Paediatric vulval conditions & - PowerPoint Presentation

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Paediatric vulval conditions & anogenital warts

Dr

Jane Connell

Designated Doctor for Safeguarding Children

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The Role of the GPMany vulval

conditions are first evaluated in primary care

Exposure to these conditions is limited throughout training for both GPs and general

paediatricians

Most conditions are simple and straightforward to treat but we need to

recognise

when further workup is indicated to exclude potentially serious pathology or CSA

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Introduction

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Gain knowledge of the common conditions

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Undertake an appropriate examination

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Investigation and treatment strategies

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Comprehensive evaluationHistorySoreness

Itch

Bleeding

Concern re appearance

Examination

Top to toe

Pubertal stagingAnogenital examination – reassurance, consent, frog legged position/knee to chest, ask

pt to cough

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Know your anatomy

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VulvovaginitisMost common

gynaecological

condition in

premenarchal

girls, usually between 2-7 years

Increased vaginal discharge is common in the months building up to menarche

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Predisposing factorsAnatomical – thin labia minora

that flare outwards, absence of labial fat pads and pubic hair, thin vaginal epithelium and close proximity to the anus, leaving vagina open when child sits/squats

Physiological – hypo-oestrogenic, vagina lacks lactobacilli leading to alkaline pH of vaginal tract

Behavioural – poor hygiene, tight fitting, non-absorbent clothing, exposure to chemical irritants (soap, bubble bath, shampoo), masturbation

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Pathogenesis75% classified as non specific

Irritants include soaps/chemicals in detergents/urine/stool.

Role of bacteria is less well defined (respiratory, enteric and sexually transmitted organisms)

Bacteria present in vaginal tract of both symptomatic and asymptomatic girls

Asymptomatic group: anaerobes, CNS, enterococci

Symptomatic group: respiratory (

Grp A strep) and enteric pathogens. Not found in healthy girls.Candida is not a common organism

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ManagementAvoid tight clothingAvoid known irritants (hypoallergenic detergents)

Keep area dry (pat don

’

t rub)

Toileting

Restrict exposure to soaps/shampoos

Sitz bath 1-2x a day

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Investigations Usually not required – only swab if obvious discharge present or severe/recurrent

Treat if enteric or respiratory organism is isolated

Treatment should be oral antibiotics (10 day course pen/

amox

/cephalexin

Grp

A Strep)

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ThreadwormsCan cause vulvar symptomsSymptoms worse at night

Treatment usually based on symptoms alone

Single dose of mebendazole to all family members

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Labial adhesions

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Labial adhesionsAquired abnormality of the labia

minora

Variable amount of fusion from posterior

fourchette

to the clitoris

Most common between 3

mths to 3 yearsIncidence 0.6-3%Usually asymptomatic

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Labial adhesionsPredisposing factors:Poor hygiene

Incontinence

Infection

Trauma

Dermatological conditions

Usually asymptomatic

May cause post void dribbling/ UTI’s

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Labial adhesions80% will resolve within a year of diagnosis

Good

perineal

hygiene

Topical

oestrogen

cream/oestradiol ointmentTwice daily for up to 8 weeks – apply directly to adhesions with pressure (50% resolve after 2-3 weeks)S/E include local irritation and vulvar pigmentation. Rarely breast budding. All resolve on cessation of treatment.

Topical steroid is an alternative (can take longer for separation)Manual separation40% risk of reoccurrence

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Vaginal BleedingUncommon but requires thorough investigation.

Most causes of vaginal bleeding are unascertained

If a specific cause is identified it is most likely to be a foreign body (90% of girls presenting with a blood stained discharge)

Other causes include

Vulvovaginitis

Vaginal/cervical

tumourVariants of precocious puberty

TraumaAnorectal bleeding/haematuria may be misinterpreted as vaginal bleedingSexual abuse is a rare cause of vaginal bleeding in the

prepubertal

girl

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Foreign bodies

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Foreign Bodies4% of girls under 13yrs presenting to gynae clinicMalodorous/ bloody discharge/abdo pain/haematuria and rectal bleeding

Not responding to usual management of vulvovaginitis

Toilet paper fragments most common FB (65 and 70%) in one study and small hard toys most common in another. FB cannot usually be seen without an EUA and saline lavage.

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Urethral prolapse

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Urethral ProlapseCircular red or bluish protrusion of distal urethra through external meatus

Prepubertal black females ( not exclusively)

Average age of presentation is 4 years

Doughnut shaped mucosa protruding through the urethral opening

Often incidental finding

Can cause dysuria/frequency/

haematuria Constipation can be an aggravating factor. May be underlying genetic predisposition.Topical oestrogen/surgical excision

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TumoursEmbryonal

rhabdomyosarcoma

/Clear cell carcinoma of the vagina/

Mesonephric

carcinoma

Can present with intermittent or catastrophic bleeding

Will require an EUA and biopsy for diagnosis Isolated menarcheIntermittent but regular bleedingRequires hormone profile/ pelvic USS /EUA to exclude other causes of bleeding

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Lichen Sclerosus

Chronic inflammatory, scarring skin condition

Well demarcated white plaque, wrinkled surface, telangiectasia/bleeding points

Characterised

by a lymphocytic response

Prediliction

for the genital areaAffects 3% females and 0.07% malesPeak incidence in prepubertal and post menopausal years.

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Aetiology unclearIncreased incidence of other auto immune conditions

Thyroid disease in women

Moisture and irritation may play a role

Rarely occurs in circumcised boys

Associated with

urostomies

and vesicostomiesTraumaMay appear in surgical wounds/radiotherapy/sunburn

Family history in 12%

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Symptoms, signs, sitesSymptoms

Itch

Pain from erosions/fissures

Signs

White plaques – figure of 8

Evidence of skin friability

Erosions/ fissures/ ecchymosis

FemalesInterlabial sulciLabia minoraClitoral hood

Perineal

body

In females 30% may have perianal lesions

Males

Foreskin

Glans

Meatus

Children do not usually have

extragenital

lesions

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Association with sexual abuseIn children ecchymoses

may be striking and mistaken for injury

LS may be caused or aggravated by sexual abuse through

Koebnerization

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ManagementChildhood LS often improves at pubertyScarring can occur in childhood

Malignancy not reported

Require referral to specialist

vulval

services

Treat with

clobetasol propionate 0.05% once daily for a month/ alternate days for a month/twice weekly for a month. Emollient as a soap substitute

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Lipschutz ulcersUncommon

Usually sexually inactive young women. Mean age 15 years (unusual

prepubertally

)

Involve labia

minora

‘kissing ulcers’LargeNecrotic ulceration with red-violaceous border

Well delineatedPainful++++

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Lipschutz ulcerOne third due to EBV.

Other

aetiologies

identified:

CMV

Influenza A and B

MycoplasmaPathogenesisHaematogenous spreadSelf inoculation

Immunologically driven inflammatory consequence/ microthrombi from immune complex deposition in dermal tissues.

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Lipschutz ulcers

Investigations – virology, HSV

Treatment

Topical analgesia

Sitz

baths

Topical high dose steroidMean duration is 17 dayIf recur consider other diagnoses (Crohn’s,

Behcets)

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Elongated labia Labia minora and labia

majora

can vary in size, colour and shape

Reassurance

Simple measures to relieve labial discomfort – comfortable underwear, emollients, avoid shaving pubic hair

Labial reduction should not be undertaken <18years

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Accidental injuries Represent 0.6% of all paediatric injuries presenting to ED in US. (national survey over 9 year period)

Most common age group is 4-7yr olds (33%), followed by 8-11yr olds (21%)

External genital injuries accounted for 79% of injuries

Female external (38%), penis/urethra(23%), scrotum/testes(20%)

Bruising commonest type of injury (36%), lacerations (33%)

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Accidental injuryBlunt force - common

straddle/ non straddle/ crush

Straddle most common mechanism of injury (71-85%), rarely involves hymen/vagina in girls, nor penis in boys

Penetrative - rare

Unusual mechanisms

Unable to determine mechanism of injury from clinical findings

Most accidental injury is witnessed/clear history of eventsIsolated anal injury occurs more commonly from penetrative abuse

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Accidental Injuries

Unoestrogenised

prepubertal

tissues are friable with excellent blood supply and lack

distensibility

Minor trauma can appear extensive

Urogenital trauma raises suspicion of NAI but is uncommonly associated with itImportant to correlate history of injury with physical findings

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Documentation Alleged mechanism of injuryConsequence of injury (erythema, oedema, bruise, linear abrasion-scratch, brush abrasion–graze, laceration, burn)

Location – clock face

Extent of injury – superficial/deep

Penetration of tissues other than skin

Opinion on whether injury can be explained by mechanism given

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Genital injury

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Important conclusionsInjuries to the hymen or vagina usually suggest a penetrative mechanism of injury

Isolated injuries to the anus are very rare in accidental trauma

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When to referPremobile infants

Non verbal/pre verbal children

No acceptable explanation

Extensive/severe injuries

Lack of correlation between history and clinical findings

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Anogenital wartsMost will present to GP

Difficulty in distinguishing innocent

vs

CSA aetiology

HPV – 200 subtypes, >30 affecting genital tract, primarily 6 & 11 and low oncogenic risk (16 &18 associated with cervical

neoplasia

); typing unhelpfulAdults – sexual transmission, mostly subclinicalChildren – vertical and sexual (postulated auto and hetero inoculation, little evidence); latency period unknown

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AGWRecent systemic review and meta-analysis looking at association AGW and CSA in children<12yrs

21% females and 18% males sexually abused

HPV typing unreliable method to ascertain CSA

Age > 2yrs makes CSA more likely

F>M 3:1.7

Site – boys

perineal, girls perineal and vulval

(regardless of occurrence of CSA)

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Questions to considerHas there been any disclosure of sexual abuse?Do the parents/carers have concerns about CSA?

Any child in the family on or been on a CPP?

Any recorded vulnerabilities in records?

If YES to any, refer to CSC for SARC assessment

If NO concern of overt CSA refer to general

paeds

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General paeds actionBackground check with HV/school nurse & social care

History and examination – if any change in behaviour leading to concern re CSA or >4yrs will refer to SARC

STI screening (with parental consent) – urine NAAT (nucleic acid amplification test) screen for chlamydia and gonorrhoea; blood for HIV, Hep B?C, syphilis; swabs for M,C,S and NAAT chlamydia and gonorrhoea

Treatment only if symptomatic as 70% resolve by 1

yr

and 90% by 2yrs

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when to suspect sexual abuseConsider: persistent or recurrent genital/anal symptoms in a child without medical explanation.

Suspect: if above symptoms are associated with a behaviour change

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ActionRefer to CSC and SARC (discussion with police)Manage acute health needs of the child (trauma, contraception, post exposure prophylaxis)

CP procedures – strategy discussion, forensic assessment, video recorded investigative interview

Uncertainty – discuss with Paediatric Consultant on call for safeguarding/named Consultant Dr Wright/designated consultant Dr Connell