Premenarchal vulvovaginitis

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.

Genital bleeding in premenarcheal children

OBJECTIVE

The earlier occurrence of secondary sexual development and the advance in diagnostic techniques prompted us to review our recent experience with genital bleeding in childhood.

METHOD

We analyzed data for all patients aged less than 10 years who were referred to Gifu University School of Medicine-affiliated hospitals from 1984 through 1993.

RESULTS

From a total of 330 girls, 62 (approximately 20%) complained of genital bleeding. The patients were distributed equally between 0 and 10 years of age. In 46 of 62 patients (74%), bleeding resulted from a local lesion of the vagina: 28 due to vulvovaginitis, six to urethral prolapse, six to trauma, three to foreign bodies and three to vaginal tumors. Malignant vaginal tumors were seen in two patients: sarcoma botryoides and endodermal sinus tumor. Both were diagnosed by histopathological examination of an exophytic vaginal tumor, with several weeks' interval from the initial episode of bleeding to diagnosis. The remaining 16 patients (26%), with no demonstrable local lesions, bled as a result of some form of precocious puberty. In six patients, precocious puberty was secondary to a hormonally active ovarian tumor, five of these patients also experiencing advanced breast development. Routine ultrasound and hormonal evaluations promptly detected the presence of tumor. None of three patients with idiopathic precocious puberty presented with secondary sexual development. No specific etiology was established in seven patients.

CONCLUSION

Genital bleeding alerts us to the possibility, though rare, of a genital tract tumor. Prompt and precise detection may lead to cure and preservation of future fertility.

Sexually transmitted diseases and child abuse

The diagnosis in a child of any infection that is usually sexually transmitted in adults should raise the suspicion of possible sexual abuse. We know sexual abuse is a common childhood experience. The American Academy of Pediatrics Committee on Child Abuse and Neglect has rated the implications of sexually transmitted diseases for diagnosing sexual abuse (Table 6).

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

In a prospective clinical and microbiological study covering 67 prepubertal children the vaginal flora of 31 asymptomatic children was compared to 36 children suffering from abnormal vaginal discharge and/or vulvovaginitis. Vaginoscopy was employed to obtain bacteriological specimens without contamination. Swabs were inoculated into prereduced transportmedia (PORT A CUL, BBL) and cultured aerobically and anaerobically. The most prevalent aerobic organisms were Staphylococcus epidermidis. Enterococci and Escherichia coli; the predominant anaerobic bacteria were Peptococcus and Peptostreptococcus, Veillonella parvula, Eubacteria, Propionibacterium and Bacteroides species. A similar microbiological pattern was found in both groups, although anaerobes, like Peptococci and Peptostreptococci and Bacteroides species, as well as yeasts, like Candida albicans were significantly more frequent in the group with signs and symptoms. Lactobacilli were less common in this group.