Vulvovaginal and common prepubertal gynaecological disorders

Overview & Definition

Three conditions dominate the prepubertal vulval complaint in the general paediatric clinic, and all three share a common starting point in the hypo-oestrogenic state of the child before puberty. The first is vulvovaginitis, an inflammation of the vulva and the lower vagina that is the single commonest gynaecological complaint of prepubertal girls. [1] The second is labial adhesions, also called labial fusion, in which the labia minora fuse together along the midline to varying degrees, sometimes closing the vaginal introitus almost completely. [5] The third is lichen sclerosus, a chronic inflammatory skin condition that produces porcelain-white, atrophic, pruritic plaques on the vulval and perianal skin in the classic figure-of-eight distribution. [8]

The reason these conditions cluster in the prepubertal years is that the vulval skin and the vaginal mucosa of the young girl lack the protective maturation that oestrogen brings at puberty. [1] Before puberty the vulval epithelium is thin, the vaginal pH is neutral rather than acidic, and the lactobacilli that dominate the adult vaginal flora are absent, so the tissue is vulnerable to irritation, to fusion under mild inflammation, and to the immune-mediated changes of lichen sclerosus. Puberty reverses much of this vulnerability, which is why labial adhesions resolve spontaneously as oestrogen rises and why vulvovaginitis becomes far less common. [2]

The clinical task at the bedside is to recognise each condition, to treat it along the evidence-based pathway, and to identify the red flags that change a simple problem into an emergency or a child protection concern. A persistent or bloody discharge raises the question of a vaginal foreign body. A specific sexually transmitted organism on a vaginal swab raises the question of sexual abuse. Unexplained prepubertal bleeding demands evaluation for trauma, foreign body, precocious puberty, or a tumour. [12]

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1. [1]Romano ME Prepubertal Vulvovaginitis. Clin Obstet Gynecol, 2020.PMID 32282354
2. [2]Brander EPA, McQuillan SK Prepubertal vulvovaginitis. CMAJ, 2018.PMID 29970369
3. [3]Baka S, Demeridou S, Kaparos G Microbiological findings in prepubertal and pubertal girls with vulvovaginitis. Eur J Pediatr, 2022.PMID 36163515
4. [4]Zuckerman A, Romano M Clinical Recommendation: Vulvovaginitis. J Pediatr Adolesc Gynecol, 2016.PMID 27969009
5. [5]Bacon JL, Romano ME, Quint EH Clinical Recommendation: Labial Adhesions. J Pediatr Adolesc Gynecol, 2015.PMID 26162697
6. [6]Kim SW, Han JY, Han SJ Effect of topical estrogen cream compared with observation in prepubertal girls with labial adhesions. J Pediatr Urol, 2023.PMID 37179197
7. [7]Norris JE, Elder CV, Dunford AM Spontaneous resolution of labial adhesions in pre-pubertal girls. J Paediatr Child Health, 2018.PMID 29436045
8. [8]Bercaw-Pratt JL, Boardman LA, Simms-Cendan JS Clinical recommendation: pediatric lichen sclerosus. J Pediatr Adolesc Gynecol, 2014.PMID 24602304
9. [9]De Luca DA, Papara C, Vorobyev A Lichen sclerosus: The 2023 update. Front Med (Lausanne), 2023.PMID 36873861
10. [10]Fistarol SK, Itin PH Diagnosis and treatment of lichen sclerosus: an update. Am J Clin Dermatol, 2013.PMID 23329078
11. [11]Kirtschig G, Kinberger M, Kreuter A EuroGuiderm guideline on lichen sclerosus-Treatment of lichen sclerosus. J Eur Acad Dermatol Venereol, 2024.PMID 38822598
12. [12]Bloomfield V, Iseyemi A, Kives S Clinical Review: Prepubertal Bleeding. J Pediatr Adolesc Gynecol, 2023.PMID 37301426