Clinical presentation, diagnosis and treatment of vulvovaginitis in girls: a current approach and review of the literature

Patterns of pediatric and adolescent female genital inflammation in China: an eight-year retrospective study of 49,175 patients in China

Background

Genital inflammation is one of the most frequent clinical complaints among girls, which was easily overlooked by the general public. This study aimed to investigate the patterns and epidemiological characteristics of pediatric and adolescent female genital inflammation in China.

Methods

A retrospective observational study (2011 to 2018) was conducted among all female patients under the age of 0-18 years at the Department of Pediatric and Adolescent Gynecology of The Children's Hospital, Zhejiang University School of Medicine. Data were collected from the electronic medical records. The abnormal vaginal discharge of patient was collected for microbiological investigation by bacterial and fungal culture. Descriptive analysis was conducted to evaluate the genital inflammation pattern and epidemiological characteristics, including age, season, and type of infected pathogens.

Results

A total of 49,175 patients met the eligibility criteria of genital inflammation and 16,320 patients later came to the hospital for follow-up over the study period. The number of first-visit increased gradually from 3,769 in 2011 to 10,155 in 2018. The peak age of the first visit was 0-6 years old. Non-specific vulvovaginitis, lichen sclerosis, and labial adhesion were the top three genital inflammation. Among the top five potential common pathogens of vaginal infection, the prevalence of Haemophilus influenzae cases was the highest (31.42%, 203/646), followed by Streptococcus pyogenes (27.74%, 176/646), Candida albicans (14.09%, 91/646), Escherichia coli (8.51%, 55/646), and Staphylococcus aureus (6.35%, 41/636). The specific disease categories and pathogens of genital inflammation vary by age groups and season.

Conclusion

Our study summarizes the pattern of pediatric and adolescent female genital inflammation over an 8-year period in China, emphasizing the need for more public awareness, healthcare services and research in this field.

Exploring the Potential of Nanotechnology in Pediatric Healthcare: Advances, Challenges, and Future Directions

The utilization of nanotechnology has brought about notable advancements in the field of pediatric medicine, providing novel approaches for drug delivery, disease diagnosis, and tissue engineering. Nanotechnology involves the manipulation of materials at the nanoscale, resulting in improved drug effectiveness and decreased toxicity. Numerous nanosystems, including nanoparticles, nanocapsules, and nanotubes, have been explored for their therapeutic potential in addressing pediatric diseases such as HIV, leukemia, and neuroblastoma. Nanotechnology has also shown promise in enhancing disease diagnosis accuracy, drug availability, and overcoming the blood-brain barrier obstacle in treating medulloblastoma. It is important to acknowledge that while nanotechnology offers significant opportunities, there are inherent risks and limitations associated with the use of nanoparticles. This review provides a comprehensive summary of the existing literature on nanotechnology in pediatric medicine, highlighting its potential to revolutionize pediatric healthcare while also recognizing the challenges and limitations that need to be addressed.

Microbiological findings in prepubertal and pubertal girls with vulvovaginitis

Vulvovaginitis is a common and challenging gynaecological problem in prepubertal and pubertal girls. Such an infection, owing to a wide range of aetiologies, if not responding to hygienic measures, needs further investigation through vaginal cultures, since treatment should be tailored accordingly. This study aimed to investigate the pathogens isolated in prepubertal and pubertal girls with signs and symptoms of vulvovaginitis. A total of 2314 symptomatic girls, 1094 prepubertal and 1220 pubertal, aged 2 to 16 years, were included. Vaginal samples were inoculated on specific culture plates followed by incubation in aerobic, anaerobic or CO2 atmosphere at 37 °C for 24 or 48 h, as appropriate. The identification of the isolated pathogens was carried out using Gram stain, conventional methods and the automated system VITEK 2 (BioMerieux, Marcy l'Etoile, France). Positive cultures were obtained from 587 (53.7%) of prepubertal girls and 926 (75.9%) of pubertal girls. A total of 613 and 984 pathogens were detected in prepubertal and pubertal subjects, respectively. Isolated bacteria included 40.1% and 22.8% Gram-positive cocci, 35.6% and 24.8% Gram-negative rods in the prepubertal and pubertal groups, respectively, with faecal pathogens being the most prevalent. Bacterial vaginosis was diagnosed in 22.8% of prepubertal and 37.9% of pubertal girls. Candida species were isolated mostly in the pubertal girls (14.5%).

CONCLUSION

Culture results should be evaluated with caution in children with vulvovaginitis. In the prepubertal girls, the most common isolated pathogens were opportunistic bacteria of faecal origin while girls in late puberty were more susceptible to bacterial vaginosis and vulvovaginal candidiasis.

WHAT IS KNOWN

• Vulvovaginitis is the most frequent and challenging reason for referral to paediatric and adolescent gynaecology services. • Microbiological examination can prove to be a significant tool to help diagnosis although results should be evaluated with caution in children.

WHAT IS NEW

• Significantly more positive vaginal cultures and pathogens were recorded in symptomatic pubertal girls compared to prepubertal children. • The prevalence of bacterial vaginosis was increased in both prepubertal and pubertal girls with vulvovaginitis although significantly more in girls at puberty.

Clinical Symptoms and Microbiological Findings in Prepubescent Girls with Vulvovaginitis

BACKGROUND

The diagnosis and treatment of vulvovaginitis in children is poorly managed because it is difficult to determine whether the agent causing vulvovaginal inflammation is a single bacterial species.

STUDY OBJECTIVE

This study retrospectively evaluated genital microbiological findings in prepubescent girls with vulvovaginitis and then compared the findings to healthy controls without discharge.

METHODS

This was a retrospective case-control study of 483 prepubescent girls aged 2-10 years with vulvovaginitis and 50 age-matched healthy asymptomatic controls. Data were collected at the Pediatric General Outpatient Unit of the Hospital of the Bezmialem Vakıf University from December 2015 to March 2021.

RESULTS

Of the 483 positive vaginal cultures in the study group, 248 (51.3%) exhibited potential causative agents. Conversely, 8 of 50 (16%) of the vaginal cultures in the control group (P < .001) exhibited potential causative agents. Streptococcus pyogenes was the most frequently detected causative agent of vulvovaginitis in the study group. S. pyogenes was present in specimens from 74 girls (15.8%) with symptoms of vulvovaginitis vs 1 (4.1%) specimen in the control group. Other specific organisms identified in the study group were Escherichia coli (12%), Haemophilus influenzae (5%), Staphylococcus aureus (4.3%), Candida albicans (4.3%), and Streptococcus agalactia (3.3%).

CONCLUSIONS

Among prepubescent girls with vulvovaginitis, 51.3% of vaginal cultures exhibited potential causative agents in the study group. Our microbiological data indicated that the most common pathogens were S. pyogenes and E. coli.

Healthy Vaginal Microbiota and Influence of Probiotics Across the Female Life Span

Vaginal microbiota plays a central role in women's health and reproduction. Vaginal microbiota is dynamic and shaped by hormonal shifts in each stage of a woman's life from pre-puberty to postmenopause. Current research has mainly focused on vaginal bacterial and fungal members of the community and emphasized their role in disease. However, the impact of balanced vaginal microbiota on health and its interaction with the host is yet poorly understood. High abundance of vaginal lactobacilli is most strongly associated with health, but the concept of health may vary as vaginal dysbiosis may be asymptomatic. Furthermore, there is a lot of variation between ethnic groups in terms of dominating vaginal bacteria. Probiotic lactobacilli could be a safe and natural means to balance and maintain healthy vaginal microbiota. Research evidence is accumulating on their role in supporting women's health throughout life. This review describes the current literature on vaginal microbiota, the major factors affecting its composition, and how the communities change in different life stages. Furthermore, we focused on reviewing available literature on probiotics and their impact on vaginal microbiota and health.

Microbiological Findings of Symptomatic Vulvovaginitis in Chinese Prepubertal Girls

STUDY OBJECTIVE

To study the bacteria and fungi causing vulvovaginitis in prepubertal girls.

DESIGN

Swabs from vaginal introitus were collected from patients with vulvovaginitis in 2018, and cultured for the identification of microorganisms with standard microbiological techniques.

SETTING

A children's hospital in Hangzhou, East China.

PARTICIPANTS

A total of 1235 Chinese prepubertal girls diagnosed with vulvovaginitis.

MAIN OUTCOME MEASURE

Bacteria or fungi in pure cultures or as the predominant organism were defined as pathogens.

RESULTS

A total of 1235 cases were diagnosed as vulvovaginitis, and 515 isolates were identified from 494 patients (40%, 494/1235). The most common pathogen was Streptococcus pyogenes (27.6%,142/515), followed by Haemophilus influenzae (27.2%,140/515), Candida albicans (22.3%,115/515), Staphylococcus aureus (5.8%, 30/515) and Escherichia coli (4.7%,24/515). All S pyogenes isolates were sensitive to penicillin, whereas 53.7% (73/136) of H influenzae isolates were sensitive to ampicillin, and 70.4% (19/27) of S aureus isolates were sensitive to oxacillin.

CONCLUSION

S pyogenes and H influenzae were the 2 most commonly identified pathogenic bacteria found in prepubertal girls with vulvovaginitis. Vulvovaginitis in prepubertal girls caused by C albicans may be more common in older children.

Clinical predictive value of the urine leukocyte esterase test positivity in childhood

BACKGROUND

False negative or positive results may occur in the urine dipstick test for leukocyte esterase (LE), which is used to determine urinary tract infection (UTI). We aimed to investigate the clinical importance of the presence or absence of pyuria in urine sediment for diagnosing UTI in the presence of positive LE in dipstick analysis.

METHODS

Patients admitted to the pediatric nephrology outpatient clinic with positive urine LE tests were divided into two groups: those without pyuria (Group 1) and those with pyuria (Group 2) in their urine sediment. Hospital files of the patients were evaluated retrospectively for demographic variables, lower or upper UTI symptoms, physical examination for phimosis and vulvovaginitis, urinalysis for LE and nitrite tests, urine sediment microscopy, urine culture, complete blood count and C-reactive protein. Both groups were compared for the significant growth of pathogenic bacteria in urine cultures along with clinical and laboratory parameters.

RESULTS

Among 578 children giving samples for urinalysis, there were 287 cases with positive LE tests. Groups 1 and 2 included 123 and 164 cases, respectively. The proportion of girls was higher in Group 1 and vulvovaginitis rate was higher among the girls in Group 1. Girls with vulvovaginitis were mostly prepubertal. Upper UTI symptoms, significant pathogen growth rate, and elevated acute phase response were more common in Group 2. In addition, the phimosis rate was more common among the boys in Group 1 with false positive LE test.

CONCLUSIONS

Children with positive LE tests without pyuria are mostly prepubertal girls and there is a high rate of vulvovaginitis in these girls. Unnecessary tests and treatments for UTI may be avoided with detailed history and physical examination in prepubertal girls who have a false positive LE test. We also found, for the first time, that a false positive LE test is significantly associated with phimosis in boys.

Characteristics of the vaginal microbiomes in prepubertal girls with and without vulvovaginitis

The present study focused on the characteristics of the vaginal microbiomes in prepubertal girls with and without vulvovaginitis. We collected 24 vaginal samples and 16 fecal samples from 10 girls aged 3–9 years with vulvovaginitis and 16 healthy girls of the same age. The samples were divided into three groups: fecal swabs from healthy controls (HF), vaginal swabs from healthy controls (HVS), and vaginal swabs from girls with vulvovaginitis (VVS). Sequencing of the V3–V4 region of the 16S rDNA gene was performed with the NovaSeq PE250 platform to reveal the vaginal microbial community structure in healthy prepubertal girls and vulvovaginitis-associated microbiota. The intestinal microbiomes of healthy children were also analyzed for comparison. This study revealed that the healthy vaginal tract in prepubertal girls was dominated by Prevotella, Porphyromonas, Ezakiella, and Peptoniphilus species, with a high diversity of microbiota. The vulvovaginitis-associated microbiota were dominated by Streptococcus, Prevotella, Haemophilus, and Granulicatella, with lower diversity than that in healthy girls. Furthermore, the compositions of the vaginal and intestinal microbiomes were completely different. ANOSIM, MRPP, Adonis, and AMOVA were used to analyze the beta diversity, and the results showed that there were significant differences in the microbial communities among the three groups. Lactobacillus deficiency and high bacterial diversity were characteristics of the vaginal microbiome in healthy prepubertal girls; this is inconsistent with that in reproductive-age women. The vulvovaginitis-associated vaginal microbiota differed dramatically from normal microbiota, and the main causative agents were not fecal in origin.

Prepubertal Vulvovaginitis

Vulvovaginitis is a common gynecologic complaint in prepubertal girls. It typically presents with complaints of vulvovaginal itching, burning, irritation, discharge, or skin changes. Prepubertal females have anatomic, physiological, and behavioral factors that most often contribute to the development of symptoms. Careful attention to history and associated complaints will direct evaluation, diagnosis, and treatment. Most cases are nonspecific in origin and treatment includes counseling to patients and parents on hygiene and voiding techniques. Antibiotic treatment for specific pathogens may be indicated. Other less common causes include foreign bodies and lichen sclerosus.

Clinical and Microbiological Findings of Vulvovaginitis in Prepubertal Girls

STUDY OBJECTIVE

To evaluate genital microbiological findings in prepubertal girls with vulvovaginitis and in healthy controls.

DESIGN

Prospective case-control study.

SETTING

Pediatric Outpatient unit of the Department of Pediatrics of the Hospital of the Lithuanian University of Health Sciences Kauno Klinikos from November 2014 to May 2017.

PARTICIPANTS

Fifty-two prepubertal girls aged 1-9 years diagnosed with vulvovaginitis, and 42 age-matched healthy controls.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Samples for microbiological culture were collected using sterile cotton swabs from the introitus and the lower third of the vagina from all study participants. Microbiological findings were analyzed according to bacteria type and intensity of growth.

RESULTS

Most of the vaginal microbiological swab results were positive for bacterial growth: 47 (90.4%) and 34 (80.9%) were similar in the study and control groups, respectively (P = .24). Sixteen (30.8%) and 9 (21.4%) of the microbiological traits results in the case and control groups, respectively, were regarded as potential causative agents (P = .27). Streptococcus pyogenes was the most frequent pathogen in the study group (P = .03); all other microorganisms detected as either a pure or dominant growth in the control group, were considered opportunistic.

CONCLUSIONS

Vaginal bacterial culture results were positive in prepubertal girls with vulvovaginitis and in healthy controls. Nonspecific vulvovaginitis without a dominant/isolated pathogen was seen to be more common than vulvovaginitis with a potential causative agent. Clinical symptoms were more frequent among girls when the potential infectious agent was identified.

Prediction of bacterial vulvovaginitis in girls at different Tanner stages of sexual development

At present, there is a paucity of research studies that comprehensively investigate the factors causing vulvovaginitis in young females. The aim of this work was to propose an algorithm for predicting the risk of vulvovaginitis in young girls and adolescents. The study recruited 252 healthy girls, who were stratified into a few groups depending on their sexual development on the Tanner scale. The composition of vaginal microbiota was determined in all the participants using real-time polymerase chain reaction (PCR); distribution of allele and genotype frequencies was assessed for the polymorphic variants of genes coding for pro- and anti-inflammatory cytokines. Based on the obtained data, we created a functional model for predicting the risk of vulvovaginitis in girls at different stages of sexual development. Favorable risk factors for Tanner I girls included predominance of obligate anaerobes in vaginal microbiota and the polymorphic IL10 variant (C-819T) homozygous for TT. The sensitivity of the model was 80%, its specificity was 78%. Favorable risk factors for prepubertal and pubertal girls included predominance of aerobes in the composition of vaginal microbiota and the presence of the TT allele in the polymorphic IL10 gene variant (C-3953T). The sensitivity of the model was 58.3%, whereas specificity, 94.1%. This study provides the rationale conforming with the principles of evidence-based medicine for using prevention measures in the groups at risk for vulvovaginitis at young age. The proposed measures allowed us to reduce the relapse rate of bacterial vulvovaginitis threefold.