Clinical and Microbiological Findings of Vulvovaginitis in Prepubertal Girls

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.

Vaginal bleeding in prepubertal females: a case of Shigella vaginitis and review of literature

Shigella vulvovaginitis is an uncommon aetiology of prepubertal vaginal bleeding that should be considered in the differential diagnosis, especially in patients who have travelled to developing countries. A young girl presented with prepubertal vaginal bleeding, pelvic pain, occasional dysuria and no gastrointestinal symptoms. After a year-long extensive workup, including vaginoscopy and biopsy, genital culture and Gram stain revealed vulvovaginitis due to Shigella flexneri After review of bacterial sensitivity, the patient was given a 30-day course of sulfamethoxazole-trimethoprim. The patient returned to the clinic 1 month later with no signs of vaginal bleeding, discharge or pelvic pain. This case prompted review of the indicated evaluation and differential diagnosis of prepubertal vaginal bleeding, including infectious aetiologies such as Shigella vulvovaginitis with the authors' goal to expedite diagnosis and treatment in paediatric patients.

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.

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.

STROBE-sequencing analysis of the vaginal microecology of 4- to 6-year-old girls in Southwest China

We investigated the vaginal flora diversity of preschool-aged (ie, 4-6-year-old) girls in southwest China.Fourteen preschool-aged girls were enrolled in this study. The statuses and differences in their vaginal flora were evaluated by Gram staining, bacterial culturing, and sequencing analysis.Gram staining and microbial culturing showed that the main vaginal flora of the preschool-aged girls were Gram-negative bacilli, whereas the main vaginal flora of healthy adult controls were large Gram-positive bacilli such as Lactobacillus crispatus. Shannon and Simpson indexes indicated that the bacterial diversity tended to decrease with age. The species abundance heat map showed that the vaginal microecology of the girls differed slightly at different ages but mainly comprised Pseudomonas, Methylobacterium, Sphingomona,s and Escherichia. The functional abundance heat map indicated that the bacterial functions increased with age.The vaginal microecology of preschool-aged girls differs from that of adults. A comprehensive understanding of the vaginal flora diversity of preschool-aged girls will aid in clinically diagnosing vulvovaginitis in preschool-aged girls.

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.