Clinical Recommendation: Vulvovaginitis

Vaginal Microbiome: Environmental, Biological, and Racial Influences on Gynecological Health Across the Lifespan

The human vaginal microbiome (VMB) is a complex and unique ecosystem composed of various microorganisms, including bacteria, fungi, archaea, viruses, and candidate phyla radiation. A healthy VMB is often characterized by the presence of Lactobacillus species, which play a crucial role in protecting and maintaining homeostasis within the vaginal environment. When this balance is disrupted, the protection of the vaginal epithelium weakens, leading to a reduction in Lactobacillus species and an increased risk of various gynecological and reproductive health issues. However, this generalized description can lead to misconceptions and an incomplete understanding of vaginal health, as Lactobacillus is not always dominant across all ages and racialized groups. Therefore, this review provides a comprehensive analysis of the environmental, biological, and racial influences on the VMB at each stage of a woman's life, highlighting their implications for gynecological health and offering a holistic understanding of the VMB for all women.

Pictorial Cases in Pediatric and Adolescent Gynecology

Having experience in conditions that range from very common to exceptionally rare may aid in diagnosis, and appropriate management algorithms can assist us in providing thorough care to our patients. We present a variety of pictorial cases in pediatric and adolescent gynecology.

Analysis of Pathogenic Bacteria and Drug Resistance Among Girls with Bacterial Vaginitis

Objective

The aim of this study was to analyze the prevalence of vaginal flora and drug resistance in bacterial vaginitis among girls.

Methods

A total of 3099 girls (0-10 years old) with vaginitis who visited the Beijing Children's Hospital from January 2020 to December 2021 were included in the present study. The clinical data, results of bacterial culture of vaginal secretions, and drug sensitivity reports of the subjects were collected and analyzed.

Results

Of the 3099 girls with vaginitis, 399 girls had a positive bacterial culture of vaginal secretions. Nineteen types of bacteria were cultured from the vaginal secretions of these 399 girls, with a total of 419 strains. The top three infective bacteria were Haemophilus influenzae (127 strains, 30.31%), Staphylococcus aureus (66 strains, 15.75%), and Streptococcus agalactiae (32 strains, 7.64%). Additionally, 20 girls were simultaneously infected with two types of bacteria. Staphylococcus aureus, Group G Streptococcus, Haemophilus parainfluenzae, and Pseudomonas aeruginosa more frequently occurred in mixed infections. The number and bacterial detection rate among school-age girls were higher than those of preschool-age girls. We found seasonal variation in infection rates, and vaginitis among girls was higher in summer. Recurrence of vaginitis in girls was not related to the type of pathogenic bacteria in the infection. Drug sensitivity analyses showed that the resistance rates of clindamycin and erythromycin were generally high, 70-100%. After the coronavirus disease 2019 outbreak, the resistance rates of some antibiotics had decreased to varying degrees.

Conclusion

Improving the understanding of vaginal flora and drug resistance in girls with vaginitis will facilitate the selection of highly effective and sensitive antibacterial drugs and reduce the production of drug-resistant strains.

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.

The Vaginal Microbiome: I. Research Development, Lexicon, Defining "Normal" and the Dynamics Throughout Women's Lives

OBJECTIVE

This series of articles, titled The Vaginal Microbiome, written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the current findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders.

MATERIALS AND METHODS

A database search of PubMed was performed, using the search terms "vaginal microbiome" (VMB) with "research," "normal," "neonate," "puberty," "adolescent," "menopause," and "ethnicities," as well as "human microbiome project." Full article texts were reviewed. Reference lists were screened for additional articles.

RESULTS

In the last 2 decades, many studies applying molecular techniques were performed, intending to characterize the vaginal microbiota. These studies advanced our understanding of how vaginal health is defined. The first article in this series focuses on the advancement of VMB research, technical definitions, the definition of "normal" VMB, and the dynamics of VMB throughout women's lives.

CONCLUSIONS

Understanding how microorganisms inhabiting the vagina interact with each other and with the host is important for a more complete understanding of vaginal health. The clinical application of microbial community sequencing is in its beginning, and its interpretation regarding practical clinical aspects is yet to be determined.

Comparison of Short-Duration and Chronic Premenarchal Vulvar Complaints

STUDY OBJECTIVE

To compare clinical characteristics, treatment histories, and microbiology of premenarchal girls who presented to a pediatric gynecology specialty clinic with short-duration and chronic vulvar symptoms.

DESIGN

Retrospective cohort study.

SETTING

Pediatric and adolescent gynecology clinic at a tertiary care children's hospital.

PARTICIPANTS

One hundred eighty-two premenarchal patients ages 2-14 years who presented to a pediatric gynecology specialty clinic with vulvar complaints and who were evaluated with a yeast and/or bacterial culture.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Chronic and short-duration vulvar symptoms, microbiology, and diagnosis.

RESULTS

Patients with chronic symptoms were more likely to present with itching (59/102 (57.8%) vs 34/80 (42.5%); P = .04), redness or rash (53/102 (52.0%) vs 22/80 (27.5%); P = .0009), and discomfort (59/102 (57.8%) vs 30/80 (37.5%); P = .006), compared with patients with short-duration symptoms. Overall, 44.5% of patients had a history of antifungal treatment, with a greater proportion of patients with chronic symptoms having received antifungal treatment compared with those with short-duration symptoms (53/102 (52.0%) vs 28/80 (35.0%); P = .02). Despite a history of antifungal treatment in nearly half of the patients, Candida albicans was isolated in only 3/144 (2.1%) yeast cultures. Bacterial vulvar cultures were positive in 75/159 (47.2%), and there was no difference among the symptom duration groups (38/71 (53.5%) vs 37/88 (42.1%); P = .15).

CONCLUSION

Vulvovaginitis is a common gynecological diagnosis among premenarchal girls with short-duration and chronic vulvar symptoms. Regardless of symptom duration, yeast cultures are rarely positive. Antifungal treatment should be avoided in toilet-trained prepubertal girls.

Evaluation of vulvovaginitis in the adolescent patient

Vulvovaginitis, referring to inflammation of the vulva and vagina, is a commonly reported concern among adolescents and young women presenting for gynecologic care. Symptoms of vulvovaginitis may include vaginal discharge, odor, itching, pain, dysuria, skin irritation, burning, and dyspareunia. Vulvovaginitis may result from infectious or non-infectious causes. Bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis represent the three most common infectious causes of vulvovaginitis in adolescents and young adults. Additionally, non-infectious causes such as the presence of a foreign body in the vagina, chemical irritants, douching, and poor hygiene may also lead to symptoms of vulvovaginitis. A thorough history in combination with the appropriate physical examination and laboratory evaluation is necessary to identify the cause of a patient's symptoms. Importantly, adolescent patients should be given the opportunity to speak privately with the provider without a parent or guardian present in the room, particularly when gathering the sexual history. Appropriate anticipatory guidance and counseling should be provided once a diagnosis has been made, and prevention of future episodes of vulvovaginitis should be discussed.

Vaginitis in Nonpregnant Patients: ACOG Practice Bulletin, Number 215

Vaginitis is defined as inflammation or infection of the vagina and is associated with a spectrum of symptoms, including vulvovaginal itching, burning, irritation, dyspareunia, "fishy" vaginal odor, and abnormal vaginal discharge. Vaginal symptoms are some of the most frequent reasons for patient visits to obstetrician-gynecologists () and may have important consequences in terms of discomfort and pain, days lost from school or work, sexual functioning, and self-image (). Distinguishing vaginal from vulvar symptoms is important to direct evaluation and treatment. The purpose of this document is to provide updated evidence-based guidance for the diagnosis and treatment of the common causes of vaginitis in nonpregnant patients. Information on the treatment of vaginitis in patients with human immunodeficiency virus (HIV) is covered elsewhere (). Guidelines are subject to change. For the most up-to-date information on vaginitis diagnosis and treatment, see the Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases webpage, which is available at https://www.cdc.gov/std/.

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.

Parental experiences of their child's vulvovaginitis: a qualitative interview study

INTRODUCTION

Vulvovaginitis is described as a common self-limiting paediatric gynaecological condition. Parents' experiences of their child being diagnosed with this condition and subsequent treatment have not previously been described.

AIM

The aim of this study was to explore parents' experiences of their child's diagnosis and management of vulvovaginitis.

STUDY DESIGN

The study was conducted in the north west of England over a two-year period. Qualitative data were generated by semistructured in-depth interviews. Mothers of nine children with vulvovaginitis consented to participate. Data were analysed using thematic analysis.

RESULTS

The analysis of the data resulted in four themes: trauma and uncertainty of initial symptoms, seeking a diagnosis; an uncertain journey, managing the symptoms; a process of trial and error and managing the impact; keeping it private. Parents experienced a difficult and protracted journey to their child's diagnosis and were involved in a process of trial and error to try and monitor and manage what can be a difficult ongoing condition.

DISCUSSION

Clinical reports suggest that vulvovaginitis is a minor childhood condition; this is not necessarily the perceptions and experiences of parents, who can experience uncertainty and ongoing difficulty after their child's diagnosis.

CONCLUSION

The diagnosis of vulvovaginitis can have a major and ongoing impact on children's and their family's lives.

Epidemiological Features and Antibiotic Resistance Patterns of Haemophilus influenzae Originating from Respiratory Tract and Vaginal Specimens in Pediatric Patients

STUDY OBJECTIVE

Haemophilus influenzae (H. influenzae) is a common pathogen of respiratory tract infections in children, however, as a possible cause of vulvovaginitis in prepubertal girls, its epidemiological features, antibiotic-resistance patterns, and treatment are seldom noted. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Specimens obtained from patients were inoculated on Haemophilus selective medium; and drug-sensitivities tests were determined using the disk diffusion method. A cefinase disk was used to detect β-lactamase.

RESULTS

A total of 610 H. influenzae strains, 81.6% (498/610) from the respiratory tract and 18.0% (110/610) from the vagina, were identified in the Children's Hospital in 2015. The age of the children with respiratory tract strains were significantly younger than those with vaginal strains (P < .001). The H. influenzae isolation rate in May was the highest. The β-lactamase positive rate was 51.5% (314/610), and 52.5% (320/610) were resistant to ampicillin. The susceptibilities rates to cefuroxime, ampicillin/sulbactam, cefotaxime, clarithromycin, and sulfamethoxazole-trimethoprim were 72.1% (440/610), 95.9%, 96.4% (588/610), 81.8% (499/610), and 36.4% (222/610), respectively. Higher resistance to ampicillin, cefuroxime, clarithromycin, and sulfamethoxazole-trimethoprim were found in respiratory tract strains, compared with vaginal strains (P < .05). All of the patients with H. influenzae in the respiratory tract were cured with oral or intravenous β-lactam antibiotics. Of all patients with vaginal strains, 50% (55/110) were cured with topical ofloxacin gel, and 44.5% (49/110) were cured with oral β-lactam antibiotics.

CONCLUSION

The drug-resistance rates of H. influenzae isolated from vagina were lower than those from the respiratory tract. Topical ofloxacin gel or oral β-lactam antibiotics are effective treatments to eliminate the H. influenza causing infection in the vagina.

Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology

Vulvovaginitis is one of the most common gynecological complaints presenting in the pediatric and adolescent female. The common causes of vulvovaginitis in the pediatric patient differ than that considered in adolescent females. When a child present with vulvar itching, burning and irritation the most common etiology is non-specific and hygiene measures are recommended. However these symptoms can mimic more serious etiologies including infection, labial adhesion, lichen sclerosis, pinworms and foreign body must be considered. Yeast infection is rare in the pediatric population but common in the adolescent. In the adolescent patient infections are more common. Yeast and bacterial vaginosis are commonly seen but due to the higher rate of sexual activity in this population sexually transmitted infections must also be considered.