CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 63, Number 3, 479–485
Prepubertal
Vulvovaginitis
MARY E. ROMANO, MD, MPH
Department of Pediatrics, Division of Adolescent/Young Adult
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Health, Vanderbilt University Medical Center, Nashville, Tennessee
Abstract: Vulvovaginitis is a common gynecologic
complaint in prepubertal girls. It typically presents with
complaints of vulvovaginal itching, burning, irritation,
discharge, or skin changes. Prepubertal females have
anatomic, physiological, and behavioral factors that
most often contribute to the development of symptoms.
Careful attention to history and associated complaints
will direct evaluation, diagnosis, and treatment. Most
cases are nonspecific in origin and treatment includes
counseling to patients and parents on hygiene and
voiding techniques. Antibiotic treatment for specific
pathogens may be indicated. Other less common causes
include foreign bodies and lichen sclerosus.
Key words: vaginitis, vulva, vagina, dysuria, vaginal
discharge, prepubertal
Background
Vulvovaginitis is a common gynecologic
problem in prepubertal females. It can often
cause anxiety in parents and children due to
its sensitive location and parental concern
that symptoms may be due to abuse or
molestation. Vulvovaginitis typically presents
with complaints of vulvovaginal irritation,
odor, burning, itching, erythema, or vaginal
Correspondence: Mary E. Romano, MD, MPH, Depart-
ment of Pediatrics, Division of Adolescent/Young Adult
Health, Vanderbilt University Medical Center, Nashville,
TN 37204. E-mail: mary.romano@vumc.org
The author declares that there is nothing to disclose.
CLINICAL OBSTETRICS AND GYNECOLOGY
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discharge. There can be associated urinary
complaints such as urinary urgency and
discomfort with voiding. The pathogenesis
workup and treatment of vulvovaginitis is
dependent on age throughout the female
lifespan. In prepubertal females, there are
anatomic, physiological, and behavioral fac-
tors that contribute to the development of
symptoms.
Prepubertal girls are at risk for develop-
ing vulvovaginitis due to the lack of estro-
genization of the prepubertal vulva.1 Before
puberty, the labia majora are lacking in
protective adipose tissue and pubic hair.
The labia minora are also underdeveloped
at this age and the combination of these
factors leaves the vagina exposed and more
vulnerable to bacteria from the anus and
irritants (soaps, bubble baths, wipes). The
vagina itself has an alkaline pH in the
prepubertal period which allows pathogenic
bacteria to overgrow. These bacteria are
typically fecal or oropharyngeal in origin.
This alkaline pH also results in decreased
amounts of “healthy” lactobacilli. Lactoba-
cilli are thought to help prevent and reduce
the overgrowth of fecal and other patho-
genic bacteria.2 Sexually transmitted organ-
isms (gonorrhea, chlamydia) can certainly
cause vulvovaginitis in this age group but
/ VOLUME 63 / NUMBER 3 / SEPTEMBER 2020
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480 Romano
when suspected, it should trigger a careful
and thorough evaluation for abuse by an
experienced and appropriately trained
health care provider.
Prepubertal girls typically have poor
hygiene at this age—both with voiding
and wiping habits. Girls at this age are less
likely to wipe after voiding, to urinate with
their legs pressed tightly together or to rush
with urination.2 This leads to the pooling of
urine in the vagina and provides an environ-
ment where bacteria or more likely to grow.
They may wipe back to front or not wipe
after a bowel movement which can intro-
duce fecal bacteria into the vaginal opening.
Lack of handwashing after voiding or after
coming into contact with the oropharynx is
another way that pathogenic bacteria may
be introduced into the vagina in this age
group. Irritation may also be caused by
exposure to chemical irritants such as
scented soap, bubble baths, wipes or laun-
dry detergent. Finally, clothing choices such
as tight-fitting pants and synthetic/noncot-
ton underwear might contribute to and/or
exacerbate the symptoms of vulvovaginitis.
Presentation
Although the symptoms of vulvovaginitis
are similar in all age groups, prepubertal
girls may have symptoms that are more
often reported by parents. Parents may
report that they have noticed discharge in
their child’s underwear or vulvar skin
changes. There may also be urinary com-
plaints, and this should prompt additional
questions about other genitourinary (GU)
symptoms patients or parents have no-
ticed. Parents may also note vaginal
bleeding or blood with wiping and this
should again prompt further questioning.
Patients themselves may complain of
burning or pain with urination. They
may also be observed to be frequently
touching, itching, or rubbing the GU area
due to general discomfort. Girls may also
have changes in their voiding habits such
as urinary incontinence or “accidents” in
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a child that was previously toilet trained.
This may be due to withholding urine or
avoiding urination due to fear of pain.
History should include questions about
recent respiratory or enteric infections in
patients or close contacts, as this may be a
source of pathogenic bacteria. It is im-
portant to ask about exposure to irritants
such as the use of scented soaps, bubble
baths, powders or wipes, and about po-
tential exposure to estrogen-containing
medications (topical, oral, or herbal). If
possible, it is important to get an idea of
voiding and stooling hygiene and whether
the child is independently toileting. Con-
cerns for abuse should prompt an addi-
tional history, taken by an appropriately
trained professional.
Pathogenesis
The majority of symptomatic prepubertal
vulvovaginitis does not have a specific cause
and patients are most often diagnosed as
having nonspecific vulvovaginitis. In up to
75% of cases no specific or singular patho-
gen is identified.3 When vaginal swabs are
obtained, mixed cultures are seen more often
than an isolated bacterial pathogen. There is
minimal research that documents the “nor-
mal” flora of the prepubertal vulva and
vagina and opportunistic bacteria can be
considered part of the “normal” vaginal
flora. This makes it difficult to determine
the cause of inflammation and whether
antibiotics for a specific bacterial pathogen
are indicated. In the small number of studies
that have looked at the vulvovaginal micro-
biology of “healthy” prepubertal females the
most commonly found bacteria include
anaeraobes, diptheroids, coagulase-negative
Staphlyococcus, and entercocci.4 It is impor-
tant to note that Candida is not commonly
found in the vagina of healthy prepubertal
girls due to the small number of lactobacilli
present. A yeast vulvitis may occur more
often in infants and toddlers that are still in
diapers or in patients with predisposing risk
factors. Risk factors include recent antibiotic

use, underlying immunosuppression or a
diagnosis of diabetes.
Respiratory and enteric organisms are
most often isolated when a specific patho-
gen is identified in symptomatic patients.
Respiratory organisms include group A
Streptococci, Neisseria meningitidis, Staph-
ylococcus aureus, Haemophilus influenzae,
Branhamella catarrhalis.4 Group A Strep-
tococcus and Streptococcus pyogenes are
the most commonly found respiratory
pathogens.5 Pathogenic enteric organisms
include Escherichia coli, Proteus, Shigella,
and Yersenia. Enteric pathogens typically
present with a mucopurulent vaginal dis-
charge. A recently published study by
Jariene et al6 found that S. pyogenes was
the most commonly isolated “high growth”
pathogen in girls with vulvovaginitis. This
study also found that the majority of
healthy controls had bacterial growth on
vaginal cultures and that potentially causa-
tive bacteria were present in equal distribu-
tion in both symptomatic patients and
healthy controls. However, clinical symp-
toms were more likely to be present in
patients when pathogenic bacteria were
present in mixed cultures. Although addi-
tional research is necessary, it may indicate
that the degree, and/or persistence, of clin-
ical symptoms should guide treatment in
conjunction with culture documented pres-
ence of pathogenic bacteria.
Symptoms of vulvovaginitis may be
present as part of an infestation with pin-
worms or Enterobiasis vermicularis.3 Parents
can check for pinworms by putting tape
around the anus first thing in the morning
to look for the presence of pinworms. This
has mixed sensitivity/specificity and if the
predominant complaint is anal pruritis, pa-
tients may be empirically treated for
pinworms.4 If there are any concerns for
abuse, cultures should be sent for sexually
transmitted infections.
The presence of a foreign body may
also cause symptoms of acute and/or
chronic vulvovaginitis such as vaginal
discharge, a change in vaginal odor or
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Prepubertal Vulvovaginitis 481
vaginal bleeding/spotting. The most com-
mon foreign body found in this age group is
toilet paper, although other common child-
hood items should be considered (hair clips,
small toys).3 Most items can be removed in
an office setting. It is important to consider
and urgently address any concerns for the
presence of button batteries, as these may
cause chemical burns to the vaginal mucosa.
The presence of a battery should be consid-
ered if the patient has significant pain and/or
the presence of gray, watery discharge.7
Urinary pathology should also a consid-
eration in patients presenting with vulvova-
ginitis symptoms, particularly those with
persistent symptoms. Voiding dysfunction
can be a contributing factor. These patients
may require urodynamic studies and
subsequent treatment of the underlying
dysfunction.8 The presence of an ectopic
ureter can cause urinary leakage which
results in chronic vulvar irritation. An ectopic
ureter can be associated with a dysplastic
kidney and patients may require an ultra-
sound or intravenous pyelogram for further
evaluation.3 These patients will ultimately
require surgical evaluation and treatment.
Inflammatory conditions of the vulva
can also cause vulvovaginal symptoms.
Lichen sclerosus is an inflammatory con-
dition of the vulva and anogenital area
which causes vulvar itching, irritation, pain,
and dysuria and may present with symp-
toms similar to vulvovaginitis. Lichen scle-
rosus has a bimodal distribution in the
prepubertal and menopausal period, with
∼15% of cases occurring in prepubertal
females.5 Patients with lichen sclerosus typ-
ically present with symptoms of itching or
irritation and findings of dermatosis in a
classic “figure of eight” pattern surrounding
the vagina and anus. This area typically
appears as thinned, whitened skin, and may
be accompanied by petechiae, bleeding, and
fissuring of the perineum. There may also be
associated labial adhesions. Treatment for
lichen sclerosus includes topical steroids
with the use of a high potency steroid until
symptoms are controlled. Once the acute
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482 Romano
symptoms have been controlled, patients
may transition to the use of a mild to
medium potency steroid for maintenance of
remission.5
Other inflammatory skin conditions
which may often be mistaken for vulvovagi-
nitis include allergic or autoimmune atopic
dermatitis. Allergic contact dermatitis may
develop after exposure to a new soap,
detergent or other irritant and this should
be queried during the history.5 Patients with
eczema or psoriasis may have vulvar lesions
which cause vulvar itching, irritation, and
bleeding. Patients with these conditions often
have lesions elsewhere and this can aide in
diagnosis of the presenting vulvar lesions.
Psoriasis will appear as a well circumscribed
pink plaques that are often found on the
extensor surfaces of the forearms but may at
times be located on the vulva or in the
inguinal and/or gluteal folds. Psoriasis may
also present with pitting of the nails. Eczema
will present with more diffuse lesions that are
scaly and shiny in appearance. Eczematous
lesions typically occur in the antecubital or
popliteal fossa and dorsum of hands.5
Diagnosis
Evaluation in patients with vulvovaginal
symptoms is guided by age and associated
complaints. A full physical examination,
with an emphasis on skin should be con-
ducted on all presenting patients, as well as
careful attention to any physical signs of
precocious puberty. GU examination should
include attention to Tanner staging of the
breasts as well as any signs of vulvar estro-
genization such as enlargement of the labia
and/or a thickened hymen. If present in
conjunction with a history of vaginal bleed-
ing, further endocrinologic workup should be
done to evaluate for central or precocious
puberty, hypothyroidism, and isolated pre-
mature menarche.5 Laboratory work should
include thyroid-stimulating hormone, estra-
diol, follicle stimulating hormone, and lutei-
nizing hormone.2,5 Evaluation should also
include imaging of the pelvis (typically with
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an ultrasound) to look for ovarian cysts or
masses.
Physical examination of the genitalia
should be done with consideration of obtain-
ing the best view of the area and ensuring
comfort of the patient. This can be done with
the child in the knee-to-chest position, dorsal
lithotomy position or lying supine in the frog-
leg position.1–3 In most positions, parents can
sit behind the child as a source of physical
support and comfort. A colposcope or oph-
thalmoscope can be used for better visual-
ization of the vagina and to allow for
adequate separation of the labia to minimize
discomfort for the child. The buttocks can be
separated with a down and out motion, or
outward traction can be applied to the labia
majora to allow for visualization of the
vaginal introitus. In infants, traction applied
to the labia majora may be the preferred
method as the labia may be larger due to
maternal estrogen exposure making it harder
to visualize the vaginal opening.
Vaginal swabs and cultures can be ob-
tained, when necessary, with the use of a
moistened Calgi swab. Calgi swabs are
smaller than Q-tips and may cause less
discomfort, especially when moistened be-
fore use.2 Pokorny and colleagues describe a
technique called “catheter-within-a-
catheter” which involves using a larger
catheter such as a bladder catheter to keep
the vaginal canal patent while a smaller
catheter such as butterfly tubing is placed
inside the catheter. This smaller catheter
may be used to inject sterile saline and
simultaneously remove secretions for fur-
ther examination and culture.9
If a foreign body is visualized, attempts
can be made to remove during the initial
examination while the patient is awake. This
can be done using sterile saline or water for
gentle irrigation. A small pediatric Foley
catheter may be used if the patient is able to
tolerate it. A rectal examination may also be
utilized as a means of attempting foreign
body removal from the vagina. If patients
are unable to tolerate examination while
awake, especially if foreign body removal is

needed, an examination under anesthesia
may be required. During examination under
anesthesia, vaginoscopy or hysteroscopy
may be used for visualization. A 2015
review by Johary et al10 found that vagino-
scopy with a pediatric cystoscope was pre-
ferred due to the low risk of complications
and the ability for simultaneous diagnosis
and treatment. Newer equipment may allow
for in office vaginoscopy, using a flexible
hysteroscope. A 2017 review of 25 pediatric
patients undergoing vaginoscopy utilizing a
hand-held endoscopy device found that
about half of the procedures were success-
fully performed in an office setting.11 Child
life specialists were utilized in this study to
aide in patient distraction during the proce-
dure.
Treatment
Treatment is aimed at underlying etiol-
ogy, and in prepubertal girls is typically
focused on addressing lifestyle changes,
hygiene, and voiding/stooling techniques.
There may be a need for the treatment of
a specific pathogen.
Tables 1 and 2 outline specific pathogens,
preferred antibiotics and appropriate dosage
TABLE 1. Prepubertal Vulvovaginal Pathogens
Antibiotic Preferred Choice Bacteria
Penicillin family Staphylococcus
epidermidis
Streptococcus viridans
Streptococcus pyogenes
Staphylococcus aureus
Haemophilus influenzae
Streptococcus group A
Streptococcus
pneumoniae
Azithromycin Escherichia coli
Trimethoprim/ Proteus vulgaris
sulfamethoxazole
Mebendazole Enterobiasis
vermicularis
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Prepubertal Vulvovaginitis 483
in this age group. Patients with respiratory
symptoms should also be encouraged to
carefully wash their hands before and after
using the bathroom to avoid further intro-
duction of bacteria into the vagina.2
Patients with inflammatory skin condi-
tions such as lichen sclerosus, atopic derma-
titis or psoriasis will need condition specific
treatment. As mentioned earlier, prepubertal
females with lichen sclerosus may require the
topical use of high dose steroids with the
eventual transition to lower potency steroids
as their maintenance regimen.5 Atopic der-
matitis and/or psoriasis may also require
topical steroids to help control symptoms.
Dermatitis that is triggered by a specific
allergen typically responds to the removal of
the offending agent.
In patients with nonspecific vulvovagi-
nitis, patients, and parents should be edu-
cated on proper hygiene and voiding
techniques with the recommendation to
avoid irritants such as scented wipes, soaps,
and bubble baths. Patients should be coun-
seled on wiping front to back and on
spreading the legs during urination.
Younger girls may find it easier to void
facing backwards in order to maximize
leg separation and urine flow. Clothing
Body Site Alternate Choice
Skin flora Azithromycin or
cephalosporin
Skin flora Azithromycin or
cephalosporin
Skin flora Azithromycin or
cephalosporin
Skin flora Trimethoprim/
sulfamethoxazole
Respiratory tract
Respiratory tract
Respiratory tract
Gastrointestinal tract
Gastrointestinal tract Cephalosporin
Pinwork Cephalosporin
Cephalosporin
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484 Romano

TABLE 2. Antibiotic Dosing

Trimethoprim/
Ampicillin Amoxicillin Sulfamethoxazole Azithromycin Mebendazole
< 20 kg 25 mg/kg q 6 h 20 mg/kg q 5 mg/kg/dose q 10 mg/kg per 100 mg ×1,
for 5-10 d 12 h for 5-10 d 12 h for 5-10 d day 1 then repeat in
5 mg/kg po 3 wk ×1
×4 d
> 20 kg 500 mg q 6 h 20 mg/kg q 12 h for 5 mg/kg/dose q 10 mg/kg per 100 mg ×1,
for 5-10 d 5-10 d 12 h for 5-10 d day 1 then repeat in 3 wk
5 mg/kg po ×1
×4 d

recommendations should include the use of
cotton underwear and loose-fitting cloth-
ing. Girls should be encouraged to sleep
without tight-fitting underwear and in
loose-fitting pajama bottoms or boxers.
Girls with significant vulvovaginal irrita-
tion may find relief in sitting in a bathtub of
warm water or using Sitz baths. Once the
area is dry, the use of a topical emollient can
act as a barrier and provide further relief. A
hair dryer on cool settings, or a dry cloth
should be used to make sure the area is
completely dry before the application of an
emollient. Rarely, a low potency steroid
may be required for symptomatic relief,
particularly in patients who have an allergic
reaction to an inciting agent or irritant.
Further evaluation should be considered
in patients who have persistent symptoms
despite adherence to the above lifestyle
changes. This should include a culture, if
not previously done, as well as further
examination to rule out the presence of a
foreign body or other pathology. An exami-
nation under anesthesia, if not previously
done, should be considered in patients with
persistent symptoms despite appropriate
treatment.
Conclusions
Vulvovaginitis is a common gynecologic
diagnosis in prepubertal girls. The pa-
tient’s age, history, and associated symp-
toms will help guide evaluation and
treatment. History should include a review
of hygiene, voiding, and stooling practices.
Examination requires a GU examination
which in this age group may include a
vaginoscopy or an examination under
anesthesia. Although the majority of vul-
vovaginitis in this age group is nonspecific,
in certain patients, a vaginal culture may
be appropriate in order to direct treatment
towards a specific pathogen. Treatment for
most patients will include education on
lifestyle changes to address hygiene, void-
ing, and stooling practices. Additional
evaluation may be required in patients
with persistent symptoms.
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Prepubertal Vulvovaginitis 485
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