A VAGINAL DISCHARGE

The likely diagnosis is vulvovaginitis. Prepubertal girls may have a clear sticky discharge that resolves with menarche. However, a malodorous discharge indicates pathology. It is most likely that a Streptococcus was the cause of the upper respiratory tract infection and that this infection was transmitted to the genital area by the child’s fingers. It is not uncommon to get a degree of dysuria in association with vulvovaginitis. Occasionally vaginal bleeding may occur. To definitively diagnose a urinary tract infection, there has to be a pure growth of 105 colony-forming units/mL WBCs. Jasmine’s results do not fulfil this criteria. Poor perineal hygiene may cause or exacerbate vulvovaginitis, which often presents shortly after girls have started self-toileting. Masturbation may also lead to vulvovaginitis. Pinworms may be associated with perianal itching, especially at night, and in about 20 per cent of cases there is an associated vulvovaginitis. If no worms are visible, Sellotape can be applied to the perianal skin, stuck onto a glass slide and then sent for microscopy to look for enterobius ova. Herpes infection can also lead to vulvovaginitis. It leads to vesicles and to discrete ulcers. These are usually due to digital contact with cold sores, but the possibility of sexual abuse should also be borne in mind. Viral swabs should be taken. Recurrent vulvovaginitis usually ceases at puberty. The differential consists of candidal infection, a foreign body, sexually transmitted disease and the very rare botryoid sarcoma. Candida leads to a creamy white discharge, vulval itching and dysuria. It is rare prepubertally but may occur in diabetics or following antibiotic use. A foreign body may consist of toilet paper or a toy. In young children it may be visible on inspection, but on occasion may require an examination under anaesthetic. Evidence of infection with an organism such as chlamydia or gonorrhoea suggests sexual abuse and should prompt a child protection investigation. A sarcoma usually presents with a bloodstained vaginal discharge. On examination, a fleshy haemorrhagic lesion is seen, which is often described as ‘grape-like’. Treatment consists of a 1-week course of penicillin. Basic hygiene measures should also be advocated, such as cleaning oneself from front to back after a bowel motion, using loose-fitting cotton knickers, having daily baths or showers using simple soaps (avoiding bubble baths or other irritants) and allowing air to dry. A short course of topical oestrogen cream may also be helpful.

KEY POINTS

• Vulvovaginitis is common in prepubertal girls.

• Advice on hygiene antibiotics is effective in treating this condition.

• In children with a vaginal discharge, the possibility of sexual abuse should also be considered.