A 1-month-old female came to clinic with a 2 day history of increased vaginal discharge. The mother noted that there was an increase in the amount but that the discharge continued to be clear-colored and have a thin consistency. The infant had had increased amounts of stools 4 days ago and the mother noted a red rash on the perineum that she had been using a barrier cream on. The infant was otherwise asymptomatic, and the mother had no concerns about potential sexual or physical abuse. The past medical history revealed a full-term infant female.
The pertinent physical exam showed a well-appearing female growing on the 10-50% growth curves and with normal vital signs. Her perineal area showed moderate generalized erythema of the convex and concave areas of the perineum, labia and buttocks. There were satellite lesions on lower abdomen and inner thighs. Normal appearing vaginal secretions were seen. Her anatomical structures were normal in appearance. The diagnosis of candidal diaper dermatitis causing vulvovaginitis was made and anti-fungal cream was recommended. The mother was educated about normal changes in vaginal secretions in young children.
Vulvovaginitis can occur at any age but is a very common problem in prepubscent females. In this age group it is often caused by irritants and non-specific inflammation. In adolescents and adult females, sexually transmitted infections become another common problem. Sexual abuse can occur at any age.
Normal vaginal secretions are usually thin, and clear to white with a variable amount. Vaginal discharge that is a different consistency, malodorous, accompanied by blood, pain, pruritis, or dysuria is usually not physiologic. Abdominal pain, emesis and fever may indicate pelvic inflammatory disease.
- If bloody, consider foreign body, Shigella, Streptococcus, abuse, estrogen withdrawal, and menses.
- If white, cottage-cheese like, consider Candida.
- If white-yellow, consider normal variation, irritation and Chlamydia.
- If yellow-green, and thick, consider foreign body, Neisseria gonorrhea and trichomonas.
Non-specific vaginal discharge is usually treated by removing the irritant, sitz baths and education about proper hygiene and increasing air flow to the area. Treatment should also be given for specific causes
The differential diagnosis of vulvovaginitis includes:
- Normal variation
- Newborn – thin discharge, may have blood with estogen withdrawal
- After newborn through puberty – thin mucoid discharge
- After puberty – leukorrhea – thin, clear to yellow, not malodorous
- Pregnancy – may increase the amount
- Irritants – one of the most common causes
- Poor hygiene
- Bubble bath and soaps
- Douches, spermicides, and latex
- Restrictive clothing
- Infectious – may be due to actual infection and/or abnormal balance of vaginal flora
- Escherichia coli
- Ureaplasma urealyticum
- Tinea cruris
- Pediculosis pubis
- Lichen sclerosis et atrophicus
- Foreign body
- Retained tampon
- Toilet paper
- Multiple other objects
- Systemic illness
- Crohn’s disease
- Scarlet fever
- Sexual abuse
- Congenital abnormality
- Urethral prolapse
Questions for Further Discussion
1. How can sexual abuse present? See also What Are Some of the Presentations for Child Abuse and Neglect? http://www.pediatriceducation.org/2005/06/06/
2. What are the legal requirements for treating minors with sexually transmitted diseases?
3. What local resources are avaiable for gynecological consultation in your location?
- Symptom/Presentation: Vaginal Discharge
- Age: Newborn
To Learn More
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Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:338-339.
Sifuentes M. Vaginitis. In Pediatrics a Primary Care Approach. Berkowitz CD, ed. W.B. Saunders Co. Philadelphia, PA. 1996;279-282.
Garden AS. Vulvovaginitis and other common childhood gynaecological conditions. Arch Dis Child Educ Pract Ed. 2011 Apr;96(2):73-8.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital