Symptoms and Causes of Vulvovaginitis in Children

Vaginitis refers to inflammation or infection of the vagina, but it can also affect the vulva, the area outside the vagina (vulvovaginitis).

Vulvovaginitis is one of the most common causes of visits to primary care for people with vaginas. Because of a lack of estrogen, which doesn't increase until puberty, the skin in and around the vagina can be thin, delicate, and easily irritated.

In addition to the fragility of the skin, people with vaginas are predisposed to vulvovaginitis because of a lack of protective pubic hair, the closer proximity of the vagina and anus, and a lack of labial fat pads that help to protect the entry of the vagina.

People with vaginas need to be taught from a young age to wipe front-to-back when going to the bathroom, not back-to-front, to avoid spreading bacteria into the urethra and vagina. Avoiding other sources of irritation can also help prevent vulvovaginitis in people with vaginas.

Causes

Vulvovaginitis can sometimes be caused by an infection with fungus (yeast infections), bacteria (bacterial vaginosis), viruses, or protozoal parasites. The majority of the time, however, the cause is nonspecific in people with vaginas and is not caused by one of these germs.

Infectious Vulvovaginitis

Approximately 25% of vulvovaginitis cases in children are from an infectious cause.

Yeast infections are fungal infections that can be problematic especially for infants with vaginas and for adolescents with vaginas. Babies can get yeast diaper rashes. Vaginal yeast infections can be uncomfortable and are more common in people with vaginas who have started their periods.

Yeast infections in a prepubescent person with a vagina are rare, but they may occur if they have had to take antibiotics, have diabetes, or if they have a problem with their immune system. For that reason, recurring yeast infections in prepubescent people with vaginas can be a sign of another health issue.

Vaginal yeast infections are most often recognized by a cottage cheese-like, lumpy, white discharge, itching, swelling, and redness.

Bacterial infections causing vulvovaginitis in children most frequently come from bacteria in the gastrointestinal or respiratory tract, and they may present with pain, redness, and a discharge that is milky, watery, or may smell "fishy." Some bacteria, such as the bacteria that cause chlamydia, are sexually transmitted.

Viral infections like herpes simplex virus (HSV) and human papilloma virus (HPV) and protozoal parasitic infections like trichomoniasis that cause vulvovaginitis are less common in younger children, as they are generally sexually transmitted.

Nonspecific Vulvovaginitis

Most cases of prepubertal vulvovaginitis are from nonspecific causes and can be addressed without the need for medication. Because most cases of vulvovaginitis are from irritants or hygiene issues, the prevention tips below are generally adequate to handle the problem.

Common causes of nonspecific vulvovaginitis in kids and adolescents include:

• Direct irritants like tight-fitting clothing, dyes and perfumes in soaps, shampoos, bubble baths, laundry detergents and dryer sheets, and dyes in underwear
• Behaviors such as wiping back-to-front on the toilet, taking bubble baths, sitting around in a wet swimsuit or damp workout clothing, being sexually active, or using douches or feminine washes
• Systemic illnesses including diabetes, immune system issues, or other systemic dermatological issues like eczema or psoriasis
• Infections from germs like fungus (yeast, especially Candida species), bacteria, viruses, and protozoal parasites. Most of these infections are from imbalances and overgrowth in our own systems and the cause is unknown. In other cases, the infection is sexually transmitted.
• Bowel issues like diarrhea or chronic constipation

If a foul odor is noted without an infection found, it may be that you have a foreign object or substance in your vagina, such as toilet paper.

Lastly, in a review of pediatric patients with a recurring vaginal discharge, 5% were later identified as having been sexually abused.

Symptoms

The most common symptoms of vulvovaginitis can include:

• Vaginal itching, soreness or irritation
• Abnormal vaginal discharge
• Redness and swelling of the vulva
• Burning with urination (dysuria)
• Urinary frequency (urinating more frequently)
• Bleeding and injury due to scratching

Some children may not yet have the language to express their symptoms, so it can sometimes be difficult to differentiate between bladder issues, bowel issues, and vulvovaginitis.

Keep in mind that some vaginal discharge can be expected after puberty. Some adolescents and people with vaginas have more discharge than others, but they may not have the other symptoms above.

Diagnosis

For many cases of vulvovaginitis in children, a single cause may not be identified. The good news is that it often gets better without treatment anyway.

Your healthcare provider may help with a diagnosis just by doing a physical exam and by finding out how and when symptoms started, how they have changed, and if anything makes the symptoms better or worse. If that isn't sufficient, they may need to do tests to check for an infection. Many of these tests can be done in the healthcare provider's office.

For both in-office and at-home testing, ruling out a vulvovaginal infection often starts with a pH test of vaginal fluid. That's because yeast infections tend to cause a lower-than-normal pH, whereas bacterial infections and trichomoniasis tend to cause a higher-than-normal pH.

Diagnosing the cause of vulvovaginitis may require a culture of vaginal fluid and occasionally a skin biopsy to diagnose skin disorders. If bleeding is present, your healthcare provider may order a pelvic ultrasound.

Other diagnoses that present similarly may need to be ruled out, including skin disorders like eczema, psoriasis, or lichen sclerosus. Pinworms can also cause similar symptoms.

Treatment

To treat vulvovaginitis, you first need to rule out infections.

If a bacterial infection is suspected, your healthcare provider might prescribe an antibiotic like oral metronidazole or oral or topical clindamycin.

If a pubertal teen has a vaginal yeast infection, they may need an oral medication like fluconazole. Topical antifungal medication, such as miconazole or clotrimazole cream, are also available if you think your teen will adhere to treatment.

Lastly, trichomoniasis is typically treated with oral metronidazole or tinidazole. If infections do not respond to these treatments, more treatment is available and testing for drug resistance my be needed.

Herpes simplex virus infections can be managed with antivirals, but infection is life-long.

For quick relief of vulvovaginitis, it can sometimes help to:

• Take a bath in plain, warm water in a clean tub free of soap, bleach, or cleaning products
• Apply a cool compress to the area
• Apply Vaseline or A&D diaper ointment to the areas of irritation

Prevention

Prevention measures are key to preventing flare-ups of vulvovaginitis. As puberty approaches, symptoms usually improve. In the meantime, you can help your child prevent vulvovaginitis by teaching them to:

• Urinate with their knees spread wide apart
• Urinate leaning slightly forward so that urine doesn't pool in the the lower part of the vagina
• Wipe front-to-back and not back-to-front when using the toilet
• Avoid baths that use bubbles, soap, or shampoo in the water
• Change out of wet clothing as soon as possible, including wet swimsuits or sweaty workout clothes
• Avoid tight clothing, including tights or pantyhose
• Wear loose-fitting, white cotton underwear that is dye-free
• Sleep without underwear in a nightgown or long shirt, or wear very loose-fitting boxer shorts as pajama bottoms
• Avoid scented products, including scented tampons, pads, or feminine washes
• Use non-irritating, mild soaps and rinse them off well after bathing or showering
• Avoid getting shampoo or soap in the vulval area
• Wash and dry the vulval area gently after showering or taking a bath
• Avoid douching

You should also wash your child's underwear with a dye- and perfume-free detergent, rinse it twice, and avoid fabric softeners and dryer sheets.

A Word From Verywell

Some people with vaginas may be embarrassed or ashamed to discuss issues involving their "privates." They should be encouraged to discuss any health issues or concerns they have, no matter which body parts are involved. This will set them up for a lifetime of positive health behaviors, including reproductive health.

Some hospitals have specialized pediatric and adolescent gynecology programs that treat recurrent vaginitis and other gynecological problems. Otherwise, for extra help or a second opinion, ask your pediatrician for a referral to an adult gynecologist who has some experience taking care of children and adolescents.