Do we need to treat vulvovaginitis in prepubertal girls?
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《英国医生杂志》
1 Department of Child Health, Llandough Hospital, Cardiff CF64 2XX, 2 Department of Community Child Health, St David's Hospital, Cardiff, 3 Department of Obstetrics and Gynaecology, Gloucester Royal Hospital, Gloucester, 4 Department of Obstetrics and Gynaecology, Royal Gwent Hospital, Newport
Correspondence to: M Joishy manoharj28@yahoo.co.uk
Introduction
The hypo-oestrogenic hormonal milieu in a preadolescent girl is a major factor in making her vaginal mucosa susceptible to infection.4 The mucosa is thin, lacks cornification, and has an alkaline pH and is therefore susceptible to invasion from pathogens. Other factors putting the girl at risk are the close proximity of the rectum, lack of labial fat pads or pubic hair, small labia minora, and children's tendency to poor local hygiene and to explore their bodies,2 4 5 spread of respiratory bacteria from hand to perineum, and local irritants such as nylon underwear.6 7
Microbiology
The vaginal microflora of prepubertal girls has not been well defined. Many organisms have been cultured, but most studies were flawed for lack of control subjects or because the study combined prepubertal and peripubertal girls.5 8 Hill et al reported a predominance of various anaerobes in the vaginal microflora of normal prepubertal girls,9 but the number of children studied was small. Hammerschlag et al studied the microbiology of the vagina in 100 healthy girls in the late 1970s.8 They found diptheroids, anaerobes, and Staphylococcus epidermidis were the commonest organisms, but they included girls who were sexually active and gave no information about sexual abuse.
Summary points
Vulvovaginitis is the commonest gynaecological problem in prepubertal girls
The hypo-oestrogenic hormonal milieu in a such girls increases the susceptibility of the vaginal mucosa to infection
Vaginal microflora have not been well studied in normal prepubertal girls, making it difficult to decide whether bacteria isolated from a patient's vaginal secretions are part of the normal microflora or are the cause of symptoms of vulvovaginitis
Current evidence suggests that in prepubertal girls with clinical features of vulvovaginitis, antibiotics should be used only if a pure or predominant growth of a pathogen is identified
Isolating an organism associated with sexual transmission should prompt a careful evaluation for sexual abuse
Gerstner et al in their case-control study of 67 prepubertal girls (36 cases and 31 controls) found that 77% of vaginal cultures from asymptomatic girls were positive for aerobic bacteria, 65% were positive for anaerobic bacteria, and 45% were positive for both.10 The most prevalent species were Staphylococcus epidermidis (35%), enterococci (29%), Streptococcus viridans (13%), and lactobacillus (39%). A similar spectrum of organisms was isolated in higher percentages from the girls with vulvovaginitis. Swabs were taken through vaginoscopy in this study, which is not common practice currently.
Jaquiery et al reported that girls with vulvovaginitis and control groups had similar microbiological flora overall, with commonly isolated organisms being mixed anaerobes, diphtheroids, coagulase negative staphylococci, and Escherichia coli.1 Mixed anaerobes and Streptococcus viridans were significantly more common in the controls, whereas Staphylococcus aureus and group A streptococcus were more common among the cases. However, the numbers were small and failed to reach significance in the case group. No child in either group in this study1 nor in that by Gerstner et al10 had Gardernella vaginalis, Trichomonas hominis, urogenital mycoplasma, or Neisseria gonorrhoeae isolated in culture, and polymerase chain reaction amplification performed for Chlamydia trachomatis was negative for all specimens.1
Haemophilus influenzae and group A haemolytic streptococcus are thought to be pathogenic organisms in the vaginal region in children.11 The incidence of group A haemolytic streptococcus varies from 8% to 47%,12 13 and various studies suggest that this infection arises from previous respiratory or skin sources.3 13-15 Although studies have reported H influenzae to be the commonest single organism in children with vulvovaginitis,11 16 a recent study did not show similar results.3 The introduction of routine vaccination against H influenzae could explain this difference. Shigella is an uncommon cause of vulvovaginitis in prepubertal children, and, of those reported cases, the causative organism is Shigella flexneri.17
Candida is usually not isolated in prepubertal girls,1 3 18 but it may be found in girls with predisposing factors, such as a recent course of antibiotics, diabetes, or the wearing of diapers.2 Organisms associated with sexually transmitted diseases also can cause vulvovaginitis: finding Neisseria gonorrhoeae or Chlamydia trachomatis should prompt a careful evaluation for sexual abuse.2
Clinical features of vulvovaginitis
Symptoms
Vaginal discharge (62-92%)
Redness (82%)
Soreness (74%)
Itching (45-58%)
Dysuria (19%)
Bleeding (5-10%)
Physical signs
Inflammation (redness of the introitus in 87%)
Excoriation of the genital area
Vaginal discharge
Other causes
Threadworms are a common cause of vulvovaginitis (fig)19 and should be considered in children whose major symptom is nocturnal perineal pruritus.3 The possibility of sexual abuse should always be considered when a child presents with genital symptoms,1 particularly in the presence of rectal or genital bleeding, developmentally unusual sexual behaviour,20 and recurrent or persistent symptoms. The presence of an organism normally associated with sexually transmitted infection is highly suggestive of sexual abuse.21 Other uncommon causes include a foreign body in the vagina, lichen sclerosis, vaginal and cervical polyps, and tumours.4 5
Adults (top) and eggs (bottom) of the threadworm (Enterobius vermicularis) are a common cause of vulvovaginitis
Non-specific aetiology
In 25-75% of girls with vulvovaginitis, a specific pathogen is not isolated.2 22 This may be due to non-specific irritation resulting from the use of bubble bath, soaps, or shampoos; poor hygiene; tight clothing; or faecal contamination.
Clinical features and management
In the management of vulvovaginitis in prepubertal girls current evidence suggests that, in addition to giving advice about hygienic measures, vaginal secretions should be obtained for microbiological investigations and that antibiotics should be used only if a pure or predominant growth of a pathogen is identified. This recommendation is based on one case-control study1 and one retrospective study.3 However, there is little literature regarding the vaginal microflora of prepubertal children, and it is therefore difficult to determine whether bacteria isolated from patients' vaginal secretions are part of the normal microflora or are the cause of symptoms of vulvovaginitis.
Of the existing studies on the microflora of the prepubertal vagina, many are flawed for lack of control subjects, and most combined prepubertal and peripubertal children, had small numbers, or lacked comprehensive cultures for a wide variety of micro-organisms. Clearly we need well designed, adequately powered, high quality studies to evaluate the vaginal microflora in asymptomatic prepubertal children and in those with symptoms of vulvovaginitis.
Contributors: AJ had the idea for the article, CSA performed the literature search and helped write the first draft. MJ helped write the first draft and is guarantor. All authors contributed to revisions. RG is guarantor.
Funding: None.
Competing interests: None declared.
References
Jaquiery A, Stylionopoulus A, Hogg G, Grover S. Vulvovaginitis: clinical features, aetiology and microbiology of genital tract. Arch Dis Child 1999;81: 64-7.
Vandeven AM, Emans SJ. Vulvovaginitis in the child and adolescent. Pediatr Rev 1993;14: 141-7.
Stricker T, Navratil F, Sennhauser FH. Vulvovaginitis in prepubertal girls. Arch Dis Child 2003;88: 324-6.
Smith YR, Berman DR, Quint EH. Premenarcheal vaginal discharge: findings of procedures to rule out foreign bodies. J Pediatr Adolesc Gynecol 2002;13: 227-30.
Altchek A. Pediatric vulvovaginitis. J Reprod Med 1984;29: 359-75.
Lang WR. Paediatric vaginitis. N Engl J Med 1955;253: 1153.
Heller RH, Joseph JH, Davis HJ. Vulvovaginitis in the premenarcheal child. J Pediatr 1969;72: 370.
Hammerschlag MR, Alpert S, Rosner I, Thurston P, Semine D, McComb D, et al. Microbiology of the vagina in children: normal and potentially pathogenic organisms. Pediatrics 1978;62: 57-62.
Hill GB, St Claire KK, Gutman LT. Anaerobes predominate among the vaginal microflora of prepubertal girls. Clin Infect Dis 1995;20(suppl 2): S269-70.
Gerstner GJ, Grunberger W, Boschitsch E, Rotter M. Vaginal organisms in prepubertal children with and without vulvovaginitis. A vaginoscopic study. Arch Gynecol 1982;231: 247-52.
Pierce AM, Hart CA. Vulvovaginitis: causes and management. Arch Dis Child 1992;67: 509-12.
Straumanis JP, Bocchini JA Jr. Group A beta-haemolytic streptococcal vulvovaginitis in prepubertal girls: a case report and review of the past twenty years. Pediatr Infect Dis J 1990;9: 845-8.
Cuadros J, Mazon A, Martinez R, Gonzalez P, Gil-Setas A, Flores U, et al for the Spanish Study Group for Primary Care Infection. The aetiology of paediatric inflammatory vulvovaginitis. Eur J Pediatr 2004;163: 105-7.
Donald FE, Slack RCB, Colman G. Streptococcus pyogenes vulvovaginitis in children in Nottingham. Epidemiol Infect 1991;106: 459-65.
Morris CA. Seasonal variation of streptococcal vulvo-vaginitis in an urban community. J Clin Pathol 1971;24: 805-7.
Macfarlan DE, Sharma DP. Haemophilus influenzae and genital tract infection in children. Acta Pediatr Scand 1987;76: 363-4.
Baiulescu M, Hannon PR, Marcinak JF, Janda WM, Schreckenberger PC. Chronic vulvovaginitis caused by antibiotic-resistant Shigella flexneri in a prepubertal child. Pediatr Infect Dis J 2002;21: 170-2.
Paradise JE, Campos JM, Friedman HM, Frishmuth G. Vulvovaginitis in premenarcheal girls: clinical features and diagnostic evaluation. Pediatrics 1982;70: 193-8.
Arsenault PS, Gerbie AB. Vulvovaginitis in the preadolescent girl. Pediatr Ann 1986:15: 577-85.
American Academy of Paediatrics, Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children: subject review (RE9819). Pediatrics 1999;103: 186-91
Thomas A, Forster G, Robinson A, Rogstad K for the Clinical Effectiveness Group. National guideline for the management of suspected sexually transmitted infections in children and young people. Sex Transm Infect 2002;78: 324-31.
Emans SJ, Goldstein DP. The gynaecologic examination of the prepubertal child with vulvovaginitis: use of the knee chest position. Pediatrics 1980;65: 758-60.
Koumantakis EE, Hassan EA, Deligeoroglou EK, Creatsas GK. Vulvovaginitis during childhood and adolescence. J Pediatr Adolesc Gynecol 1997;10: 39-43.
Lindner JGEM, Plantema FHF, Hoogkamp-korstanje JA. Quantitative studies of the vaginal flora of healthy women and of obstetric and gynaecological patients. J Med Microbiol 1978;11: 233-41.
Onderdonk AB, Polk BF, Moon NE, Goren B, Bartlett JG. Methods for quantitative vaginal flora studies. Am J Obstet Gynecol 1977;128: 777-81.
Correspondence to: M Joishy manoharj28@yahoo.co.uk
Introduction
The hypo-oestrogenic hormonal milieu in a preadolescent girl is a major factor in making her vaginal mucosa susceptible to infection.4 The mucosa is thin, lacks cornification, and has an alkaline pH and is therefore susceptible to invasion from pathogens. Other factors putting the girl at risk are the close proximity of the rectum, lack of labial fat pads or pubic hair, small labia minora, and children's tendency to poor local hygiene and to explore their bodies,2 4 5 spread of respiratory bacteria from hand to perineum, and local irritants such as nylon underwear.6 7
Microbiology
The vaginal microflora of prepubertal girls has not been well defined. Many organisms have been cultured, but most studies were flawed for lack of control subjects or because the study combined prepubertal and peripubertal girls.5 8 Hill et al reported a predominance of various anaerobes in the vaginal microflora of normal prepubertal girls,9 but the number of children studied was small. Hammerschlag et al studied the microbiology of the vagina in 100 healthy girls in the late 1970s.8 They found diptheroids, anaerobes, and Staphylococcus epidermidis were the commonest organisms, but they included girls who were sexually active and gave no information about sexual abuse.
Summary points
Vulvovaginitis is the commonest gynaecological problem in prepubertal girls
The hypo-oestrogenic hormonal milieu in a such girls increases the susceptibility of the vaginal mucosa to infection
Vaginal microflora have not been well studied in normal prepubertal girls, making it difficult to decide whether bacteria isolated from a patient's vaginal secretions are part of the normal microflora or are the cause of symptoms of vulvovaginitis
Current evidence suggests that in prepubertal girls with clinical features of vulvovaginitis, antibiotics should be used only if a pure or predominant growth of a pathogen is identified
Isolating an organism associated with sexual transmission should prompt a careful evaluation for sexual abuse
Gerstner et al in their case-control study of 67 prepubertal girls (36 cases and 31 controls) found that 77% of vaginal cultures from asymptomatic girls were positive for aerobic bacteria, 65% were positive for anaerobic bacteria, and 45% were positive for both.10 The most prevalent species were Staphylococcus epidermidis (35%), enterococci (29%), Streptococcus viridans (13%), and lactobacillus (39%). A similar spectrum of organisms was isolated in higher percentages from the girls with vulvovaginitis. Swabs were taken through vaginoscopy in this study, which is not common practice currently.
Jaquiery et al reported that girls with vulvovaginitis and control groups had similar microbiological flora overall, with commonly isolated organisms being mixed anaerobes, diphtheroids, coagulase negative staphylococci, and Escherichia coli.1 Mixed anaerobes and Streptococcus viridans were significantly more common in the controls, whereas Staphylococcus aureus and group A streptococcus were more common among the cases. However, the numbers were small and failed to reach significance in the case group. No child in either group in this study1 nor in that by Gerstner et al10 had Gardernella vaginalis, Trichomonas hominis, urogenital mycoplasma, or Neisseria gonorrhoeae isolated in culture, and polymerase chain reaction amplification performed for Chlamydia trachomatis was negative for all specimens.1
Haemophilus influenzae and group A haemolytic streptococcus are thought to be pathogenic organisms in the vaginal region in children.11 The incidence of group A haemolytic streptococcus varies from 8% to 47%,12 13 and various studies suggest that this infection arises from previous respiratory or skin sources.3 13-15 Although studies have reported H influenzae to be the commonest single organism in children with vulvovaginitis,11 16 a recent study did not show similar results.3 The introduction of routine vaccination against H influenzae could explain this difference. Shigella is an uncommon cause of vulvovaginitis in prepubertal children, and, of those reported cases, the causative organism is Shigella flexneri.17
Candida is usually not isolated in prepubertal girls,1 3 18 but it may be found in girls with predisposing factors, such as a recent course of antibiotics, diabetes, or the wearing of diapers.2 Organisms associated with sexually transmitted diseases also can cause vulvovaginitis: finding Neisseria gonorrhoeae or Chlamydia trachomatis should prompt a careful evaluation for sexual abuse.2
Clinical features of vulvovaginitis
Symptoms
Vaginal discharge (62-92%)
Redness (82%)
Soreness (74%)
Itching (45-58%)
Dysuria (19%)
Bleeding (5-10%)
Physical signs
Inflammation (redness of the introitus in 87%)
Excoriation of the genital area
Vaginal discharge
Other causes
Threadworms are a common cause of vulvovaginitis (fig)19 and should be considered in children whose major symptom is nocturnal perineal pruritus.3 The possibility of sexual abuse should always be considered when a child presents with genital symptoms,1 particularly in the presence of rectal or genital bleeding, developmentally unusual sexual behaviour,20 and recurrent or persistent symptoms. The presence of an organism normally associated with sexually transmitted infection is highly suggestive of sexual abuse.21 Other uncommon causes include a foreign body in the vagina, lichen sclerosis, vaginal and cervical polyps, and tumours.4 5
Adults (top) and eggs (bottom) of the threadworm (Enterobius vermicularis) are a common cause of vulvovaginitis
Non-specific aetiology
In 25-75% of girls with vulvovaginitis, a specific pathogen is not isolated.2 22 This may be due to non-specific irritation resulting from the use of bubble bath, soaps, or shampoos; poor hygiene; tight clothing; or faecal contamination.
Clinical features and management
In the management of vulvovaginitis in prepubertal girls current evidence suggests that, in addition to giving advice about hygienic measures, vaginal secretions should be obtained for microbiological investigations and that antibiotics should be used only if a pure or predominant growth of a pathogen is identified. This recommendation is based on one case-control study1 and one retrospective study.3 However, there is little literature regarding the vaginal microflora of prepubertal children, and it is therefore difficult to determine whether bacteria isolated from patients' vaginal secretions are part of the normal microflora or are the cause of symptoms of vulvovaginitis.
Of the existing studies on the microflora of the prepubertal vagina, many are flawed for lack of control subjects, and most combined prepubertal and peripubertal children, had small numbers, or lacked comprehensive cultures for a wide variety of micro-organisms. Clearly we need well designed, adequately powered, high quality studies to evaluate the vaginal microflora in asymptomatic prepubertal children and in those with symptoms of vulvovaginitis.
Contributors: AJ had the idea for the article, CSA performed the literature search and helped write the first draft. MJ helped write the first draft and is guarantor. All authors contributed to revisions. RG is guarantor.
Funding: None.
Competing interests: None declared.
References
Jaquiery A, Stylionopoulus A, Hogg G, Grover S. Vulvovaginitis: clinical features, aetiology and microbiology of genital tract. Arch Dis Child 1999;81: 64-7.
Vandeven AM, Emans SJ. Vulvovaginitis in the child and adolescent. Pediatr Rev 1993;14: 141-7.
Stricker T, Navratil F, Sennhauser FH. Vulvovaginitis in prepubertal girls. Arch Dis Child 2003;88: 324-6.
Smith YR, Berman DR, Quint EH. Premenarcheal vaginal discharge: findings of procedures to rule out foreign bodies. J Pediatr Adolesc Gynecol 2002;13: 227-30.
Altchek A. Pediatric vulvovaginitis. J Reprod Med 1984;29: 359-75.
Lang WR. Paediatric vaginitis. N Engl J Med 1955;253: 1153.
Heller RH, Joseph JH, Davis HJ. Vulvovaginitis in the premenarcheal child. J Pediatr 1969;72: 370.
Hammerschlag MR, Alpert S, Rosner I, Thurston P, Semine D, McComb D, et al. Microbiology of the vagina in children: normal and potentially pathogenic organisms. Pediatrics 1978;62: 57-62.
Hill GB, St Claire KK, Gutman LT. Anaerobes predominate among the vaginal microflora of prepubertal girls. Clin Infect Dis 1995;20(suppl 2): S269-70.
Gerstner GJ, Grunberger W, Boschitsch E, Rotter M. Vaginal organisms in prepubertal children with and without vulvovaginitis. A vaginoscopic study. Arch Gynecol 1982;231: 247-52.
Pierce AM, Hart CA. Vulvovaginitis: causes and management. Arch Dis Child 1992;67: 509-12.
Straumanis JP, Bocchini JA Jr. Group A beta-haemolytic streptococcal vulvovaginitis in prepubertal girls: a case report and review of the past twenty years. Pediatr Infect Dis J 1990;9: 845-8.
Cuadros J, Mazon A, Martinez R, Gonzalez P, Gil-Setas A, Flores U, et al for the Spanish Study Group for Primary Care Infection. The aetiology of paediatric inflammatory vulvovaginitis. Eur J Pediatr 2004;163: 105-7.
Donald FE, Slack RCB, Colman G. Streptococcus pyogenes vulvovaginitis in children in Nottingham. Epidemiol Infect 1991;106: 459-65.
Morris CA. Seasonal variation of streptococcal vulvo-vaginitis in an urban community. J Clin Pathol 1971;24: 805-7.
Macfarlan DE, Sharma DP. Haemophilus influenzae and genital tract infection in children. Acta Pediatr Scand 1987;76: 363-4.
Baiulescu M, Hannon PR, Marcinak JF, Janda WM, Schreckenberger PC. Chronic vulvovaginitis caused by antibiotic-resistant Shigella flexneri in a prepubertal child. Pediatr Infect Dis J 2002;21: 170-2.
Paradise JE, Campos JM, Friedman HM, Frishmuth G. Vulvovaginitis in premenarcheal girls: clinical features and diagnostic evaluation. Pediatrics 1982;70: 193-8.
Arsenault PS, Gerbie AB. Vulvovaginitis in the preadolescent girl. Pediatr Ann 1986:15: 577-85.
American Academy of Paediatrics, Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children: subject review (RE9819). Pediatrics 1999;103: 186-91
Thomas A, Forster G, Robinson A, Rogstad K for the Clinical Effectiveness Group. National guideline for the management of suspected sexually transmitted infections in children and young people. Sex Transm Infect 2002;78: 324-31.
Emans SJ, Goldstein DP. The gynaecologic examination of the prepubertal child with vulvovaginitis: use of the knee chest position. Pediatrics 1980;65: 758-60.
Koumantakis EE, Hassan EA, Deligeoroglou EK, Creatsas GK. Vulvovaginitis during childhood and adolescence. J Pediatr Adolesc Gynecol 1997;10: 39-43.
Lindner JGEM, Plantema FHF, Hoogkamp-korstanje JA. Quantitative studies of the vaginal flora of healthy women and of obstetric and gynaecological patients. J Med Microbiol 1978;11: 233-41.
Onderdonk AB, Polk BF, Moon NE, Goren B, Bartlett JG. Methods for quantitative vaginal flora studies. Am J Obstet Gynecol 1977;128: 777-81.