Symptoms and Causes of Vulvovaginitis in Children

Vaginitis refers to inflammation or infection of the vagina, but it can also affect the vulva, the area outside the vagina (vulvovaginitis).

Vulvovaginitis is one of the most common causes of visits to primary care for young girls. Because of a lack of estrogen, which doesn't increase until puberty, the skin in and around the vagina can be thin, delicate and easily irritated.

In addition to the fragility of the skin, girls are predisposed to vulvovaginitis because of a lack of protective pubic hair, the closer proximity of the vagina and anus, and a lack of labial fat pads that help to protect the entry of the vagina.

Girls need to be taught from a young age to wipe front-to-back when going to the bathroom, not back-to-front, to avoid dragging bacteria from the anus into the urethra and vagina. Avoiding other sources of irritation can also help to prevent vulvovaginitis in girls.

Types

Vulvovaginitis can sometimes be caused by an infection from fungus (yeast infections), from bacteria (bacterial vaginosis), from viruses, or from protozoal parasites. The majority of the time, however, the cause is nonspecific and is not caused by one of these germs.

Infectious Vulvovaginitis

Approximately 25% of vulvovaginitis cases in children are from an infectious cause.

Yeast infections are a fungal infection that can be problematic especially for infant girls and for adolescents. Babies can get yeast diaper rashes. Vaginal yeast infections can be uncomfortable and more common for girls who have started their periods.

Yeast infections in a prepubescent girl out of diapers are rare, but they may occur if she has had to take antibiotics, has diabetes, or if she has a problem with her immune system. For that reason, recurring yeast infections in prepubescent girls can be a sign of another health issue.

Vaginal yeast infections are most often recognized by a cottage cheese-like lumpy, white discharge, itching, swelling, and redness.

Bacterial infections causing vulvovaginitis in children most frequently come from bacteria in the gastrointestinal or respiratory tract, and they may present with pain, redness and a discharge that is milky, watery, or may smell "fishy". Some bacteria, such as the bacteria that cause chlamydia, are sexually transmitted.

Viral infections like herpes simplex virus (HSV) and human papilloma virus (HPV) and protozoal parasitic infections like Trichomoniasis that cause vulvovaginitis are less common in younger children, as they are generally sexually transmitted.

Nonspecific Vulvovaginitis

Most cases of prepubertal vulvovaginitis are from nonspecific reasons and can be addressed without the need for medication. Because most cases of vulvovaginitis are from irritants or resolvable hygiene issues, the prevention tips below are generally adequate to handle the problem.

If a foul odor is noted without an infection found, it may be that the girl has a foreign object or substance in her vagina, such as toilet paper. Lastly, in a review of pediatric patients with a recurring vaginal discharge, 5% were later identified as having been sexually abused.

Symptoms

The most common symptoms of vulvovaginitis can include:

• Vaginal itching, soreness or irritation
• Abnormal vaginal discharge
• Redness and swelling of the vulva
• Burning with urination (dysuria)
• Urinary frequency (urinating more frequently)
• Bleeding and excoriations (secondary to severe inflammation and scratching)

Some children may not yet have the language to express their symptoms, so it can sometimes be difficult to differentiate between bladder issues, bowel issues, and vulvovaginitis.

Keep in mind that some vaginal discharge can be normal after puberty. Some adolescents and women have more discharge than other women, but they may not have the rest of the symptoms above.

Causes

Common causes of vulvovaginitis in kids and adolescents include:

• Direct irritants like tight-fitting clothing, dyes and perfumes in soaps, shampoos, bubble baths, laundry detergents and dryer sheets, and dyes in underwear
• Behaviors such as wiping back-to-front on the toilet, taking bubble baths, inserting foreign objects in the vagina like toilet paper, sitting around in a wet swimsuit or damp workout clothing, being sexually active, or using douches or feminine washes
• Systemic illnesses including diabetes, immune system issues, needing antibiotics, or other systemic dermatological issues like eczema or psoriasis
• Infections from germs like fungus (yeast, especially Candida species), bacteria, viruses, and protozoal parasites. Most of these infections are from imbalances and overgrowth in our own systems and the cause is unknown. In other cases, the infection is sexually transmitted.
• Bowel issues like diarrhea or chronic constipation

Diagnosis

For many cases of vulvovaginitis in children, a single cause may not be identified. The good news is that it often gets better without treatment anyway.

Your doctor may be able to help with a diagnosis just by doing a physical exam and by finding out how and when symptoms started, when they changed, and if anything makes the symptoms better or worse. If that isn't sufficient, they may need to do tests for an infection. Many tests for infections can be done in the doctor's office.

For both in-office and at-home testing, ruling out a vulvovaginal infection often starts with a pH test of vaginal fluid. That's because yeast infections tend to have a lower-than-normal pH, whereas bacterial infections and trichomonas tend to have a higher-than-normal pH.

Diagnosing the cause of vulvovaginitis may need a culture of vaginal fluid and occasionally a skin biopsy to diagnose skin disorders. If bleeding is present, the doctor may order a pelvic ultrasound.

Other diagnoses that present similarly may need to be ruled out, including skin disorders like eczema, psoriasis, or lichen sclerosus. Pinworms can also cause similar symptoms.

Treatment

To treat vulvovaginitis, you first need to rule out infections.

If a bacterial infection is suspected, your doctor might prescribe an antibiotic like oral metronidazole or oral or topical clindamycin.

If a pubertal teen has a vaginal yeast infection, she may need an oral medication like fluconazole. Topical antifungal medication, such as miconazole or clotrimazole cream, are also available if you think your teen will adhere to treatment.

Lastly, trichomoniasis is typically treated with oral metronidazole or tinidazole. If infections do not respond to these treatments, more treatment is available and testing for drug resistance my be needed.

Herpes simplex virus infections can be managed with antivirals, but infection is life-long.

For quick relief of vulvovaginitis, it can sometimes help to:

• Take a bath in plain warm water in a clean tub free of soap, bleach, or cleaning products
• Apply a cool compress to the area
• Apply Vaseline or A&D diaper ointment to the areas of irritation

In addition, remind girls of good hygiene habits, including wiping from the front to the back after a bowel movement to keep the bacteria away from the vulva.

Prevention

Prevention measures are key to preventing flare-ups of vulvovaginitis. As puberty approaches, symptoms usually improve. In the meantime, you can help your child prevent vulvovaginitis by teaching her to:

• Urinate with her knees spread wide apart
• Urinate leaning slightly forward so that urine doesn't pool in the the lower part of the vagina
• Wipe front-to-back and not back-to-front when using the toilet
• Avoid baths that use bubbles, soap, or shampoo in the water
• Change out of wet clothing as soon as possible, including wet swimsuits or sweaty work-out clothes
• Avoid tight clothing, including tights or pantyhose
• Wear loose-fitting, white cotton underwear that is dye-free
• Sleep without underwear in a nightgown or long shirt, or wear very loose-fitting boxer shorts as pajama bottoms
• Avoid scented products, including scented tampons, pads, or feminine washes
• Use non-irritating, mild soaps and rinse them off well after bathing or showering
• Avoid getting shampoo or soap in the vulval area
• Wash and dry the vulval area gently when she showers or takes a bath
• Avoid douching

You should also wash your child's underwear with a dye- and perfume-free detergent, rinse it twice, and avoid fabric softeners and dryer sheets.

A Word From Verywell

Some girls may be embarrassed or ashamed to discuss issues involving their "privates." Girls should be encouraged to discuss any health issues or concerns they have, no matter which body parts. This will set them up for a lifetime of positive health behaviors, including about reproductive health.

Some hospitals have specialized pediatric and adolescent gynecology programs that treat recurrent vaginitis and other gynecological problems. Otherwise, for extra help or a second opinion, ask your pediatrician for a referral to an adult gynecologist who has some experience taking care of children and adolescents.