- Prepubertal anatomy, such as the absence of labial fat pads and pubic hair, leads to diminished protection of the introitus.
- The proximity of the vagina to the anus and poor hygiene increases the likelihood of infection. Prepubertal girls have diminished estrogen concentration and lack lactobacilli, leaving the mucosa susceptible to irritation and microbial infection.
While candidal diaper dermatitis is common, Candida vulvovaginitis is uncommon in a healthy child who is no longer in diapers. However, it may occur in the face of predisposing factors including antibiotic use, diabetes mellitus (see diabetic vulvitis), an underlying primary skin disease, and immunosuppression. Infection with pinworms is present in up to 15% of children in the United States and is a common cause of childhood anal erythema and pruritus. Cases of vaginal pinworm infestation have been reported resulting in discomfort and discharge.
Vulvovaginitis typically presents in prepubertal girls with localized pain, dysuria, pruritus, erythema, or discharge, making it difficult to distinguish from an STI due to sexual abuse. Bloody, copious, or foul-smelling discharge increases the likelihood of an STI, a non-venereal pathogen, or vaginal retained foreign object.
Childhood sexual abuse is a problem of epidemic proportions affecting children of all ages and economic and cultural backgrounds. Although awareness is increasing, it is often challenging to differentiate between vulvovaginitis attributable to child sexual abuse from those of non-sexually transmitted infections.