Primary prevention is achieved by promoting good perinealhygiene and managing underlying risk factors for UTI, suchas chronic constipation, encopresis, and daytime and nighttime urinary incontinence. There is evidence that antibioticprophylaxis may prevent more severe symptomatic recurrentinfections, although the effect is small. The impact of secondary prophylaxis to prevent renal scarring is unknown.Acidification of the urine with cranberry juice is not recommended as the sole means of preventing UTI in children at high risk.
Vulvovaginitis, which is inflammation of the vulva or the vagina or both, is the most common gynecologic problem inchildren. Low prepubertal levels of estrogen result in thin, atrophic vaginal epithelium that is susceptible to bacterialinvasion. At puberty estrogen increases, and the pH of the vagina becomes more acidic. There are several specific causesof vulvovaginitis (Table 115-1), including sexually transmitted infections such as Trichomonas vaginalis and herpes simplex virus (see Chapter 116). Nonspecific vaginitis results from overgrowth of normal aerobic vaginal flora that is associated with poor hygiene. Bacterial vaginosis is caused by Gardnerella vaginalis, which interacts synergistically with vaginal anaerobes, including Bacteroides, Mobiluncus, and Peptostreptococcus.
Nonspecific vaginitis is the most common cause of vulvovaginitis in young girls. G. vaginalis is often present as part of the normal vaginal flora in preadolescent girls but is more common in girls who are sexually active. Candida is much less common in preadolescent girls than in women.
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The primary symptoms of vulvovaginitis are vaginal discharge, erythema, and pruritus. Characteristics of specific etiologies are outlined in Table 115-1.
Wet mount microscopic examination, prepared by mixing vaginal secretions with normal saline solution, and culture may be used to confirm a specific diagnosis (see Table 115-1).Clue cells are vaginal epithelial cells that are covered with G. vaginalis and have a granular appearance. Vaginal cultures for
G. vaginalis are not useful. Candida may be identified by saline wet mount or by culture.
Noninfectious causes of vulvovaginitis include physicalagents (foreign body, sand), chemical agents (bubble bath,soap, detergent), and vulvar skin disease (atopic dermatitis, seborrhea, psoriasis). Physiologic vaginal discharge orphysiologic leukorrhea of desquamated vaginal cells andmucus occurs normally in girls soon after birth, with discharge lasting for about 1 week, and appears again at 6 to 12months before menarche. The discharge is minimal, clear,and thin without pruritus or inflammation. No treatment is necessary.
The treatment of vulvovaginitis depends on the etiology (see Table 115-1). Treatment of nonspecific vaginitisfocuses on improving perineal hygiene. The recommendedtreatment for bacterial vaginosis is oral metronidazole orclindamycin. Imidazole creams and vaginal tablets andsuppositories all are effective for the treatment of acute
Physiologic vaginal discharge Minimal, clear, thin discharge No pathogenic organisms on Reassurance
Nonspecific vaginitis Vaginal discharge, dysuria, Evidence of poor hygiene; no Improved hygiene, sitz baths 2−3 itching; fecal soiling of underwear pathogenic organisms on culture times/day
Bacterial vaginosis Often asymptomatic; possible thin vaginal discharge with a “fishy” odor