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Fifteen-minute consultation: Vulval soreness in the prepubertal girl

A general practitioner (GP) refers to your general paediatric outpatient clinic a 6-year old girl with an intermittently sore vulva with occasional discharge. Her mother noticed her ‘vagina’/genitalia has been slightly red, and there is intermittent minimal white discharge. Clotrimazole (Canestan), prescribed by her GP, has not made any difference.

In this article, we discuss the aetiology and initial assessment of vulval soreness and related symptoms in the prepubertal girl. The article does not include the differential diagnoses in the peripubertal and postpubertal adolescent cohort, thereby excluding conditions related to menstruation and pregnancy (see box 1).

Box 1 
### Anatomy of prepubertal and pubertal girls

The prepubertal girl’s anatomy is different from that of the pubertal girl. During puberty, labial fat pads begin to form; pubic hair grows; the vaginal mucosa becomes thicker and less thin-walled; and the squamous cells in the epithelial lining of the vagina undergo cornification, leading to increased protection against pathogens.4 Hormonal changes during puberty include oestrogenisation of the vulva, hymen and vaginal mucosa, and acidification of the pH, which was previously alkaline or neutral.7 Together, these changes decrease susceptibility to inflammation and infection.

Vulval soreness, or pain, and discharge in prepubertal girls are common reasons for referral by primary care physicians to secondary care. It is often worrying for parents, particularly if symptoms are long-standing or disruptive to the child’s daily activities.

Epidemiological data on vulval pain as a presenting symptom to primary or secondary care are sparse. One study from a UK district general hospital reported that 86% of new paediatric and adolescent patients were referred from primary care, and the the most common presentations were vulvovaginitis (18%), labial adhesions (14%) and abdominal pain (7%).1 This differs from data on children attending a UK tertiary referral centre, where one-third of patients presented with anomalies of the genital tract, with …