Vulval and vaginal problems in prepubertal females

Vulval and vaginal problems in young girls usually result in pruritus vulvae (itch affecting the female genital area). It is a common problem in this age group. Causes and treatments differ slightly between prepubertal females and mature women.

What causes pruritus vulvae?

The main cause of pruritus vulvae in prepubertal females is poor hygiene and the presence of chemical and/or mechanical irritants.

• Poor hygiene is usually the result of a back to front wiping motion after urinating or bowel movement. This contaminates the vulva with faeces and faecal pathogens. An infection may readily develop as at this age the vulva is thin, delicate, and has a neutral pH, which makes it an excellent medium for bacterial growth.
• Soaps, bubble baths, laundry detergents, shampoo, and chlorinated pool water are all potential chemical irritants. Mechanical irritation may occur from scratching the area, harsh wiping with toilet paper, or rubbing from tight-fitting underwear. The prepubertal vulva is particularly vulnerable because of the lack of oestrogen-induced labial fat pads, thickening of the skin, and pubic hair.

Prepubertal pruritus vulvae may also be a symptom of other vulvar or vaginal problems. These include:

• Primary skin disease such as contact dermatitis, atopic dermatitis, seborrhoeic dermatitis, psoriasis, and lichen sclerosus. Lesions elsewhere on the body are often present.
• Presence of a foreign body in the vagina
• Primary infection
  • Non-sexually transmitted bacterial causes include S pyogenes, S pneumoniae, H influenzae, N meningitidis, S aureus, Shigella, Yersinia entercolitica and E coli. Mixed bacterial cultures usually indicate poor hygiene.
  • Sexually transmitted bacterial causes include Trichomoniasis, Chlamydia and Gonorrhoea.
  • Infestations with pinworms, lice and scabies. Pinworms are common in children; they may move from the anus to the vagina where they cause itching especially at night time. Lice are however rarely seen in prepubertal girls whom lack pubic hair.
  • Fungal infections such as candidiasis and tinea are rarely the cause of pruritus vulvae in prepubertal females.
  • Viral causes may include molluscum contagiosum, genital herpes and genital warts.

Often several of these factors are present, and it can be difficult to determine the exact cause. The doctor will need to examine the affected area and take swabs for microbiological examination. Other areas of the skin will be examined to determine the likelihood of a more widespread skin disorder being the cause.

Sometimes, a skin biopsy is necessary to determine the exact nature of the skin condition.

Patch tests are sometimes performed to see whether any contact allergy is present such as to a fragrance, medicament or other material.

What treatment is available?

Prepubertal vulvar and vaginal problems can be treated and prevented by instituting good hygiene measures and by avoiding things that may cause irritation or infection. Some basic general practices include:

• Using a front to back motion when wiping the vulva after urination or bowel movement.
• Change underpants frequently if soiled.
• Wear loose fitting cotton underwear and outer clothing.
• Avoid tight-fitting nylon clothing such as leotards and pants that restrict airflow and promote sweating.
• Avoid using bubble baths or allowing the child to sit in soapy bath water for long periods. However a soap free bath can be very soothing and will improve hygiene. The child should gently use her fingers to separate the folds of the vulva.
• Avoid harsh soaps; try a soap-free cleanser instead of conventional soap.
• Pat dry the vulva with a clean towel after bathing rather than rubbing vigorously.
• Avoid scratching or rubbing the affected area.

Bland emollients such as aqueous cream or petrolatum can be used. Hydrocortisone cream is generally safe, but if it seems to irritate, discontinue its use and seek advice from your doctor. Dermatological or infectious causes may be treated with medicines prescribed by your doctor.