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Dealing with a foreign body. If on vaginal examination you visualizea foreign body, you may be able to remove it with a cotton-tipped applicatoror by lavaging the vagina with saline or warm water after anesthetizingthe introitus with viscous lidocaine.

Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass.

Obtaining cultures. When a child has vaginal discharge or bleeding andthe source such as a foreign body is not obvious, obtain samples for cultureand saline preparation.

If you suspect candidal vulvovaginitis, obtain apotassium hydroxide KOH preparation; a Gram stain may be useful if thedischarge is purulent. Remember that this procedure can be painful to achild if you use a dry cotton swab or do not perform the examination gently.

A better way of obtaining specimens from the prepubertal child is to usea nasopharyngeal Calgiswab moistened with nonbacteriostatic saline.

Beforeinserting the Calgiswab, allow the child to feel a similar swab on her skin. If the Calgiswab does not touch the edges of the hymen, it should causethe child no discomfort.

You can also ask the child to cough in order todistract her and cause her hymen to open. A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently.

If you needmultiple samples, you can use a small feeding tube attached to a syringecontaining a small amount of saline to perform a vaginal wash and aspiration,or you can insert through the hymen a soft plastic or glass eyedropper with4 to 5 cm of IV plastic tubing attached.

The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium.

Cultures for C trachomatis are recommended because of the possibilityof false-positive test results with indirect and slide immunofluorescenttests and insufficient data on tests that utilize polymer chain reactionand ligase chain reaction techniques.

Cultures for other organisms shouldbe done by placing the Calgiswab into a transport Culturette II with medium,or by sending the aspirated fluid to the bacteriology laboratory for directplating.

The bacteriology laboratory should plate the swabs on standardgenitourinary media, including blood agar, MacConkey, and chocolate media.

If you send a culture for N gonorrhoeae and the results are positive, thelaboratory should identify the species unequivocally in a premenarchal girlbecause of the possibility of sexual abuse.

Examination of the vagina under anesthesia may be necessary if culturesdo not identify a pathogen, the child has a persistent discharge or bleedingand adequate examination is not possible, or you suspect a foreign body.

Referral should be made to a gynecologist with experience in pediatric gynecology. Rectoabdominal exam.

After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine.

This is especiallyimportant in girls who have persistent vaginal discharge, bleeding, or pelvicpain because it often is possible for an examiner to express vaginal discharge,palpate a foreign body, and detect masses.

The child should be told thatthe examination will be similar to having her temperature taken or havinga bowel movement, and that a finger has a smaller diameter than a bowelmovement.

After the newborn period, when the uterus is enlarged becauseof maternal estrogen effect, your examination should reveal a small, button-likecervix and uterus.

Abdominal or upper pelvic masses that are palpable mayrepresent ovarian tumors. At the end of the examination, use your fingerto "milk" the vagina and assess for discharge or, very rarely,polypoid tumors.

After your examination is complete, congratulate the child for her cooperationand bravery. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed.

Thegynecologic examination of the prepubertal child can be challenging, butit can also be quite rewarding for a clinician who understands the uniqueanatomic and physiologic characteristics of a prepubertal child and approachesthe examination with patience, gentleness, and respect.

Philadelphia, PA, Raven-Lippincott, Blake J: Gynecologic examination of the teenager and young child. Obstet Gynecol Clin North Am ; Pediatrics ; Gidwani GP.

Approach to evaluation of premenarcheal child with a gynecologicproblem. Clin Obstet Gynecol ; Pokorny SF.

The genital examination of the infant through adolescence. Curr Opin Obstet Gynecol ; Capraro VJ: Gynecologic examination in children and adolescents.

Pediatr Clin North Am ; Am J Obstet Gynecol ; Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls.

Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination. The history and examination usually clinch the diagnosis of vulvovaginitisand vaginal bleeding, but selected laboratory tests such as culture arehelpful in some cases.

The history should include the quality of the discharge color, odor, presence of blood , hygiene, medications, irritants such assoaps and bubble bath, anal pruritus, enuresis, the possibility of a foreignbody or sexual abuse, any recent infections, and a history of systemic ordermatologic conditions.

Questions about caretakers, behavioral changes,fears, and somatic symptoms may help to diagnose sexual abuse. As described in detail elsewhere in this review, the physical exam shouldinclude an inspection of the perineum, vulva, hymen, and anterior vagina.

Visualization of the vagina and cervix and rectoabdominal examination alsois necessary if a child has persistent discharge, bleeding, pain, or ifyou suspect presence of a foreign body.

Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. Vulvitis, or vulvar inflammation, can occur alone or in combination withvaginitis, or vaginal inflammation.

Risk factors for vulvovaginitis in theprepubertal child include hypoestrogenism, which can lead to an atrophicvaginal mucosa; close proximity of the vagina and anus; lack of protectivehair and labial fat pads; poor hygiene; use of irritants such as bubblebath; and contact with nonabsorbent clothing.

Clinical manifestations includepruritus, vaginal discharge and odor, vaginal bleeding, dysuria, and vulvarredness and irritation.

Nonspecific vulvovaginitis. Nonspecific vulvovaginitis often is associatedwith an alteration in vaginal flora, which may be due to a change in theaerobic flora or overpopulation with fecal aerobes and anaerobes.

Vaginalcultures will reflect normal flora, including lactobacilli, Staphylococcusepidermidis, diphtheroids, Streptococcus viridans, enterococci, and enterics Streptococcus faecalis, Klebsiella species, Proteus species, Pseudomonasspecies.

Specific vulvovaginitis. Vulvovaginitis also may be associated with aspecific infectious agent. Bacterial causes include group A, b-hemolyticStreptococcus, Haemophilus influenzae, Staphylococcus aureus, Branhamellacatarrhalis, Streptococcus pneumoniae, Neisseria meningitidis, and Shigella.

Sexually transmitted infections include Neisseria gonorrhoeae, Chlamydiatrachomatis, herpes simplex virus, Trichomonas, and human papillomavirus.

It is important to note that these organisms also can be vertically transmittedat birth and herpes can be transmitted by nonsexual contact.

N gonorrhoeaerarely persists beyond the newborn period without symptoms. Thus, a positivevaginal culture should be considered evidence of sexual abuse in the child.

Likewise, C trachomatis rarely persists beyond age 2 to 3 years, and mostinfants and toddlers have been treated since birth with an antibiotic thatwould treat Chlamydia.

Therefore, a positive culture from the vagina ina 5-year-old requires reporting and evaluation for child sexual abuse.

Thefinding of genital herpes type 2 is a strong indication of sexual abuse. Coexisting primary oral and genital herpes type 1 may occur in young children,but a finding of type 1 in the genital area alone should prompt an evaluationbecause this is more likely to be acquired by abuse.

New onset of Trichomonas vaginitis in theprepubertal child is associated with sexual abuse. HPV is also verticallytransmitted and lesions may appear in the first few years of life.

However,new onset of genital warts in the older prepubertal child is associatedwith sexual contact. Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse.

Typical findings are a maculopapular brightly erythematous rash withsatellite papules. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area.

Diagnosis can befacilitated by performing the tape test: press a piece of cellophane againstthe child's perineum in the morning, affix the tape to a slide, and examineit under the microscope for the characteristic eggs.

Adult pinworms maybe visible at night. Noninfectious causes of vulvovaginitis also are common. Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge.

Vaginal orcervical polyps or tumors also can present with symptoms of vaginitis. Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease.

Vulvarskin disorders are common, and often easily recognizable on exam. Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting.

Seborrhea also is commonly found on the scalp,behind the ears, and in the nasolabial folds. Children usually are asymptomatic,but they may present with secondary infection.

The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous. Excoriations are common, and lesions in other areas of thebody or a history of allergy or atopy may help in making the diagnosis.

Psoriasis, scabies, and autoimmune bullous diseases also can present asvulvovaginitis. Lichen sclerosus may present as vulvar discomfort or pruritus.

It is characterized by atrophy of the vulvar skin, which causes the labiaand clitoral hood to appear thin, white, and parchment-like.

The atrophymay distort the anatomy of the labia and clitoris. Other findings includeecchymoses and "blood blisters," which often develop after mildtrauma such as riding a bicycle.

Other associations. Vaginal complaints also can be associated with masturbationor psychosomatic illness, or they may be factitious.

Physiologic leukorrheacan be confused with vulvovaginitis. Newborns and pubescent girls sometimeshave significant vaginal secretions because of estrogen effect.

The dischargeis usually white and not malodorous, and wet preparation demonstrates multipleepithelial cells without polymorphonuclear cells.

Urethral lesions alsoshould be considered. An ectopic ureter can present as persistent wetnessor purulent discharge. Urethral prolapse, a mucosal inversion at the urethral meatus, may beasymptomatic but it also can become inflamed and cause dysuria, perinealdiscomfort, and bleeding.

It may appear as a brightly erythematous, annular,periurethral mass see figure "A". In girls with persistent, purulent, or recurrent vaginal discharge, orthose with a suspicion of sexual abuse, obtain a wet preparation and culturesfor bacterial pathogens, C trachomatis, and N gonorrhoeae.

A KOH preparationor Biggy agar culture is useful to rule out candidal infection. A tape testmay be useful for suspected pinworm.

Managing vulvovaginitis. A girl who has nonspecific vaginitis shouldbe counseled to do the following: 1 practice good perineal hygiene; 2 urinate with her knees spread apart; 3 wear white cotton underpants andloose clothing; 4 take sitz baths once or twice a day; 5 avoid irritantssuch as bubble bath and use hypoallergenic soaps; and 6 apply a barrierointment such as A and D, Vaseline, or Desitin to the perineum.

If the child'ssymptoms of vulvovaginitis persist, you should review your diagnosis. Forunusually persistent cases, it is appropriate to prescribe a day trialof antibiotics amoxicillin, amoxicillin-clavulanate, or a cephalosporin or occasionally a two- to three-week course of an estrogen cream.

If youidentify a specific pathogen, appropriate antibiotic therapy is indicated,in addition to the measures previously described.

If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching.

If a child's symptoms are severe,a one- to four-week course of a moderate-potency ointment can be recommended,followed by a lower-potency preparation.

In severe cases, clobetasol Temovate may be useful, applied twice daily for two weeks and then gradually taperedover the next several weeks, but this requires expertise and careful supervisionwith frequent follow-up.

Urethral prolapse often resolves after treatmentwith topical estrogen cream twice daily and sitz baths, but surgical excisionmay be required if there is necrosis.

Genital bleeding should always be assessed thoroughly. The source maybe the vulva, vagina, endometrium, and occasionally the urethra.

A carefulhistory is important; a history of hormonal medications or signs of precociouspuberty may suggest the cause of the bleeding.

A history of trauma--whetheraccidental, intentional for example, scratching due to pinworm infection or caused by sexual abuse--also should be elicited.

Vaginal foreign bodiesare a common cause of bleeding, but children often are reluctant to admitto foreign body insertion. Vaginal bleeding is also associated with vulvovaginitis.

Group A streptococciand Shigella are the most common causes. Endocrinologic issues, such asneonatal bleeding due to maternal estrogen withdrawal, precocious puberty,exogenous hormone preparations, and hypothyroidism should be ruled out.

Dermatoses such as lichen sclerosus can cause bleeding. Condylomata acuminataalso can cause bleeding but may be difficult to recognize, because in prepubertalchildren, they often do not have the typical cauliflower-like appearance.

Rather, genital warts typically present as exophytic lesions or papuleswith small red punctations over the surface.

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