23.
Vaginal discharge in a six year old child:
| a. | is often due to a foreign body | False | |
| b. | may be the first sign of diabetes | False | |
| c. | is an indication for oestrogen therapy | False | |
| d. | is usually due to chlamydia | False | |
| e. | is rarely a matter of hygiene | False |
(See also MCQ8, question 41, MCQ9. question 35, and
MCQ11, questions 35 & 36.)
There is a detailed article by Hayes & Creighton in TOG: 2007, number 3, which MRCOG candidates should read and formulate into cards.
This gives a strong possibility that the subject will
appear soon in the MRCOG essays.
There is a BMJ article by Joishy et al that is worth reading and is not too long.
Factors predisposing a child to vulvo-vaginal infection.
Causes:
Dermatological conditions:
Uncommon.
May cause itching and odour & consequent
distress.
May cause parental anxiety e.g. re infertility.
May be persistent / relapsing.
Commonly associated with poor perineal hygiene.
Most often associated with non-specific
bacteria.
bowel
coliforms and skin organisms.
May be due to specific bugs:
Vulval & perineal itching may be due to threadworm infestation.
May be part of an exanthema:
May be associated with vulval skin conditions:
May occur with contact dermatitis:
excessive intervals between nappy changes,
? soaps / bubble baths etc,
? refer to a dermatologist,
? allergy / sensitivity testing.
May be related to playing in sandpits.
There may be a foreign body.
May be a manifestation of sexual abuse.
Small print stuff:
may be due to:
labial adhesions impairing urine drainage,
ectopic ureter & urethral prolapse,
cervical & vaginal tumours.
Examination can usually be done on a couch.
Appropriate explanation to be given first.
Ideally the child to be accompanied by mother or
other close female relative.
Internal examination:
should not be done without general anaesthesia
which needs an anaesthetist accredited for paediatric anaesthesia
and special instruments
in
my experience it rarely helps.
Possible to
train mother to take introital swabs.
Good toilet
hygiene is essential.
the bum to be wiped from front to back,
ensure the vulva is dry after micturition and bathing,
? washing the perineum with soap and water after bowel movements.
Specific infections to be treated.
Sooothing ointments/ creams & barrier creams may help.
Vaginal discharge is uncommon in children.
But is the commonest reason for a girl to be referred to a general gynaecological clinic.
May cause itching and odour & consequent
embarrassment and distress.
May cause parental anxiety e.g. re
infertility, sexual abuse.
May be persistent / relapsing.
The child’s anatomy makes her more liable to infection than the mature woman.
The anus adjoins the vagina so it is no great trek for bowel organisms.
The labia are
underdeveloped and the vagina lacks the effects of oestrogen that, with
lactobacilli, produce a hostile pH.
Commonly associated with poor perineal hygiene.
smearing of faeces over the vulval area,
failure to clean the perineum / vulva,
failure to dry the perineum / vulva after micturition.
This leads to the most important hygiene advice:
getting the child to wipe her bum from front to back after a bowel movement.
She should also dry the vulval area after micturition and bathing.
In persistent or relapsing cases I used to get the mother to make sure the child’s bottom was washed:
with soap and water after bowel movements,
and every morning and evening.
Swabs usually show a mix of bugs hence the commonest diagnosis is of “non-specific” vulvo-vaginitis.
Jaquiery et al found evidence of infection in only 20% of cases.
They noted that these girls had:
more copious discharge,
more severe skin inflammation.
I had to include this as the report came from Alice Springs, one of those almost mythical destinations.
Specific organisms include:
Group A haemolytic streptococci,
often in conjunction with an upper-respiratory tract infection,
with the presumption that there has been spread from there to the vulval area.
Haemophilus influenzae is the next most common.
Appropriate
antibiotics should be prescribed, paying heed to the sensitivities and any drug
allergy.
Studies have suggested that Bacteroides, Staphylococcus epidermidis and Diphtheroides are commensals.
This could be
a MRCOG MCQ.
Candida is rare and usually associated with something else:
nappies being left unchanged for too long, so that the skin breaks down,
or antibiotic treatment.
Infantile diabetes does not present with candidal infection of the genital area, though it can do in the elderly.
The onset of infantile diabetes tends to be acute and dramatic.
It is possible that candida could contribute in poorly-controlled diabetes in the child.
But this must
be very rare and I have not seen a case.
Vulval & perineal itching may be due to threadworm infestation.
There are varying reports of its incidence in girls with discharge.
Pierce & Hart found it to be the commonest cause of discharge after poor hygiene.
I saw it rarely.
Maybe most of the cases had been treated by the GP.
Making
cases referred to hospital a skewed population.
May be part of an exanthema:
You would hope that someone would notice that the rash is not restricted to the genital area!
May be associated with vulval skin conditions:
eczema, lichen
sclerosus, that can raise suspicions of sexual abuse.
Pierce & Hart found a 14% incidence in 200 cases.
They recommended involvement of a dermatologist.
Nappies predispose the skin to problems.
If not changed frequently the skin will be damp & in contact with bowel bacteria.
You need to enquire about their use.
Noxious effects from soaps, perfumes, bubble-baths etc. are always implicated, as in the adult woman.
I can’t say I have ever been impressed with them as a significant factor.
They are usually mentioned by the woman with discharge who stresses that she never uses them, but still gets discharge!
Nor can I remember a case where advice to discontinue their use has made a difference.
However, they are real for the purposes of the exams.
Similarly, women are always advised to avoid tight jeans, to use cotton underwear and not to wear underwear in bed.
I’m not too sure about the science behind this advice, but it is ubiquitous in women’s magazines, so it is unlikely to go away.
Labial adhesions are not uncommon.
They may act as a dam, stopping proper urine drainage.
The urine may subsequently leak onto the underwear and be taken for vaginal discharge.
Adhesions may
predispose to urine or vaginal infection, but I have seen so confirmatory
evidence.
in my experience this is very uncommon,
the most common is a fragment of toilet paper.
urethral prolapse, which is more common in those of African descent,
ectopic ureter, which should be diagnosed earlier as the child will always be wet,
tumours of cervix and vagina etc.
The commonest tumour is sarcoma botryoides but it is very, vary rare.
I remember learning the classical presentation as a student: bleeding & discharge with a mass with grape-like vesicles.
And much good it did me!
I was not asked about it in the MRCOG exam and never saw a case.
Precocious puberty is a theoretical cause: See MCQ6, question 22.
The onset
could be brown discharge and it might be some time before cyclical bleeding
became established.
Examination has to be done with recognition that it may cause the child embarrassment and distress.
It has to be limited to external examination.
The need for it should be explained and the fact that swabs will only be taken by “touching the skin” or some other suitable form of words.
Mostly the child can be examined on a normal couch in the "frog" position.
Sandpits get singled out for mention.
The idea is that they get infected by dogs and cats.
A little girl squatting in the sand is then exposed to the infection.
I am not convinced that it is a major hazard.
However, the advice to cover sand pits when not in use is reasonable.
And it deals with the possible risk of toxoplasmosis.
You obviously need to take a history.
Examination can usually be done on a couch with the child in the "frog" position.
It is a supine frog, with the knees drawn up and the soles of the feet together.
Examination has to be done with recognition that it may cause the child embarrassment and distress.
It has to be limited to external examination.
The need for it should be explained and the fact that swabs will only be taken by “touching the skin” or some other suitable form of words.
Appropriate explanation to be given first.
Ideally the child to be accompanied by mother or other close female relative.
If internal examination is necessary to exclude a foreign body or tumour, it may be time to refer.
Many Regions now have someone with a special interest in paediatric gynaecology.
I doubt that they would want to see every child with discharge.
But referral of relapsing cases, those with bleeding etc. might be appropriate.
Phone them and ask!
Remember for the exam that special instruments are needed.
A small nasal speculum is often used.
The child having examination under anaesthesia also needs a specialist anaesthetist.
Sexual abuse has to be borne in mind, though I have never seen a case present like this.
a classic exam question would be about a swab growing Trichomonas or
other STI.
in practice, fortunately uncommon.
Trusts are now supposed to have protocols in place for suspected cases.
If you think this might be the problem, discuss it with your consultant and the child sexual abuse lead.
The mainstay of treatment is hygiene training.
Antibiotics should be used for proven infections.
But not prescribed just in the hope of doing something.
Simple creams and barrier creams may help.
The sorts
that one might use with nappy rash.
Oestrogen therapy has been used for chronic discharge in the hope that it will improve resistance to infection.
I used it on only a few occasions and was not impressed that it did any good.
In one case
it caused pigmentation of the vulval skin, which added to my reluctance ever to
use it.
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