Pediatrics is usually the most appropriate first line of referral for children with genital problems requiring a specialist opinion. Referral on to gynecology, urology, dermatology or GU medicine for a combined assessment can then take place if considered necessary. Consider seeking advice at an early stage, particularly if there is the slightest concern about sexual abuse. A telephone call and discussion prior to referral is often appreciated in the less straightforward cases.
21.1 GIRLS
21.1.1 Vaginal Discharge
Prepubertal girls do occasionally produce a small amount of clear, non-malodorous vaginal discharge. In addition, a slightly thicker, off-white discharge is often seen during the first week after birth and during the months preceding the menarche. A discharge which is particularly heavy or malodorous suggests an infective or pathological cause. This may be associated with vulval irritation and possibly evidence of vulval and vaginal erythema.
The more common causes of pathological discharge include the following:
(1) Infection
(a) Candidiasis. Candida is an uncommon pathogen in prepubertal girls; however, symptoms, when they occur, are identical to the adult with vulval irritation and evidence of a vulvitis. Candida may develop on a pre-existing skin disorder such as eczema or seborrhoeic dermatitis. It is worth inquiring whether the mother has symptoms suggestive of "thrush" as transfer of Candida from mother to baby may sometimes occur.
(b) Bacterial vaginosis. Although usually associated with sexual activity, bacterial vaginosis has been documented in sexually inexperienced adolescents. The condition is occasionally seen in very young children; however, the prevalence of bacterial vaginosis in this age group has not been reported.
(c) Group A and Group B streptococci
(d) Escherichia coli
(e) Haemophilus influenzae. Although the above three groups of organisms have been reported to cause vulvovaginitis, asymptomatic carriage may also occur. Positive bacterial culture from a vaginal swab may therefore not always signify pathogenicity. A true pathogenic role may be assumed if symptoms resolve with antibiotic treatment.
(f) Shigella flexneri. Has been reported but generally considered an uncommon cause of vulvovaginitis.
(g) Chlamydia. The prepubertal vagina is susceptible to chlamydial infection. This is in contrast to the adult where the cervix and urethra are the prime sites of infection. Prepubertal chlamydial infection should raise a strong suspicion of sexual abuse, although in the very young infection may have occurred by vertical transmission from the mother at birth. This may persist for up to 2 years after birth and possibly longer. Asymptomatic vaginal and rectal infection has been reported in as many as 15% of infants born to infected mothers. Conjunctivitis and pneumonitis are more common complications and have been reported in 50-70% of exposed infants.
(h) Gonorrhea. This is a sexually transmitted infection and should be considered diagnostic of sexual abuse in the majority of cases.
(2) Foreign bodies
Young girls occasionally insert small objects or pieces of toilet paper into the vagina as part of normal exploratory behavior.
With time these objects may give rise to a malodorous discharge. Insertion of objects that mimic a penis suggests possible sexual abuse rather than self-stimulation.
21.1.2 Genital Irritation
21.1.2.1 Vaginal Discharge
This may cause vulval erythema and irritation secondary to persistent dampness. Alternatively, vulval symptoms may be directly attributable to the initiating infection, for example Candida.
21.1.2.2 Threadworms
Generally considered a cause of anal irritation, threadworms may track to the vulval area and give rise to predominantly genital symptoms. The major symptom is nocturnal perineal pruritis and examination may reveal vulval and perianal erythema.
21.1.2.3 Chemical Irritants
"Bubble-bath," scented soaps, and shampoos may cause an irritant dermatitis or a true contact dermatitis. As for adults, aqueous cream is a useful soap substitute.
21.1.2.4 Poor Hygiene
Whereas excessive washing with scented soaps may cause problems, inadequate genital bathing and poor hygiene leading to prolonged exposure to urine or feces may also predispose to irritation. Non-cotton and tight fitting underwear may aggravate symptoms.
21.1.2.5 Masturbation
Children masturbate or play with their genitalia from the time their hands can reach that far. This is considered a normal part of sexual development, although it frequently generates a degree of anxiety in the parents. Public and "excessive" masturbation may be seen in the learning disabled as part of their disability. The possibility of sexual abuse should be considered in other children, particularly if masturbation is performed in public.
21.1.2.6 Lichen Sclerosus
This condition may affect young children and, to the unwary, may be misdiagnosed as evidence of sexual abuse. The clinical features are the same as seen in the adult.
20.1.3 Boys
Balanoposthitis is not an uncommon problem in uncircumcised young boys. Symptoms are usually mild and settle with simple measures, such as bathing. Recurrent inflammation is unusual and often associated with a non-retractile foreskin or poor hygiene. At birth the prepuce adheres to the glans penis in most infants. By 6 months 15% of infants have a retractile foreskin and by the age of 5 years just over 90% of boys can fully retract the foreskin. This increases to 99% by the age of 17 years. An inability to retract the foreskin may be due to phimosis which is a pathological scarring of the foreskin, often secondary to lichen sclerosus (balanitis xerotica obliterans). Phimosis should be distinguished from a normal but non-retractile foreskin. Preputial adhesions represent a stage in the normal process of separation of the two epithelial surfaces of the glans and the prepuce and will usually spontaneously resolve without treatment.