Vaginal Discharge in the Prepubertal

n

Sandra

L. Elvik,

Girl .

MS, RN, CPNP

Vaginal discharges are commonly seen in the prepubertal girl. Because of the anatomy of young girls, any offending agents have easy access to the genital area. The discharge can be caused by numerous organisms, including those associated with sexually transmitted diseases. Also, chemical and mechanical reactions, as well as poor hygiene on the part of the child, may cause genital irritation. Treatment is based on the historical events and a physical examination that includes cultures of the discharge. The goal is to effectively treat the underlying cause of the discharge, either by initiating proper therapeutic measures or by teaching the child about proper hygiene. J PEDIATR HEALTH CARE. (1990). 4, 181-185.

A

vaginal discharge in the prepubertal girl can be disturbing to a parent, especially with the number of child sexual abuse cases reported by the media. Although molestation and sexually transmitted diseases may cause a vaginal discharge, there are many other reasons for a vulvovaginitis, with or without a discharge, in this age-group. n

ANATOMIC

CONSIDERATIONS

Vulvovaginitis, along with an accompanying discharge, is the most common gynecologic complaint among prepubertal girls. The girl usually has a primary vulvitis. This is different from adolescents and adult women whose problem begins primarily with an infection of the vagina and cervix (Altcheck, 1984; Arsenault & Gerbie, 1986; Williams, Callen, & Owen, 1986). Several anatomic factors predispose a girl to genital irritation. The prepubertal girl does not have labial fat pads or pubic hair as does the older girl and woman. This leaves the vulva virtually unprotected from offending agents. The labia minora of the girl are small, and they open whenever the child is in a squatting position, again exposing the vulvar structures to insult @check, 1984). Also the anus is closer to the vagina in a young girl, and many girls in this age-group have poor hygienic practices (Arsenault & Gerbie, 1986). n

ETIOLOCIC

T

he second time a physiologic discharge occurs is approximately to 1 year before menarche.

vaginal 6 months

AGENTS

There are two times when a vaginal discharge is considered to be physiologic. The first instance is at birth,

Sandra L. Elvik is medical coordinator of the Family and Child Advocate Team at Harbor/UCLA Medical Center in Torrance, California. Reprint requests: Sandra L. Elvik, CPNP, Medical Coordinator, Family and Child Advocate Team, Harbor/UCLA Medical Center, 1000 W. Carson St., BIN 437, Torrance, CA 90509. 25/1115023

JOURNAL

when maternal estrogens stimulate the vaginal mucosa of the infant, resulting in a thick, mucoid discharge. The discharge may become slightly tinged with blood several days after birth. Many new mothers become alarmed by this phenomenon and often will call the practitioner for advice. Within 7 to 10 days after birth this physiologic leukorrhea of the newborn will disappear (Arsenault & Gerbie, 1986). The second time a physiologic vaginal discharge occurs is approximately 6 months to 1 year before menarche. The leukorrhea is nonirritating, is white to gray, does not have an odor, and may be pasty in consistency @check, 1984). Yeast infections are less common in children than in adolescents and adult women and often are associated with antibiotic use, diabetes mellitus, or an immunodeficiency (Altcheck, 1981). Yeasts such as Candida dbicans can cause intense pruritis and erythema of the genitalia. In addition, the hymen and labia become sensitive to the touch, and there is an occasional milky white discharge. Cultures may be negative even with these symptoms.

OF PEDIATRIC

HEALTH

CARE

The Enterobius vermicula~ (pinworm) may cause an extreme vulvovaginitis with a discharge in 20% of girls who have infestation of the rectum (Williams et al. 1986). This occurs when the female parasite leaves the anus at night to deposit eggs on the surface of the perineum. There is usually an associated anal pruritis, which is increased at night. A vaginal foreign body causes a persistent, purulent, brownish discharge with a foul odor (Wil181

182

Elvik

-HISTOEK2?+L ITEMS lEELATED TO VAGINAL n Onset of discharge . Is discharge continuous or sporadic? w Related symptoms: dysuria, vaginal itching n Color . Consistency n Amount, whether profuse or scant n Presenceor absenceof odor . Brand of soap or detergents used; any recent change of products . Frequency of bubble bath . Use of nylon underwear, tight-fitting slacks = Direction of wiping after bowel movements n Possibility of sexual abuse ---~-__-.--.

.-

I / / 8

i I I 1 I

to a vaginal discharge include those caused bv CXh mydia t~$~tis and the herpes simplex \nus (HSV) . Although the discharge may be clear to wh ire or yellow, many children mav be asymptomatic cxcept for the lesions of HSV. . There are a number of chemical and mechanical reactions from such things as soap, laundrv detergents, bubble bath, sand, tight-fitting slacks’and nylon underpants that can give a child a vaginal discharge. Depending on the girl, anv or all of these things can lead to a localized inflammation, pruritis, and discharge that is slight in amount and variable in color (Altcheck, 1984). m HISTORICAL CONSIDERATIONS

~.

liams et al., 1986). The most common foreign body in this age-group is bits of toilet paper deposited in the vagina when the child wipes herself, often vigorously, after urinating. The discharge occasionally can be blood tinged, which causes major concern for the parents. A vulvovaginitis that is acute, usually with a greenish discharge, can develop in the child who has an infection with a specific bacterial agent in such areas as the ear, skin, urinary tract, and pharynx. Commonly seen organisms are group A, @hemolytic Streptowccus, pneumococcus, and meningococcus. The exact mechanism of infection to the genital area is unknown, although the girl may autoinoculate herself with the organism (Altcheck, 1984). Sexually transmitted diseases can give a child a vulvovaginitis with a discharge. Nei;rseriagonorrhoeae often leads to a severe infection with genital swelling, dysuria, and an often profuse, thick green discharge (Altcheck, 1984). Although symptoms usually appear within a week of exposure, some children may be asymptomatic for up to 6 months. Trichomoniasis is a rare cause of pediatric vaginitis because the organism prefers the moist, estrogen-rich vagina of the postpubertal woman (Altcheck, 198 1) It is thought to occur in 3% to 5% of girls, but it is not an organism commonly considered in a prepubescent girl. The discharge may be green and rnalodorous, but it is more watery in consistency than a gonorrheal infection. Microscopically, one is able to see motile trichomonads. Gardnerella vqgindli, or nonspecific vaginitis, is also rare in children (Bump, Sachs, & Buesching, 1986). The discharge is watery, adherent, and graywhite. Other sexually transmitted diseases that may lead

The caretaker and, if possible, the child should be questioned regarding the vaginal discharge and related symptoms (see boxed material). The practitioner would want to know the onset, color, and consistency of the discharge, as well as the presence of an odor. Sexually transmitted diseases can be malodorous as can a vaginal foreign body. The brands of detergents, soaps, and lotions are important to identify, especially if the family is using a new product. Frequent use of bubble bath may affect the girl’s genital structures. Some children arc extremely sensitive to the blue or green deodorant soaps, and their use can cause a vaginal discharge. Vaginal and anal pruritus, especially at night, is notable. This is a frequent complaint with pinworm infestation. It is also common to hear of vaginal itching when a child has a candidal infection. The nurse practitioner should ask about rcccnt infections such as otitis media or streptococcus pharyngitis and about the use of systemic antibiotics. In addition to the possibility of autoinoculation of an infecting organism into the genital area, use of antibiotics suppresses normal vaginal flora. This can lead to the overgrowth of yeasts and a resulting candidiasis.

F

requent use of bubble girl’s genital structures.

bath

may affect

the

The child’s hygiene patterns are important in prcvention of a discharge. Therefore the practitioner would want this information, especially the direction a child wipes herself after a bowel movement. The issue of sexual abuse should be addressed in a sensitive manner to both the caretaker and the girl. The practitioner can ask if the parent is concerned that the discharge is related to someone “touching”

Journal of Pediatric Health

the child’s genital area. On the basis of the answer, more specific questions relative to molestation can be asked of the child and parent separately. . PHYSICAL EXAMINATION

When there is a history of vaginal discharge, an examination of the child’s external genital and anal regions should be performed. Most likely the discharge is due to a primary vulvitis, in which case the genital structures may appear inflamed and there is no need to visualize the cervix. Therefore a speculum is not used to assess a prepubertal child. In cases of suspected vaginal trauma the girl should be referred for a gynecologic examination under anesthesia. The physical examination includes patient preparation. One approach to the procedure is a statement such as, “I need to look at your private area [or another word the girl uses for genitalia] to make sure everything is O.K.” A complete head-to-toe examination may further calm the child; however, small girls of 18 months to 2% years may view the entire assessment as intrusive and protest loudly. The preferred position is a modified lithotomy, or “frog leg,” position. This is accomplished by placing the girl on her back with her legs apart. The labia majora are separated gently to allow observation of the hymen and vaginal opening. If the girl has a vulvitis and discharge, the hymen may appear normal because of the genital edema common during an infection. --~___-

The issue of sexual abuse should

be addressed in a sensitive manner to both the caretaker and the girl.

The practitioner who suspects sexual abuse will of course report it to the authorities. An acute infection, however, should be treated and resolved before the diagnosis of molestation is confirmed by physical examination (Elvik, 1987). The external genital structures can change dramatically once the swelling of an acute infection is gone, and the practitioner may see many abnormalities that initially were not visible. n

Vaginal

Care

MANAGEMENT

Any girl with a vaginal discharge should have cultures done to determine if a specific organism is involved. Swabs of the discharge should be cultured for (a) Netis& Bonorrboeae by means of Thayer-Martin agar, (b) Chlam~&~ tracbmtk, and (c) general sensitivity. The chlamydia antigen detection tests such as Microtrak (Syva Co., Palo Alto, Calif.) or Chla-

Discharge

183

mydiazyme (Abbott Laboratories, Abbott Park, Ill.) are not recommended for use in children, because these tests have been shown to yield false positive results (Hammers&lag, Retig, & Shields, 1988). Depending on the equipment available, a wet mount slide may assist the practitioner in determining how to manage a child’s vaginal discharge. The slide, which is made by mixing equal parts of discharge and normal saline, should first be examined for trichomonads under the microscope. One then may look for “clue cells,” that is, bacteria coated with epithelial cells, which provides the diagnosis for Gardnerella vq+nitk

The addition of one drop of 10% potassium hydroxide (KOH) solution to the wet mount slide may release a charcteristically fishy odor (“whiff test”) in the presence of Gardnerella. KOH also will dissolve remaining cellular elements on the wet mount slide and will allow observation of the hyphae of Candidu albicans. Although cultures are available for Gardnerella organisms, they are expensive and are not routinely done.

A

ny girl with a vaginal discharge should have cultures done to determine if a specific organism is involved.

A pediatric Gardnerella infection has not been observed to date. However, given the presence of these organisms in a sexually active population, the diagnosis of Gardnerella vu&auk or trichomonal, chlamydial, or gonorrheal infections must be reported to the authorities as suspicous for sexual abuse. Protection of the child must be a high priority in the mind of the practitioner. Once the case has been reported, safety of the child is under the jurisdiction of the legal system. The child and family should be referred for counseling. In addition, recultures are needed 7 to 10 days after the medication course is completed to ensure adequate treatment of the infection. This should be stressed to the authorities at the time of reporting because the child may be placed in a foster home a great distance from where the examination occurred. Treatment of the child with a sexually transmitted disease depends on the culture results. Recommended therapy is as follows: . Gonomhea. Ceftriaxone-125 mg, intramuscularly, if the child is 100 pounds Cblmydia. Erythromycin-30-50 mglkglday orally for 7 days n

184

Elvik

e

FIGURE

I Thick,

profuse,

. Ttichomonimis vaginalis. Metronidazole-250 mg, three times a day orally for 7 days m Gardnerella vaginah. Metronidazolc-500 mg, two times a day for 5 to 7 days (U.S. Department of Health and Human Services. 1985) In cases of vaginal discharge that are not related to sexually transmitted diseases, the vaginal culture that grows mixed bacteria such as EnteTococcusspecies ~dEschicbia coli has different antibiotic sensitivities and generally is not treated with systemic antibiotics. Treatment is required if the vaginal cultures grow such organisms as group A p-hemolytic Streptococcus, S&ella-Salmonella, or Staphylowccus aureus in toxic shock syndrome (Altcheck, 1984). A test for pinworms should be obtained if the girl has vaginal or anal itching that increases at night. The child can be treated with a single dose of mebendazole (Vermox), 100 mg orally, although this medication has not been studied effectively in children younger than 2 years of age, and it should be used with caution in this age-group. These children may be treated on the basis of history and clinical findings while awaiting test results. Girls with clinical symptoms of yeast infection, regardless of cultures, also may be treated. Treatment consists of sitz baths and topical antifungal cream such as miconazole (Monistat) twice daily for 7 to 10 days. For a retained foreign body, vaginal irrigation may have to be done. This can be accomplished by. placing a small feeding tube at the hymenal openmg and

purulent

vaginal

discharge.

injecting warm saline slowly into the vagina. The girl can sit on a basin during the procedure, which often results in the expulsion of numerous wads of foulsmelling toilet paper. Vaginal discharges caused by chemical or mechanical agents ofien are improved tier a course of warm-water sitz baths in which the girl sits in a batltub of warm water, without soap, for 20 to 30 minutes twice daily. Changing to a white, nonperfumed bath soap also may help. Some girls will have to eliminate bubble bath use, whereas others can tel. erate them once every 1 to 2 weeks. The child should be instructed to wipe herself from front to back after a bowel movement. Other modifications include changing to a nonperfumed toilet tissue and using either all-cotton or cotton-crotch underpants. The parents are often anxious during the workup of the child’s discharge, and many are sensitive to the possibility of molestation. Although this should be explored, families are relieved by the knowledge that vaginal discharges are common in children. The practitioner should spend time with family members and aIlow them to discuss their concerns. m CASE REPORTS Case 1 A lo-year-old girl and her mother reported the child’s complaint of a vaginal discharge during the previous 3 to 4 weeks. The girl described the discharge to be “like muc~s.” There was no associated dysuria nor anal or vaginal itching, nor did the girl find the discharge to be annoying.

Journal of Pediatric Health Care

Vaginal

The girl denied any sexual activity or sexual abuse. The mother did not think the girl had been molested but was concerned because “there is so much abuse around.” On examination, the external genitalia was normal in color. The girl’s sexual development for pubic hair was categorized as Tanner stage III-IV. The hymen was estrogen-rich and full, without tears, and a moderate, milky white discharge was present. The child’s vaginal cultures were normal. Given the girl’s physical development and the characteristic of the discharge, the child and her mother were reassured that this was normal physiologic leukorrhea. Case 2 The mother of a 3-year-old girl reported that the child’s underwear “smelled like sperm.” The mother had major concerns that the child was being molested by her stepfather because the man bathed the girl and assisted her to the bathroom-always behind locked doors. Examination of the external genitalia revealed that the girl’s hymen was red and edematous, although no obvious tears or scars were seen. Of note was a thick, profuse, purulent discharge from both the vagina and the anus of the girl (Figure 1). A Gram’s stain of the discharge revealed gram-positive, intracellular diplococci, and the presumptive diagnosis of gonorrheal vaginitis was made. Cultures, which were later confirmed to be positive for Nefiseria gonowhoeae, were obtained from the vagina and anus. The girl was treated with cefiriaxone, 125 mg, intramuscularly. In addition, the local law enforcement agency was notified, and the girl was placed in protective custody pending investigation.

Case 3 A ‘/-year-old girl had a 6-week history of a purulent, brown discharge. The mother reported that the child had a constant odor, such that the children at school made fun of her. There were no urinary problems. The child did complain of vaginal itching. There were no suspicions or dis-

closures of sexualabuse.

On examination the external gen-

ital structures were slightly inflamed. The hymen was normal, without tears or scarring. There was a malodorous, thin, brown discharge from the vagina. Vaginal irrigation

Discharge

185

was performed on this child while she sat on a small basin. Within minutes, numerous clumps of brown, foul-smelling toilet paper were washed from the girl’s vagina. The child and her mother

were counseled

on proper

wiping

after

urination. At the follow-up visit 2 weeks later, the discharge, odor, and genital irritation n

had resolved.

SUMMARY

Vaginal discharges often are seen in prepubescent girls. Although the discharge itself is not normal, the problem may be easily treated. Sexual abuse is one of many causes of a discharge. The child should be treated for sexually transmitted diseases and the case reported to the authorities who must legally protect her. Many vaginal discharges can be eliminated with proper hygiene. The practitioner can provide education to the family regarding affecting agents and can furnish support through a time of frustration and concern for both parent and child. n REFERENCES Altcheck, A. (1981). Vulvovaginitis, vulvar skin disease, and pelvic i&mmatoty disease. Pediatric Clinic of Nwtb America, 281397-421. Altcheck, A. (1984). Pediatric vulvovaginitis. The Journal of Reproductive

Medicine,

29, 359-375.

Arsenault, P. S., & Gerbie, A. B. (1986). Vulvovaginitis in the preadolescent girl. Pediatric Annals, 15, 577-585. Bump, R. C., Scabs, L. A., & Buesching, W. J. (1986). Sexually transmitted infectious agents in sexually active and virginal asymptoamtic adolescent girls. Pediuhs, 77, 488-494. Elvik, S. (1987). From disclosure to court: The facets of sexual abuse. JOWL& of Pediatric Heakb Care, 1, 136-140. Hammers&lag, M. R., Rettig, P. J., & Shields, M. E. (1988). False positive results with the use of chlamydia antigen detection tests in the evaluation of suspected sexual abuse in children. Pediatric In..ctk Diceuse, 7: 11-14. U.S. Department of Health and Human Services. (1985). 1985 SlYD treatment and &dlelines. Atlanta: Centers for Disease Control. Williams, T. S., Callen, J. P., & Owen, L. G. (1986). Vulvar disorders in the prepubertal female. PediatricAnnals, 15,588605.

Vaginal discharge in the prepubertal girl.

Vaginal discharges are commonly seen in the prepubertal girl. Because of the anatomy of young girls, any offending agents have easy access to the geni...
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