Vulvovaginal and common prepubertal gynaecological disorders

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Target exams

Red flags

• A prepubertal girl with persistent or bloody vaginal discharge that may indicate a vaginal foreign body such as retained toilet paper or a small object requiring examination under anaesthesia
• A prepubertal girl with a specific sexually transmitted infection pathogen on vaginal swab that raises the concern of sexual abuse and mandates child protection referral
• A prepubertal girl with severe labial adhesions causing urinary obstruction or recurrent urinary tract infections that requires prompt treatment with topical estrogen or manual separation
• A girl with lichen sclerosus showing bruising, fissuring, or scarring in conjunction with behavioural concerns that warrants careful consideration of coexisting sexual abuse
• Any prepubertal vaginal bleeding that is not clearly explained by a local cause and that requires evaluation for a foreign body, trauma, precocious puberty, or a tumour

Life stages

Care settings

Clinical exam formats

Board mappings

• Vulvovaginitis as the commonest prepubertal gynaecological complaint driven by the hypo-oestrogenic thin mucosa and the neutral vaginal pH
• Labial adhesions as the fusion of the labia minora peaking between three months and six years and usually resolving spontaneously
• Lichen sclerosus as the chronic inflammatory dermatosis presenting with porcelain-white pruritic plaques treated with an ultra-potent topical corticosteroid
• The microbiological spectrum of specific vulvovaginitis including Group A Streptococcus, Shigella, Haemophilus influenzae, and pinworm
• The stepwise management of labial adhesions from observation through topical estrogen to manual separation only for urinary obstruction
• The long-term follow-up and malignancy surveillance for paediatric lichen sclerosus and the role of biopsy in atypical disease
• The hygiene measures and empiric approach to nonspecific vulvovaginitis and the specific treatment of identified pathogens
• The red flags of vaginal foreign body, sexual abuse, and unexplained prepubertal bleeding
• The distinction between lichen sclerosus and vulvovaginitis when a girl presents with vulval itch and white plaques
• Short case examination of a prepubertal girl with vulval complaints including inspection technique and swab interpretation
• Long case counselling of a family on the chronic relapsing course of lichen sclerosus and the need for maintenance therapy
• Communication station on reassuring a family that labial adhesions will resolve and that topical estrogen is safe
• Level 1 Recognition of the common prepubertal vulval complaints and the hypo-oestrogenic physiology that underlies them
• Level 2 Application of the first-line hygiene measures for vulvovaginitis and the topical estrogen pathway for labial adhesions
• Level 3 Coordination of paediatric, dermatology, and child protection input for lichen sclerosus with atypical features
• The anatomy and physiology of the prepubertal vulva and vagina and the predisposition to vulvovaginitis
• The aetiology and natural history of labial adhesions and the rationale for conservative management
• The clinical features, first-line treatment, and long-term outlook of paediatric lichen sclerosus
• Examination of the prepubertal child with a vulval complaint and the collection and interpretation of vaginal swabs
• Communication with the family on hygiene measures, reassurance, and the safe short-term use of topical estrogen or steroid
• Recognition of the red flags of foreign body, sexual abuse, and unexplained bleeding
• Prepubertal vulvovaginitis, labial adhesions, and lichen sclerosus as the three common prepubertal gynaecological disorders
• The hypo-oestrogenic environment as the unifying pathophysiology and the neutral vaginal pH as the diagnostic clue
• The first-line treatments: hygiene for vulvovaginitis, topical estrogen for adhesions, and ultra-potent corticosteroid for lichen sclerosus
• Patient Care recognition and treatment of the common prepubertal vulval conditions in the outpatient setting
• Medical Knowledge the hypo-oestrogenic physiology and the microbiology of specific vulvovaginitis
• Systems-Based Practice timely child protection referral when a specific sexually transmitted pathogen or atypical injury is identified
• The Canadian approach to prepubertal vulvovaginitis with hygiene as first-line and targeted antimicrobials for specific pathogens
• Observation versus topical estrogen for labial adhesions with manual separation reserved for urinary obstruction
• Paediatric lichen sclerosus management with ultra-potent corticosteroid and long-term follow-up