Vulvovaginitis in children

Vulvovaginitis is inflammation or irritation of the delicate skin of the vagina and vulva (external female genital area) ¹⁾. The vulva is the outside area of the female genitals; the vagina connects the vulva and the uterus. Mild vulvovaginitis is the most common gynecological problem in prepubertal girls, and some children will have vulvovaginitis many times ²⁾. Once puberty has begun, vulvovaginitis usually occurs less often.

The most common symptoms and signs of vulvovaginitis include itchiness (pruritus), soreness, burning, painful urination (dysuria), redness (erythema), whitish discharge (leucorrhea) and swelling (edema) ³⁾. Sometimes children with vulvovaginitis have a slight discharge from the vagina, which will stain the underpants and produce a strong odor.

Parents often first become aware of the problem when their child complains about the redness and soreness of the skin, which is the most common sign of vulvovaginitis.

Most often, vulvovaginitis is caused when the vulvar and vaginal skin become irritated. This irritation can be caused by the use of products that are too strong for the delicate vulvar skin, clothing that rubs, dampness and less commonly, a skin or vaginal infection. The prevalence of non-specific vulvovaginitis ranges between 25% and 75% of cases in prepubertal girls ⁴⁾. Interestingly, a high percentage of non-specific vulvovaginitis cases are recurrent ⁵⁾. Vulvovaginitis is can be caused by either a pathogenic infection (including intestinal parasites, respiratory streptococci and Candida secies) or by a non-specific cause, such as trauma, skin problems such as eczema or congenital disorders ⁶⁾.

Vulvovaginitis can also be caused by sexual abuse. Vulvovaginitis may result from several of these causes at the same time.

In most cases, vulvovaginitis is not a serious problem and it will usually improve with simple steps at home. Usually no medical treatment or tests are needed.

Some hygienic sanitary measures are fundamental in the management of non-specific vulvovaginitis, such as avoiding wet clothing (in contact with the genital area) for long periods and avoiding the use of tight-fitting and synthetic clothing ⁷⁾. While the use of cotton underwear and adequate cleansing of the body with warm water and soap, excluding the genital area, are recommended ⁸⁾.

Vulvovaginitis toddler key points to remember:

• Mild vulvovaginitis is a very common problem in prepubertal girls ⁹⁾.
• It may recur now and then, but will improve as your child gets older.
• In most mild cases, no medical treatment or tests are necessary.
• Avoid the things that make vulvovaginitis worse, such as tight underwear and irritants like soap.

Figure 1. Pediatric vulvovaginitis

Footnote: Vulvovaginitis is an irritation of the skin in the vulvar and vaginal area. It causes soreness, itching, burning and can be seen as red and irritated skin.

Vulvovaginitis toddler causes

While your child is young, the lining of her vagina and vulva can be quite thin and this can lead to it being easily irritated. Moisture or dampness around the vulva can also lead to vulvovaginitis – this is made worse by tight clothing or being overweight. Another cause of vulvovaginitis is irritants, such as soap residue, bubble baths and antiseptics.

Microorganisms, isolated from vaginal smears, were detected in 48.9% of the patients. Escherichia coli was shown in the urine culture of 3 patients with vulvovaginitis (6.70%). In microscopic stool analysis parasites were detected (45.9%). Scientists found some relevant personal hygiene factors, such as wiping back to front (42.9%), cleaning by herself after defecation (89.3%), using toilet paper (60.7%) and wet wipes (21.4%), and bathing standing (14.3%) and sitting (46.4%) among patients ¹⁰⁾. They also showed that the children wore tight clothing (35.7%).

The findings from this study ¹¹⁾ suggest that vulvovaginitis in prepubertal girls is related not only to microorganisms but also poor personal hygiene, the educational status of mothers, and specific irritants.

Factors associated with the risk of vulvovaginitis include a hypoestrogenized vaginal mucosa in a preadolescent girl, lack of development of the labia minora, close proximity of the vagina to the anus, poor hygiene, tight-fitting clothing or the use of shampoos or soaps ¹²⁾. The hypoestrogenic hormonal milieu in a preadolescent girl is a major factor in making her vaginal mucosa susceptible to infection ¹³⁾.

Pinworms or threadworms sometimes cause or worsen vulvovaginitis. Pinworm infection is caused by a small, thin, white roundworm called Enterobius vermicularis ¹⁴⁾. Children with pinworms often scratch a lot at night. If itching is a major symptom, then you may want to treat your child for pinworms (threadworms).

The medications used for the treatment of pinworm are either mebendazole, pyrantel pamoate, or albendazole. Any of these drugs are given in one dose initially, and then another single dose of the same drug two weeks later. Pyrantel pamoate is available without prescription. The medication does not reliably kill pinworm eggs. Therefore, the second dose is to prevent re-infection by adult worms that hatch from any eggs not killed by the first treatment. Health practitioners and parents should weigh the health risks and benefits of these drugs for patients under 2 years of age.

Repeated infections should be treated by the same method as the first infection. In households where more than one member is infected or where repeated, symptomatic infections occur, it is recommended that all household members be treated at the same time. In institutions, mass and simultaneous treatment, repeated in 2 weeks, can be effective.

Skin in the vaginal area changes over time

In young children, before puberty, the skin in the vaginal area is thin and delicate. This delicate skin is easily irritated. When they grow and begin to produce their own sex hormones, pubic hair and thickened skin will develop and protect the vaginal area. Normal vulvar skin should not look reddish or raw.

Activities and clothing

Many normal things children do can irritate the skin around the vagina. For example, playing in sandboxes or on slides and teeter-totters, and wearing wet clothes, bathing suits or tight ballet leotards can irritate the skin.

Sometimes chidren wait too long to go to the bathroom

Children who are playing often forget to go to the bathroom until the last minute. Sometimes they do not wipe themselves properly. When this happens, bacteria from the anus can get into the vagina. Dirty underwear can also bring bacteria into contact with the vagina and the surrounding skin. Most children will not wash their vaginal area at bath time. Children need to be helped with bathing so they clean themselves properly.

Other problems: soaps and the weather

• Soaps, bubble baths and perfumes can irritate a child’s skin. Strong laundry detergents and fabric softeners can also be a source of irritation.
• Dry winter air can be irritating to the skin.
• Heat and humidity can also irritate the skin, especially if combined with wet bathing suits or tight clothing.

Vulvovaginitis toddler prevention

Things your child can do to treat and avoid vulvovaginitis:

• Take sitz baths twice a day when the skin is irritated.
• Do not use soaps in the vulvar region. It is best to clean with warm water on a soft face cloth. No bubble baths.
• Use gentle detergent on the underwear and do not use fabric softener.
• If the skin is very sore, try using cotton balls with mineral oil after a bowel movement instead of toilet paper.
• Do not wear underwear to bed.
• Do not wear tight clothing such as pantyhose, tight pants or leotards.
• Change out of wet bathing suits or any other wet clothing as soon as possible.
• Girls who are menstruating should not use perfumed tampons or pads.
• Do not use topical medications, or topical antibiotic ointments or feminine hygiene sprays.
• Use petroleum jelly or zinc oxide diaper cream on the area. It can be soothing and is harmless.

Vulvovaginitis toddler symptoms

If your child has vulvovaginitis, she may have:

• itching in the vaginal area
• some discharge from the vagina
• redness of the skin between the labia majora (outside lips of the vagina)
• burning or stinging when she passes urine.

The most common symptoms among the patients were vaginal discharge (44.4%), vulvar erythema (37.8%), and vaginal itch (24.4%) ¹⁵⁾.

Vulvovaginitis toddler diagnosis

If your child develops skin irritation in the vaginal area, develops an odor in the area or has discharge from the vagina, she should see her health-care provider. The diagnosis of vulvovaginitis in toddler gir is clinical and is mainly based on an adequate history and physical examination ¹⁶⁾.

Depending on the problem and how severe the symptoms are, your doctor may refer them to a gynecology clinic.

The gynecologist will ask questions about your child’s health and do a physical examination. The doctor will want to make sure that there is no infection or skin problem that needs treatment. Sometimes, a small vaginal swab will be taken to look for infection. If there has been any bleeding, the doctor may need to examine further.

The doctor will also ask questions and examine your child to make sure that they have not been subject to any sexual abuse. Tell your child what the examination is about, using words they can understand. The goal is to let your child feel comfortable with the examination and make sure they do not have a painful or frightening experience.

After the examination, the doctor will tell you what the best treatment is. Whatever treatment is recommended, there will be some things that you can do to help at home.

Vulvovaginitis toddler treatment

The treatment of vulvovaginitis will depend on the cause of the irritation. Usually, the irritation comes from hygiene measures. It may be that your child is not cleaning themselves well enough. It is important to remember that the most common cause of vaginal discharge in children with vulvovaginitis is skin irritation. It is rare to find an infection. If there is an infection, it can be treated with antibiotics or antifungals.

In most mild cases of vulvovaginitis, you can care for your child at home without visiting a doctor. Reassure your child that they don’t need to worry, as vulvovaginitis is a common problem and a normal part of growing up.

You can help your child by starting some simple habits and routines. Because your child’s skin is so delicate, anything you can do to help keep the vaginal area clean, dry and healthy will help. Here are some of the things you can do.

Try avoiding the things that make vulvovaginitis worse:

• Wear loose cotton underwear and avoid tight jeans etc.
• If your child is overweight, seek advice on how to maintain a healthy weight with diet and exercise.
• Don’t use a lot of soap in the bath or shower, and make sure any soap is well rinsed from the vulva. Avoid bubble baths and antibacterial products.

Some parents find vinegar baths helpful: add half a cup of white vinegar to a shallow bath and soak for 10 to 15 minutes. Do this daily for a few days and see if it helps.

Soothing creams (for example, soft paraffin, nappy-rash creams) may help settle the soreness, as well as protect the skin from moisture or any discharge, which can be irritating.

You may have to repeat these simple measures if the problem comes back.

Clean and dry underwear and clothes

Make sure your child changes into clean underwear often, especially if their underwear has gotten dirty. Try to have your child change their underwear more than once a day. White cotton underwear are best. Your child should change out of wet or tight-fitting clothing as soon as possible. Encourage your child to not wear underwear at night.

Do not use pantiliners to contain vaginal discharge as this will actually increase symptoms. It is better to make sure your child changes their underwear often.

Wiping properly after the bathroom

Make sure your child knows how to clean themselves well after using the toilet. This is a particular problem for parents whose children go to daycare or to babysitters, because the parents are not there to help their child. Children should wipe themselves from front to back. Use only white toilet paper. Many children can clean themselves better with alcohol- and perfume-free wet wipes. These wipes are easier on the skin than dry toilet paper. A little packet of wet wipes tucked into your child’s things when they go off to daycare may be helpful.

Bathing

If using wet wipes does not solve the problem, have your child take a shallow sitz bath when they get home to make sure that they are nice and clean. A sitz bath is a small tub that can be placed on the toilet and filled with warm water to soak the vulvar region. You can purchase a sitz bath at most drug stores. Do not use soaps, bubble baths or perfumed products on your child. When they have signs of vulvovaginitis, it is a good idea to have your child bathe two to three times a day. Adding non-allergenic skin softeners to the water will help soften and soothe the vulvar skin. You can consider applying a barrier cream such as petroleum jelly or a zinc oxide after bathing to help soothe the skin.

Encourage your childr not to scratch their bottom because scratching can cause more irritation and infection.

After a bath

After the bath, gently blot or pat dry the child’s vaginal area. Do not use scratchy towels or rub the skin too hard. You may find it helpful to use a hairdryer on a low, cool setting to dry the area gently. It is all right for the child to run around the house wearing skirts or loose shorts without underwear to let the air reach their bottom.

A good daily hygiene routine

Your child needs to learn how to take care of their vaginal area. It is an important part of their body that needs special cleaning, just as their teeth need special care. If creams have been recommended, your child can learn how to put their own cream on. They can learn to wash their hands before and after and use a hand mirror so that they can put the cream exactly where it is needed. In this way, your child will learn that this is their body and they have a responsibility to care for it.

Vulvovaginitis prognosis

Vulvovaginitis often comes back. About half the girls who have vulvovaginitis will have it more than once during their childhood. It usually gets better as girls grow up, and will not cause them any long-term harm.

If the irritation comes back, begin strict hygiene measures again. Your child may need to be seen at the clinic again. Sometimes, if the inflammation comes back it may be caused by something different.

The better your child gets at being clean and dry, the less likely they are to get vulvovaginitis again.

If your child has any pain or bleeding, see your health-care provider.