenosis and cytology of prepubertal and adolescent girls: their role in health and disease

BACKGROUND

Clinicians and investigators often do not appreciate the importance of vaginal microbiocoenosis and vaginal cytology in the health of prepubertal and adolescent girls.

DATA SOURCES

Based on recent publications in human medicine and our own experience with vaginal cytology and microbiology in children and adolescent girls, we review the principles of vaginal microbiocoenosis and cytology and their roles in disease prevention in prepubertal and adolescent girls.

RESULTS

The main role of vaginal microbiocoenosis and cytology in diagnosing as well as developing vulvovaginitis is demonstrated. Clinicians can identify states of vaginal health and disease by important well-known diagnostic tools, including vaginal cytology. Lactobacilli are infrequently observed in the prepubertal girls, but become more abundant in adolescent girls. Three basic types of vaginal smears are presented in addition to a classification of inflammatory urogenital diseases. Management of common types of vulvovaginitis is also considered.

CONCLUSIONS

This essential shift in vaginal biocoenosis is important to prevent the growth of potentially pathogenic flora in the vagina. The detection of vaginal microbiocoenosis problems and recognition of changing cytology in vaginal development can provide helpful clues to identifying and preventing vaginal diseases in this pediatric population.

Vulvovaginitis in childhood

Symptoms related to vulvitis and vulvovaginitis are a frequent complaint in the paediatric age. Knowledge of the risk factors and the pathogenetic mechanisms, combined with thorough clinical examination, helps to distinguish between dermatological diseases, non-specific vulvitis and vulvovaginitis proper. On the basis of microbiological data, the most common pathogens prove to be Streptococcus pyogenes, Haemophilus influenzae and Enterobius vermicularis; fungal and viral infections are less frequent. The possibility of isolating opportunistic pathogens should also be considered. In rare situations, the isolation of a micro-organism normally transmitted by sexual contact should prompt a careful evaluation of possible sexual abuse. Current treatments for specific and non-specific forms are outlined, together with pointers for the evaluation of recurrence.

Lifetime changes in the vulva and vagina

The morphology and physiology of the vulva and vagina change over a lifetime. The most salient changes are linked to puberty, the menstrual cycle, pregnancy, and menopause. The cutaneous epithelia of the mons pubis, labia, and clitoris originate from the embryonic ectoderm and exhibit a keratinized, stratified structure similar to the skin at other sites. The mucosa of the vulvar vestibule, which originates from the embryonic endoderm, is non-keratinized. The vagina, derived from the embryonic mesoderm, is responsive to estrogen cycling. At birth, the vulva and vagina exhibit the effects of residual maternal estrogens. During puberty, the vulva and vagina acquire mature characteristics in a sequential fashion in response to adrenal and gonadal maturation. A trend to earlier pubertal onset has been observed in Western developed countries. In women of reproductive age, the vaginal mucosa responds to steroid hormone cycling, exhibiting maximal thickness and intracellular glycogen content at mid-cycle. Vulvar skin thickness remains unchanged but menstrual cycle-associated changes in ortho- and parakeratosis occur at the cytological level. The vulva and vagina further adapt to the needs of pregnancy and delivery. After menopause, tissue atrophy ensues. Post-menopausal changes in skin barrier function, skin hydration, and irritant susceptibility have been observed on exposed skin but not on the vulva. Nevertheless, older women with incontinence are at increased risk for developing incontinence dermatitis. A combination of factors, such as tissue atrophy, slower dissipation of excess skin hydration, shear forces associated with limited mobility, and lower tissue regeneration capacity increase the risk of morbidity from incontinence dermatitis in older women.

Vulvovaginitis in prepubertal girls

This retrospective study evaluated the clinical features and findings in bacterial cultures and in microscopic examination of vaginal secretions in 80 prepubertal girls, aged 2-12 years, with vulvovaginitis. Vaginal secretions were obtained directly from the vagina with a sterile catheter carefully inserted into the vagina. Pathogenic bacteria were isolated in 36% of cases. In 59% of these cases the isolated pathogen was group A beta-haemolytic streptococcus. Candida was not found in any of the patients. The finding of leucocytes in vaginal secretions as an indicator for growth of pathogenic bacteria had a sensitivity of 83% and a specificity of 59%. Antimicrobial treatment should therefore be based on bacteriological findings of vaginal secretions and not on the presence of leucocytes alone.

Is antibiotic resistance in cutaneous propionibacteria clinically relevant? : implications of resistance for acne patients and prescribers

It is well recognized that some patients with acne do not respond adequately to antibiotic therapy. It is important to distinguish antibiotic recalcitrant acne which we would suggest represents acne that shows a diminished response to treatment irrespective of the cause as opposed to 'antibiotic-resistant acne' which is acne that is less responsive to treatment as a direct consequence of skin colonization with resistant propionibacteria. Here we show that antibiotic-resistant acne is not just a theoretical possibility but a real phenomenon that could have important consequences for patients and prescribers. The relationship between skin colonization by antibiotic-resistant propionibacteria and treatment outcomes is a complex one that is explained at the follicular level by physiological differences affecting local drug concentrations. A systematic review of the literature on antibiotic-resistant propionibacteria revealed methodological shortcomings in studies of their prevalence and a paucity of evidence on their clinical significance. Despite the elucidation of resistance mechanisms in cutaneous propionibacteria, our continuing inability to distinguish between strains of Propionibacterium acnes means that we still do not fully understand how resistance spreads, although person-to-person transfer is most likely. Finally, we present a decision tree for acne management in an era of prudent antimicrobial prescribing that provides an alternative to existing treatment algorithms by placing topical retinoids and not antibiotics at the cornerstone of acne management.

Premenarchal vaginal discharge: findings of procedures to rule out foreign bodies

STUDY OBJECTIVE

Vaginal discharge in children is a common gynecologic complaint and may be resistant to symptomatic and/or antibiotic treatment. In recurrent or unresponsive patients, an evaluation to rule out a foreign body is traditionally recommended. The objective of this study is to review cases of vaginal discharge referred to our institution and assess outcome and diagnosis in those who required irrigation or vaginoscopy to rule out a foreign body.A retrospective chart review was performed on all premenarchal girls identified through the University of Michigan Pediatric and Adolescent Gynecology Clinic database who were seen for evaluation of vaginal discharge between June 1996 and December 2001. The records were reviewed for age, length of time of discharge, aspects of discharge, procedures done to rule out foreign bodies, and findings of such procedures.

SETTING

The study was performed in a tertiary care university hospital.

PARTICIPANTS

Forty-one premenarchal girls were evaluated for vaginal discharge. The average age was 6.0 yr (range 3 months-11 yr).

RESULTS

The average duration of vaginal discharge prior to presentation was 13.7 months (range 1-42 months). Of the 41 girls, 18 girls underwent 1 procedure each, 2 girls underwent 2 procedures each, and 1 girl underwent 5 procedures. Ten vaginal irrigations in clinic were performed in 7 girls, 3 by the referring physician and 7 by us. These irrigations removed a foreign body (tissue paper) in 4 of 10 (40%) cases, 3 at our institution and 1 at an outside institution. In the three irrigation cases with foreign bodies performed at our institution, the foreign body was visible on genital examination prior to the irrigation. Seventeen vaginoscopies under anesthesia were performed in 16 girls, 5 by the referring physician and 12 by us. In the girls who underwent a vaginoscopy under anesthesia a foreign body was found in 3 of 17 (17.6%). The other findings of the vaginoscopies included: biopsy-proven severe dermatitis with no infection in 1 patient, lymphatic duct chylous drainage in 1 patient, nonspecific vulvovaginitis in 11 patients, and normal exam with eventual diagnosis of malingering in 1 patient. In all cases where a foreign body was identified, the patient presented with bloody or brown discharge.

CONCLUSIONS

Foreign bodies as a cause of persistent vaginal discharge in a tertiary care referral clinic were identified in 4 of 41 girls (9.8%) and 7 of 27 procedures (25.9%). One child had recurrent foreign bodies removed during 4 of 5 procedures for discharge. In children with persistent vaginal discharge, vaginal irrigation was feasible in older children (average age 7.7 yr). However, no foreign bodies were removed by irrigation that had not already been visually identified prior to the procedure. Exam under anesthesia and vaginoscopy allowed the identification of foreign bodies, and it facilitated the diagnosis of other unusual conditions.

Vulvovaginitis: clinical features, aetiology, and microbiology of the genital tract

AIM

To clarify the contribution of clinical and environmental factors and infection to the aetiology of vulvovaginitis in premenarchal girls, and to determine clinical indicators of an infectious cause.

DESIGN

It was necessary first to define normal vaginal flora. Cases were 50 premenarchal girls > 2 years old with symptoms of vulvovaginitis; 50 controls were recruited from girls in the same age group undergoing minor or elective surgery.

RESULTS

Interview questionnaire showed no difference between cases and controls in regards to hygiene practices, exposure to specific irritants, or history of possible sexual abuse. Normal vaginal flora was similar to that described in previous studies, with the exception of organisms likely to be associated with sexual activity. 80% of cases had no evidence of an infectious cause. In the 10 cases in whom an infectious cause was found, there was significantly more visible discharge and distinct redness of the genital area on examination compared with other cases.

CONCLUSIONS

The findings suggest that vulvovaginitis in this age group is not usually infectious or necessarily related to poor hygiene, specific irritants or sexual abuse, although any of these can present with genital irritation. The possibility of sexual abuse should always be considered when a child presents with genital symptoms, but our data indicate it is not a common contributing factor. Infection is generally associated with vaginal discharge and moderate or severe inflammation.

Anogenital skin diseases of childhood

Evaluation of anogenital lesions in children is a challenging problem. The differential diagnosis includes a spectrum of traumatic, infectious, neoplastic, and genetic disorders. The possibility of sexual abuse should always be considered and investigated as indicated. A systematic work-up will expedite the correct diagnosis and limit unnecessary anxiety for parents, children, and physicians. Referral to a center that provides specialized service for the evaluation and treatment of these disorders may be indicated.

Comparison of the vaginal flora in sexually abused and nonabused girls

The presence of sexually transmitted pathogens in the vagina of the sexually abused girl may provide direct evidence of sexual abuse; the presence of other abnormal vaginal organisms may provide indirect evidence of abuse. To identify abnormal vaginal organisms, we prospectively studied the flora of 209 sexually abused girls (cases) and compared it with that in a concurrent control group of 108 girls. Case and control subjects were from the same community, were predominantly white, and 71% of each group were 3 to 10 years of age. The sexually transmitted pathogens (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, herpes simplex virus) were isolated exclusively from the case group at a low frequency (less than 1%). The isolation of Mycoplasma species exclusively in the case group (4%), and of Gardnerella vaginalis in 7% of the case group versus 1% of the control group, suggests that both these organisms may be sexually transmitted. Other bacteria also were collectively more frequent in the case group (16% vs 6%). There may be an association between sexual activity and colonization of the lower genital tract in young girls.