Pediatric emergency medicine trisk 393

TABLE 80.1DIFFERENTIAL DIAGNOSIS OF VAGINITIS IN THE PREPUBERTAL CHILD... iii Stevens–Johnson syndromeiv Scarlet fever v Viral infections f Skin conditions i Atopic dermatitis ii Contact

TABLE 80.1

DIFFERENTIAL DIAGNOSIS OF VAGINITIS IN THE PREPUBERTAL CHILD

1 VAGINITIS ASSOCIATED WITH VAGINAL DISCHARGE

(a) Nonspecific vaginitis

(b) Specific etiology

(i) Respiratory and enteric flora

(1) Streptococcus pyogenes

(2) Staphylococcus aureus

(3) Nontypable Haemophilus influenza

(4) Streptococcus pneumonia

(5) Neisseria meningitides

(6) Moraxella catarrhalis

(7) Shigella flexneri

(8) Yersinia enterocolitica

(ii) Sexually transmitted infections

(1) Neisseria gonorrhoeae

(2) Chlamydia trachomatis

(3) Trichomonas vaginalis

(iii) Foreign body

(iv) Congenital Abnormalities

(1) Ectopic ureter

(2) Urethral prolapse

DISCHARGE

(a) Sexually transmitted infections

(i) Herpes simplex

(ii) Condyloma acuminate

(b) Pinworms and other helminths

(c) Tumors, polyps

(d) Trauma

(e) Systemic illnesses

(i) Kawasaki disease

(ii) Crohn disease

(iii) Stevens–Johnson syndrome

(iv) Scarlet fever

(v) Viral infections

(f) Skin conditions

(i) Atopic dermatitis

(ii) Contact dermatitis

(iii) Lichen sclerosis

Other causes of vaginal complaints in the prepubertal child include cervical polyps and tumors, systemic illnesses such as Kawasaki disease, Stevens–Johnson syndrome, and Crohn’s, certain infectious diseases including scarlet fever and some viral illnesses, parasitic diseases such as pinworms, and skin diseases such as atopic dermatitis, contact dermatitis, and lichen sclerosis

Examination

In the prepubertal patient, examination begins with a general physical examination Examination of the prepubertal patient should be performed in the presence of a parent or caregiver Explaining what will occur during the examination helps to alleviate anxiety surrounding the exam in some children Provide a gown or drape when possible Examination of the external genitalia is often best accomplished by having the infant or child lie supine in the frog-leg position The child’s parent or caregiver can assist

by placing the child on his or her lap or between the parent’s legs on the examining table If the patient is unable to tolerate this position, an alternate position for examination can be obtained by having the patient lie prone in the knee to chest position The examination should include inspection of the perineal area, vulva, and vaginal introitus Specimen testing can be obtained

by using a cotton-tipped swab moistened with sterile nonbacteriostatic saline or swabs provided in PCR testing kits

Diagnostic Testing and Treatment

In the majority of prepubertal girls who present with vaginal discharge, no specific etiology can be found Treatment of nonspecific vaginitis includes

practicing good perineal hygiene and removing any mechanical and chemical sources of irritation

Nonspecific Vaginitis Treatment

Avoid bubble baths and harsh soaps

Bathe daily for 10 to 15 minutes in warm water

Supervise children under 5 years and assist with toilet hygiene, including front to back wiping and proper positioning during urination

Allow for air circulation with sleepwear; nightgowns are preferred over pajama bottoms

Wear cotton underpants

Avoid the use of fabric softeners and other dryer additives

Launder clothing with hypoallergenic detergents

Avoid tight-fitting clothes

Change into dry clothing as soon as possible after swimming

Protect the vulvar skin with a barrier ointment, such as A&D or zinc oxide Antibiotic treatment for infectious causes of vaginal discharge is guided by clinical index of suspicion, vaginal culture, and sensitivities (see Chapter 92 Gynecology Emergencies )

If sexual abuse is suspected, test for sexually transmitted diseases Vaginal swabs or urine specimens using nucleic acid amplification tests

(NAATs) are most sensitive and specific in initial testing for C trachomatis , N gonorrhea , and T vaginalis genital infection in prepubertal children

(with high sensitivity and specificity) Be familiar with local requirements for forensic evidence as some states still require culture confirmation

Treatment for a retained intravaginal foreign body is removal of the foreign body Treat the hymen with topical lidocaine jelly and remove by irrigation with warmed saline is usually tolerated well Palpation and removal of small round objects can also be accomplished by a digital rectal exam by palpation and application of gentle outward pressure In rare cases,

if the patient is unable to cooperate for the procedure or the foreign body is sharp or too large, exam by a gynecologist or pediatric surgeon under sedation or general anesthesia may be necessary Identification of certain