Genital Complaints in Prepubertal Girls

Background

Complaints of genital redness, itching, discharge, and/or bleeding are relatively common in young girls before the onset of puberty. Most of these problems have benign causes and respond to the removal of irritants.¹ However, because a genital complaint such as discharge or bleeding may be caused by trauma to the area or a sexually transmitted infection, assessment of each patient requires the clinician to be sensitive to possible unspoken concerns of parents regarding suspicions of molestation.² For more information on this, see the eMedicine article Child Abuse & Neglect, Sexual Abuse.

When a child makes a statement or a disclosure of abuse and describes sexual touching, all 50 US states mandate that the clinician report suspected child sexual abuse to the local child protective services agency, law enforcement, or both. However, if the concern of possible abuse is based only on a physical sign or symptom, the child must be examined by a health care provider who is familiar with the nonabusive causes of the symptoms or signs. Understanding the wide variations in the appearance of the hymen and other genital tissues in prepubertal girls is also necessary.

The American Academy of Pediatrics has recently published a clinical report on the subject of suspected child sexual abuse with guidance for the clinician in deciding when a report to protective services is necessary.³ Guidelines for medical care of children with suspected sexual abuse have also been updated.⁴

History

The following questions are helpful in determining the possible causes of genital redness, itching, discharge, or irritation:

• Is the child completely toilet trained? If not, how often does she wear diapers, and what kind of diapers are worn? Ultra-absorbent disposable diapers can hold urine and feces close to the skin for hours without the parent realizing that the diaper needs to be changed.
• If out of diapers, how is the child bathed? Does she take showers or baths? Does she play in a tub with bubble bath or shampoo suds? What kind of soap is used? Does the mother or caregiver scrub the genital area with soap or a washcloth? Bubble bath, shampoo, perfumed soaps, and vigorous scrubbing can cause irritant vulvitis.
• Does the child wear cotton or nylon panties? Does she often wear Lycra clothing or other types of clothing that restrict air circulation to the genital area? Does she like to wear her wet bathing suit all day? Nylon, Lycra, and other occlusive materials can cause genital irritation after prolonged wear.
• Is the child recently toilet trained? If so, does her mother or other caregiver still help her with hygiene after a bowel movement? If the child cares for her own toilet needs, does her mother or caregiver frequently find streaks of stool on the child’s underwear? Fecal soiling can cause irritant vulvitis. Does she wipe front to back?
• Has the caregiver noticed a bad odor from the genital area or seen dark discharge on the panties? (See Vaginal Discharge.)
• Does the child frequently complain of itching in the genital and anal area, or does the caregiver observe her to be constantly scratching or rubbing herself in that area? (See Vaginal Itching.)
• Does the child have eczema, allergic rhinitis, or diarrhea, or has she had recent upper respiratory infections? These could explain itching, irritation, or discharge.
• Has the caregiver ever noticed the child trying to insert objects into her own vagina? (See Vaginal Discharge.)
• Has the caregiver ever noticed blood on the child’s underwear or after wiping? (See Vaginal Bleeding.)
• Does the caregiver have any concerns about possible sexual abuse based on the child’s statements or sexualized behaviors? (See the eMedicine article Child Abuse & Neglect: Sexual Abuse.)

Physical examination

To perform a careful genital inspection, the following are necessary:

• A clinician who has time, knowledge, and skill with children
• A relaxed or distracted child (Books read by the mother or caregiver are great sources of distraction.)
• A good light source

If vaginal discharge is evident upon examination, obtain cultures using small urethral swabs (calcium alginate, Dacron, or cotton) moistened with sterile saline. A wet mount slide, routine vaginal culture, and cultures for gonorrhea and Chlamydia can be obtained. A nucleic acid amplification test may also be used to detect gonorrhea and Chlamydia, either from a urine sample or a vaginal swab, but the current criterion standard for diagnosis in cases of suspected sexual abuse is still culture.

Nucleic acid amplification tests are very sensitive and generally yield a low false-positive rate; however, if the urine nucleic acid amplification test findings are positive for either gonorrhea or Chlamydia, the child should be asked to return for a repeat test with a different type of nuclear acid amplification if Chlamydia cultures are not available. See the recommendations from the Centers for Disease Control and Prevention.

One position for the patient while the physician is conducting the examination is lying on her back on the examination table in the supine frog-leg position with her knees bent and the soles of her feet touching. The labia majora are then gently spread laterally using separation or grasped and pulled forward toward the examiner using labial traction. In this way, the hymen and vestibular tissues are clearly identified.

If the hymen fails to open up with labial traction to reveal the hymenal opening or if vaginal cultures need to be taken, the child can be turned over and placed in the prone knee-chest position. In this position, cultures can be taken with a urethral swab from the vagina without touching the hymen and causing pain and without the child being alarmed by the sight of the swab.

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eMedicine – Genital Complaints in Prepubertal Girls