Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Vulvovaginitis in the Prepubertal Child
Vulvovaginitis is inflammation of the vulva and vaginal introitus characterized by dysuria, pruritus, and vaginal discharge
I. Etiology
A. Often a contact reaction to irritants, such as bath soaps, bubble bath, laundry products, deodorants, perfumed powders, nylon underpants, panty hose, or tights.
B. Anal scratching (secondary to pinworm infestation), poor perineal hygiene, and masturbation may cause contamination of the vaginal area.
C. Lack of estrogen makes the immature vaginal mucosa susceptible to infection.
II. Incidence: Common in prepubertal females
III. Subjective data
A. Vaginal discharge
B. Dysuria
C. Pruritus
D. Inflammation
E. Pertinent subjective data to obtain
1. Use of bubble bath
2. Use of harsh soaps
3. Recent change in laundry products
4. Use of nylon underpants, tights, tight jeans
5. Improper toileting hygiene; have child demonstrate toileting technique.
6. Symptoms of pinworm infestation (see Pinworms, p. 368)
7. Exposure to infection (e.g., streptococcal upper respiratory infection)
8. Recent infection (e.g., GABHS)
9. Recent course of antibiotics
10. Determine duration, amount, and type of discharge: Bloody, purulent, mucoid
1 1. Masturbation
1 2. Detailed history to determine any question of sexual abuse. Include any behavioral changes that may suggest a possibility of abuse.
IV. Objective data
A. Vaginal discharge: Thin and mucoid, but may be copious and purulent
B. Erythema of vulva and vaginal introitus
C. Check hymenal opening: A minute high hymenal opening can impair vaginal drainage.
D. If symptoms are severe, examine vagina with child in the kneechest position using an otoscope with a nasal speculum or veterinary otoscope.
E. Check for anal excoriation.
F. Rectal exam to detect foreign body or mass
G. Laboratory tests
1. Urinalysis to rule out UTI and diabetes
2. Hematocrit to rule out anemia
3. Culture of purulent discharge, both aerobically and on ThayerMartin medium
V. Assessment
A. Diagnosis: 80% of cases in prepubertal children are nonspecific vulvovaginitis.
B. Differential diagnosis
1. Physiologic leukorrhea
2. Foreign body: Foreign body visualized; foul-smelling drainage
3. Gonorrhea: Culture positive for Neisseria gonorrhoeae
4. Herpes simplex: Vesicular eruptions; may be ulcerations; painful. Herpes simplex type 1 can cause simultaneous lesions in the mouth and vulva of young girls.
5. Moniliasis: Vulvar and vaginal erythema; white, cheesy vaginal discharge; presence of C. albicans in potassium hydroxide wet preparation.
6. Trichomonas vaginitis: Vaginal erythema; profuse frothy discharge that is gray or green and malodorous. Trichomonas is seen as motile, pear-shaped, flagellated protozoa on microscopic examination of wet preparation. Trichomonas may also be detected by Pap smear.
7. Pinworms: Pinworm eggs visualized microscopically on scotch tape slide.
8. Sexual abuse: Rule out by careful history. If high index of suspicion and history negative, refer to mental health worker with expertise in the field.
VI. Plan
A. Sitz baths 3 times a day
B. Proper perineal hygiene
C. White cotton underpants
D. Use mild soap: Dove or Johnson’s Baby Bath
E. Scotch tape slide for pinworms if infestation suspected
F. Neosporin ointment or 1% hydrocortisone cream applied locally 3 to 4 times a day
G. Antibiotics as indicated by culture
1. GABHS or pneumococcus
a. Penicillin 125 to 250 mg qid for 10 days or
b. Erythromycin 50 mg/kg/d in 4 divided doses for 10 days (>20 kg, give 250 mg qid)
2. H. influenzae: Amoxicillin 40 mg/kg/d in 3 divided doses for 10 days (>25 kg, give 250 mg tid)
3. N. gonorrhoeae
a. Consult with physician for parenteral penicillin.
b. Order serology for syphilis.
VII. Education
A. Teach careful perineal hygiene.
1. Use cool, wet tissue, cotton balls, or Tucks (witch hazel pads).
2. Wipe from front to back.
B. Sitz baths
1. Warm water
2. May add baking soda
3. Duration of 15 to 20 minutes
4. Pat dry or air dry after bathing (do not rub). May use hair dryer on cool setting
C. Avoid shampooing hair in bathtub.
D. Do not use bubble bath.
E. Use Dove or other bland soap in bath.
F. Change underpants frequently. White cotton underpants should be used; they are more absorbent than synthetic materials and free of dyes.
G. Use Ivory Snow for laundry.
H. Discontinue use of bleach and fabric softeners.
I. Avoid perfumed powders.
J. Avoid nylon underpants, tight jeans or slacks, panty hose, and tights; they lead to maceration of the vulva.
K. Encourage child to void in tub if dysuria is a problem.
L. Wash all new items of clothing before child wears them.
M.Avoid long periods of time in wet bathing suits or spandex.
N. Overweight girls are particularly prone to recurrences.
VIII. Follow-up
A. Mild symptoms: Have parent call back in 5 days
B. Moderate to severe symptoms
1. Have parent call back in 24 to 48 hours.
2. If pruritus is still a problem, use
a. 1% hydrocortisone cream tid on vulva or
b. Benadryl PO, 5 mg/kg/d in 4 doses
C. Most cases of nonspecific vulvovaginitis improve within 2 weeks. If symptoms have not improved, vaginal examination and cultures must be done. If no specific causative organism is found, give amoxicillin 3 times daily (dosage according to age and weight) and Vagitrol or Sultrin cream locally.
IX. Consultation/referral
A. Any question of sexual abuse
B. No improvement within 2 weeks using plan outlined above
C. Culture positive for N. gonorrhoeae