Pediatric & Adolescent Gynecology
Small bodies, different causes: hygiene, foreign bodies, and the red flags for abuse
Prepubertal vulvovaginitis
Why young girls are vulnerable. Before puberty the vaginal mucosa is thin and unestrogenized with a neutral pH, the labia lack fat pads and hair, and the anus sits close to the introitus. Most vulvovaginitis in this age group is therefore nonspecific irritation from soaps, bubble baths, tight or synthetic clothing, and back-to-front wiping.
Hygiene first. Teach front-to-back wiping, cotton underwear, no bubble baths or scented products, plain warm-water sitz baths, and voiding with the knees apart so urine does not pool in the vagina.
Specific infections. Culture persistent or purulent discharge. Group A streptococcus causes bright red, painful, sharply demarcated vulvitis, often after pharyngitis or with perianal dermatitis, and responds to penicillin or amoxicillin. Shigella causes mucopurulent, often bloody discharge, sometimes without diarrhea, and is treated with culture-directed antibiotics. Candida is uncommon once a child is toilet-trained unless she has diabetes, recent antibiotic exposure, or immunosuppression.
Pinworm. Female Enterobius vermicularis lay eggs on the perianal skin at night, causing nocturnal perianal and vulvar itching. A clear adhesive tape pressed to the perianal skin in the morning before bathing captures the eggs. Albendazole is given and repeated in 2 weeks, with the household treated as well.
Vaginal foreign body. Retained toilet paper is the most common object. The clue is persistent, foul-smelling, blood-tinged discharge despite good hygiene. Examine in the knee-chest position; warm saline irrigation often flushes the material out, and vaginoscopy under anesthesia is used if irrigation fails or is not tolerated.
When to suspect sexual abuse
Sexually transmitted infections. Gonorrhea, syphilis, or HIV not acquired perinatally, and chlamydia or trichomoniasis beyond the perinatal window, indicate sexual contact. Perform a forensic evaluation, test for other STIs, and report to child protective services.
Injury pattern. Accidental straddle injuries from a bicycle bar or furniture crush soft tissue against the pubic bone, bruising the labia, clitoral hood, or periurethral area on one side while the hymen stays intact. Injury to the hymen or posterior fourchette, or a history that does not match the injury, suggests penetrating trauma and abuse.
Labial adhesions and prepubertal bleeding
Labial adhesions. Low estrogen plus irritation fuses the labia minora, leaving a thin, pale, avascular midline line. Asymptomatic adhesions are observed because pubertal estrogen separates them. Symptomatic adhesions (post-void dribbling, UTIs, retention) are treated with topical estrogen or steroid cream. Forced separation is painful, frightening, and followed by recurrence.
Urethral prolapse. Circumferential eversion of the distal urethral mucosa, seen mostly in prepubertal Black girls, appears as a red-purple, friable, donut-shaped mass around the meatus, with spotting on the underwear or dysuria. Sitz baths and topical estrogen usually resolve it; excision is reserved for necrosis or failure.
Lichen sclerosus. Itching accompanies thin, white, crinkled skin in a figure-8 around the vulva and anus, with fissures and purpura that bleed. An ultrapotent topical steroid such as clobetasol ointment is the treatment. Its subepithelial hemorrhages can be mistaken for sexual abuse.
| Cause | Clue | Management |
|---|---|---|
| Neonatal withdrawal | Small bleed in the first 1–2 weeks of life | Reassurance; normal |
| Foreign body | Foul, bloody discharge | Irrigation or vaginoscopy |
| Trauma | Straddle (anterior, unilateral) vs penetrating (hymen, fourchette) | Examine; report if abuse suspected |
| Urethral prolapse | Donut-shaped periurethral mass | Sitz baths, topical estrogen |
| Lichen sclerosus | Figure-8 white skin, purpura | Clobetasol ointment |
| Precocious puberty | Breast budding before age 8 | Bone age, LH/FSH evaluation |
| Sarcoma botryoides | Grape-like vaginal mass, usually under 5 years | Biopsy; oncologic treatment |
Exogenous estrogen and estrogen-secreting ovarian lesions also cause bleeding with breast development; bleeding plus pubertal signs needs endocrine evaluation.
Adolescent problems
Imperforate hymen. The classic patient is a young teen with primary amenorrhea despite normal breast and pubic hair development, monthly cyclic pelvic pain, and a bulging bluish membrane distended by hematocolpos; urinary retention or a suprapubic mass may occur. Treatment is surgical hymenotomy; needle aspiration risks infection and is avoided.
| Condition | Exam | Cyclic pain | Treatment |
|---|---|---|---|
| Imperforate hymen | Bulging bluish membrane at introitus | Yes | Hymenotomy |
| Transverse vaginal septum | Normal hymen, short blind vagina, no bulge | Yes | Excision with reanastomosis |
| Müllerian agenesis | Short vagina, absent uterus, normal hair | No | Vaginal dilators |
| Androgen insensitivity | Blind vagina, scant pubic/axillary hair, 46,XY | No | Gonadectomy considered after breast development (timing individualized, may be deferred); estrogen afterward |
Ovarian torsion. Sudden severe unilateral pelvic pain with nausea and vomiting, usually with an ovarian cyst or benign teratoma but sometimes a normal ovary, suggests torsion. Doppler shows an enlarged ovary, yet preserved flow does not exclude torsion. Urgent laparoscopic detorsion with ovarian preservation is standard, with removal of any cyst. A dusky, blue-black ovary usually recovers, so oophorectomy is rarely needed.
First reproductive health visit. Recommended at 13–15 years, it builds rapport through a confidential interview covering menses, sexuality, contraception, STI prevention, relationship violence, and HPV vaccination. An internal pelvic exam is not routinely needed; sexually active teens receive urine NAAT for gonorrhea and chlamydia, and cervical cytology still begins at 21.