Vulvovaginitis during childhood and adolescence

Prevalence of group B streptococcal colonization in the healthy non-pregnant population: a systematic review and meta-analysis

BACKGROUND

Colonization and transmission precede invasive group B streptococcal (GBS) disease. Data on GBS colonization prevalence, detection methods and risk factors for carriage are relevant for vaccine development and to understand GBS pathogenesis.

OBJECTIVES

To evaluate GBS colonization prevalence after the first week of life in the healthy non-pregnant population.

DATA SOURCES

Pubmed/Medline, Embase, Latin American and Caribbean Health Sciences Literature, World Health Organization Library Information System, and Scopus. Search performed 12 January 2021 with search terms related to 'GBS' and 'colonization, epidemiology, prevalence or screening' without restrictions.

STUDY ELIGIBILITY CRITERIA

All studies that reported prevalence of GBS colonization (any site) in the healthy population.

PARTICIPANTS

All individuals (>6 days of age), with no indication of pregnancy, invasive disease or severe underlying immunological co-morbidities.

METHODS

Logit transformation and a random effects model (DerSimonian and Laird) were used to pool colonization estimates. Subgroup analysis and meta-regression on a priori determined subgroups were performed.

RESULTS

We included 98 studies with 43 112 participants. Our search identified 9309 studies of which 8831 were excluded based on title and abstract and 380 after reading the full text. Colonization rates varied considerably between studies (I² = 97%), which could be partly explained by differences in culture methods (R² = 27%), culture sites (R² = 24%), continent (R² = 10%) and participant's age (R² = 6%). Higher prevalence was found with selective culture methods (19%, 95% CI 16%-23% versus non-selective methods 8%, 95% CI 6%-9%; p < 0.0001). Colonization rates were highest in rectum (19%, 95% CI 15%-24%), vagina (14%, 95% CI 12%-17%) and urethra (9%, 95% CI 5%-18%). In participants with negative rectal cultures, 7% (95% CI 5%-9%) had GBS cultured from another niche. Colonization prevalence was lower in children (6 months to 16 years; 3%, 95% CI 2%-5%) compared with adults (16%, 95% CI 14%-20%; p < 0.0001). Using selective culture methods in adults resulted in a prevalence of 26% (95% CI 19%-33%) rectal, 21% (95% CI 17%-25%) vaginal and 9% (95% CI 6%-14%) urethral colonization.

CONCLUSION

The rectum is the most common body site colonized by GBS. The best approach to screen for any GBS colonization is to screen multiple body sites using selective culture methods.

Microbial ecology of the lower genital tract in women with sexually transmitted diseases

Sexually transmitted diseases (STDs) in women are of great concern to all health-care providers since many of them are preventable and/or treatable conditions which, if left untreated, could have serious sequelae such as pelvic inflammatory disease, infertility, cervical cancer, systemic disease, etc. They may also become a major public health problem when dealing with diseases such as hepatitis, etc., or in people with human immunodeficiency virus. We present here a comprehensive review of the common causes of STDs and their treatment.

Microbiological aspects of vulvovaginitis in prepubertal girls

This study aimed to establish the vaginal introitus microbial flora in girls with and without symptoms of vulvovaginitis, and to present the distribution of isolated microorganisms by age groups in girls with vulvovaginitis. We enrolled 500 girls with vulvovaginitis symptoms, aged 2-12 years, referred by their pediatricians for microbiological examination of the vaginal introitus swabs, and 30 age-matched asymptomatic girls. Similar microbial flora was isolated in both groups, but the symptomatic girls had significantly more common positive microbiological findings compared to controls (p < 0.001). In symptomatic girls, the following pathogenic bacteria were isolated: Streptococcus pyogenes (4.2%), Haemophilus influenzae (0.4%), and Staphylococcus aureus (5.8%). Bacteria of fecal origin were found in vaginal introitus swabs in 33.8% of cases, most commonly Proteus mirabilis (14.4%), Enterococcus faecalis (12.2%), and Escherichia coli (7.0%). The finding of fecal flora was more common compared to controls, reaching a statistical significance (p < 0.05), as well as in girls aged up to 6 years (p < 0.001). Candida species were found in 2.4% of girls with vulvovaginitis symptoms.

CONCLUSION

The microbial ecosystem in girls with clinical signs of vulvovaginitis is complex and variable, and the presence of a microorganism does not necessarily imply that it is the cause of infection. The diagnosis of vulvovaginitis in prepubertal girls requires a complex and comprehensive approach, and microbiological findings should be interpreted in the context of clinical findings.

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.

The role of examination under anesthesia (EUA) and vaginoscopy in pediatric and adolescent gynecology: a retrospective review

BACKGROUND

Examination under anesthesia (EUA) with diagnostic vaginoscopy is an invaluable method in the lower genital tract assessment of pediatric and adolescent females. The literature on this topic remains scarce.

METHODS

This is a retrospective medical notes review of all patients who underwent EUA with or without vaginoscopy over the past 5 years at a pediatric and adolescent gynecology unit specializing in disorders of sex development (DSD).

RESULTS

From 2005 to 2010, 83 patients underwent 92 procedures. All procedures were performed under general anesthesia, and a 3-mm pediatric cystoscope was used for vaginoscopy. Of the 92 cases, 33 (36%) were EUA alone and 59 (64%) consisted of a combined EUA and vaginoscopy. The mean age was 13.3 ± 3.7 years. The most common indications included assessment for reconstructive surgery (33.7%), vaginal stenosis (21.7%), vaginal discharge (19.6%), vaginal bleeding (16.3%), and pelvic pain (8.7%). Most (61%) of those presenting for assessment for reconstructive surgery had a DSD and history of surgical correction in early childhood. In 88 cases (96%), the evaluation was satisfactory and a diagnosis was reached or normality confirmed. Four cases (4%) required further investigation. No significant intraoperative or postoperative complications were encountered. Of the 92 cases, 15 (16%) required a further minor procedure, which was performed at the time of the EUA/vaginoscopy. Another 33 (36%) required further major surgery, which was performed at a later date.

CONCLUSION

EUA/vaginoscopy is a safe and highly useful method in the assessment of the lower genital tract in pediatric and adolescent patients.

Perfil clínico-epidemiológico das doenças sexualmente transmissíveis em crianças atendidas em um centro de referência na cidade de Manaus, Amazonas, Brasil

FUNDAMENTOS: Doenças Sexualmente Transmissíveis em crianças permanecem um problema de saúde pública pouco estudado, sendo ainda necessários esclarecimentos sobre seu manejo e a relação destas com o abuso sexual infantil. OBJETIVOS: Descrever o perfil clínico-epidemiológico das Doenças Sexualmente Transmissíveis em crianças atendidas em centro de referência na cidade de Manaus. MÉTODOS: Realizou-se estudo descritivo exploratório para verificar características clínicas, epidemiológicas e laboratoriais das Doenças Sexualmente Transmissíveis em crianças atendidas durante o período de janeiro/2003 a dezembro/2007. RESULTADOS: Foram incluídas no estudo 182 crianças que apresentavam DST. A maioria era do sexo feminino (65,4%) e de cor parda; a média de idade foi de 8,5 anos; 89% eram procedentes da cidade de Manaus; os pais foram os principais acompanhantes na consulta; verruga genital foi o principal diagnóstico em ambos os sexos; e, 90,1% apresentavam apenas uma DST. CONCLUSÃO: As frequências e características clínicas das DST nas crianças do estudo não diferiram do encontrado na literatura. Embora, com base em sinais e sintomas referentes tão somente às DST nas crianças, não se tenham parâmetros fidedignos de confirmação de abuso, deve-se sempre estar alerta para esta possibilidade, visto que estas doenças podem ser sinalizadoras de ofensas sexuais, por vezes, dissimuladas e repetidas.

Chronic vulvitis in pre-pubertal girls

Pre-pubertal girls with inflammatory chronic vulval disease excluding lichen sclerosus are often described as having 'non-specific vulvovaginitis'. The aim of this retrospective case series was to determine the aetiology of chronic vulvovaginitis in pre-pubertal (Tanner Stage 1) girls, with particular reference to candidiasis. A chart review recorded and compared the characteristics of 38 girls and 68 post-menarchal adolescents and pre-menopausal women with chronic vulvitis. Nineteen (50%) of the pre-pubertal children had been previously diagnosed with candidiasis and 21 (55%) had been treated unsuccessfully with topical antifungal agents. Candida albicans was isolated in two (5%) of the children and 37 (54%) of the adults (P < 0.001). A positive Candida culture was causally associated with chronic vulvovaginitis in 50% of the adults but in none of the children (P < 0.001). In 28 (74%) of the children and 28 (41%) of the adults, no pathogens were isolated on microbiological testing. General skin examination of the girls revealed signs of psoriasis in 27 (71%) and atopic dermatitis in nine (24%). Symptoms were controlled with topical anti-inflammatory treatment and environmental modification, including cessation of topical antifungals. Pre-pubertal girls with chronic vulvitis are likely to have either psoriasis or atopic dermatitis. Chronic vulvovaginal candidiasis is not seen in Tanner Stage 1 girls.

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.

Cutaneous mimickers of child abuse: a primer for pediatricians

The annual incidence of child abuse was estimated to be 2.8 million by the national incidence study conducted in the USA in 1993, which is a two-fold increase compared to 1986. Awareness of child abuse has been increasing since the 1960s. Although most victims of child abuse present with cutaneous lesions, many genuine skin diseases may appear as non-accidental injuries which, if not recognized, may lead to misdiagnosis of child abuse. Here, we review the most common cutaneous mimickers of child abuse in order to increase awareness of these disorders and reduce erroneous diagnosis of child abuse.

Premenarchal, recurrent vaginal discharge associated with an incomplete obstructing longitudinal vaginal septum

STUDY OBJECTIVE

To describe an unusual, premenarchal presentation of an obstructive vaginal anomaly.

DESIGN

Case Report.

SETTING

University Medical Center.

PARTICIPANTS

Premenarchal subject

INTERVENTIONS

Vaginogram, vaginal septum resection.

RESULTS

Vaginal septum resection with resolution of vaginal discharge.

CONCLUSIONS

This case demonstrates some of the typical features of uterus didelphys bicollis with incomplete obstructing hemivagina, but had a unique presentation with premenarchal, recurrent vaginal discharge. Typically, patients with an obstructing mullerian anomaly present after menarche with pelvic pain and a mass. The vaginogram assists in the preoperative definition of abnormal anatomy which allows the surgeon to develop the most appropriate surgical approach. Resection of this incompletely obstructing vaginal septum resulted in resolution of the recurrent vaginal discharge.

Group B streptococcal vaginitis in postpubertal adolescent girls

PURPOSE

The purpose of this study was to explore the clinical findings, diagnosis, and treatment of group B streptococcal (GBS) vulvovaginitis in a sample of adolescent girls and young women found to have this condition.

METHODS

Descriptive retrospective analysis of charts of 13 adolescent girls and young women found to have GBS vulvovaginitis was performed.

RESULTS

Of the girls and young women with GBS vulvovaginitis, almost all were found to have a purulent vaginal discharge (n = 12). Three had frank cervicitis and/or vaginitis on examination. Only 1 was diagnosed accurately with GBS vulvovaginitis at the time of the visit and 4 were treated with appropriate antibiotics at the time of the visit.

CONCLUSIONS

GBS vulvovaginitis is a poorly diagnosed disease entity in the adolescent and young adult population. Further study is needed in the epidemiology of GBS vaginitis in postpubertal adolescent girls and women to improve the recognition, pathogenesis, and treatment of GBS vaginitis.

Vulvovaginal candidiasis in children and adolescents with type 1 diabetes mellitus

In this prospective study we investigated the frequency of vulvovaginal candidiasis, the results of yeast cultures and detection of ketoconazole resistance in female children and adolescents with type 1 diabetes mellitus (DM1). The study consisted of 35 patients with DM1 (age 1.7-20 years) and 22 controls (age 1.5-18 years). Age, duration of DM1 and evidence of genital symptoms were recorded initially. After a pelvic examination, two separate swabs and samples for blood glucose and hemoglobin A1c (HbA1c) were taken. One of the swabs was used for direct examination and the second was placed on Sabouraud's dextrose agar and incubated. In vitro susceptibility of Candida species to ketoconazole was established by using Etest (AB B1ODISC). Candida species were isolated in 32 of 61 (52.5%) swabs of patients with DM1 and five of 22 (18.2%) of the control group. The predominant Candida species isolated from patients with DM1 were C. albicans (72.7%), C. glabrata (22.7%), C. tropicalis (2.3%), and C. parapsilosis (2.3%). The mean HbA1c in diabetic patients from whom Candida species were isolated was significantly higher than that of patients without Candida infection (p = 0.002). Most of the C. glabrata isolates were significantly resistant to ketoconazole. During the follow-up of patients with DM1, genital candidiasis is generally overlooked. It should not be forgotten that species other than C. albicans might cause genital candidiasis.

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.

[Prevalence of vaginal candidiasis in a low-risk obstetric population in Santander]

OBJECTIVES

To find the prevalence of vaginal candidiasis in pregnant women monitored through primary care and to see whether it is on the increase.

DESIGN

Descriptive and retrospective study of pregnant women.

SETTING

Cazoña Health District (34,783 inhabitants).

SUBJECTS

The entire obstetric population monitored by our health centre between 1992 and 1997 inclusive.

MEASUREMENTS AND RESULTS

Retrospective study of clinical histories of all the pregnant women seen at our health centre (878 pregnancies). After discounting those referred to obstetricians, abortions/miscarriages and premature births, 549 normal low-risk pregnancies (62.30% of the total) were monitored to completion in primary care. The women's age range was 16 to 40. The mean prevalence of candidiasis was 18% (CI, 15.0-21.6). Its frequency increased as the number of pregnancies increased and dropped as the age of the pregnant women increased.

CONCLUSIONS

Prevalence found in our study was 18% and did not increase as the years passed.

Combined oral and vaginal treatment of severe vulvovaginitis during childhood

STUDY OBJECTIVE

To evaluate the efficacy and safety of combined oral and vaginal administration of antibiotics.

DESIGN

Treatment and follow-up examination of 54 cases of severe vulvovaginitis.

SETTING

Division of Pediatric and Adolescent' Gynecology, Second Department of Obstetrics and Gynecology, University of Athens, Greece.

PARTICIPANTS

Girls aged 1-10 years seen at the clinic of the above-listed institution.

INTERVENTIONS

Vaginal application of antibiotics.

MAIN OUTCOME MEASURES

Vaginal culture and vaginoscopy.

RESULTS

Treatment achieved microbial eradication in 51 of 54 patients (94%). In most patients, relief of symptoms was achieved after 2-3 days. No adverse effects were reported.

CONCLUSIONS

Treatment was highly effective and simple to administer, and no complications were observed. A further advantage of this approach is the shorter duration of treatment.