II. Pathophysiology

  1. Low levels of Estrogen in the vagina
  2. Poor peri-vaginal hygiene in toddlers

III. Symptoms

  1. Streaking in underwear or diaper
  2. Small amount of Vaginal Bleeding may be present
  3. Vulvar Pruritus

IV. Signs

  1. Perform with child in open frog leg position
  2. Vaginal erythema
  3. White Vaginal Discharge
  4. Vulvar excoriations may be present

V. Labs

  1. Culture of peri-vaginal and peri-anal skin
    1. Consider in suspected Bacterial Infection (Streptococcus, Shigella)

VI. Differential Diagnosis

  1. See Vaginitis
  2. See Vaginal Discharge
  3. Child Sexual Abuse
  4. Vaginal Foreign Body (e.g. rolled up toilet paper)
    1. Associated with foul smelling copious discharge
    2. May irrigate with warm saline via IV catheter tip (without needle)
  5. Yeast Vaginitis
    1. Rare in pre-pubescent girls (even with recent antibiotic use)
  6. Bacterial Infection
    1. Streptococcal Vulvovaginitis
      1. Similar to Perianal Streptococcal Dermatitis
    2. Shigella Vulvovaginitis
      1. Associated with copious discharge and recent Diarrheal illness

VII. Management

  1. Improve peri-vaginal hygiene
  2. Apply hypoallergenic topical to the affected area
    1. Aquaphor
    2. Vaseline
    3. Desitin
  3. Avoid irritants
    1. Avoid baby powders
    2. Avoid scented lotions
    3. Avoid bubble bath
    4. Avoid tight synthetic pants or underwear
    5. Avoid sitting in a soapy bath
      1. Apply soap at the end of the bath
      2. Rinse well with fresh water

VIII. References

  1. Claudius and Willner in Herbert (2019) EM:Rap 19(1): 2-4

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