Clinical overview
Vaginal discharge is the commonest gynaecological complaint of childhood, and vulvovaginitis — usually non-specific and hygiene-related — accounts for the great majority of cases. The clinical challenge is rarely the diagnosis; it is the examination, which is the focus of this objective. A prepubertal child is not a small adult: the assessment must be gentle, unhurried, consented, witnessed, and conducted without instruments, and it must always be carried out through a safeguarding lens — because while most discharge is benign, a minority signals a vaginal foreign body, a dermatosis, a tumour, or sexual abuse, and the examination is where those clues are found or missed.
Two principles frame everything that follows. First, the prepubertal vulvovagina is hypo-oestrogenic — thin, atrophic, neutral-pH mucosa with no protective labial development and the anus close by — which is exactly why non-specific vulvovaginitis is so common and why candida (which needs oestrogenised, glycogen-rich epithelium) is rare in this age group. Second, a single, well-prepared, atraumatic examination is worth more than repeated distressing attempts: get it right once. This chapter covers the relevant anatomy and causes, then sets out the examination in detail, the investigations, and management — including the South African child-protection pathway. It links to Lichen sclerosus, Vaginal tumours (the bloody-discharge tumour to fear), STI pathology, and Gender based violence.
Core knowledge
Why the prepubertal child is vulnerable
- Hypo-oestrogenic mucosa: thin, atrophic vaginal epithelium with neutral-to-alkaline pH and no lactobacilli — easily irritated and colonised.
- Anatomy: absent labial fat pads and pubic hair, a short distance between anus and vestibule, and a tendency to poor wiping technique → faecal contamination.
- Behaviour: exploratory behaviour, bubble baths, tight synthetic clothing, and chemical irritants (soaps).
- Physiological discharge is normal at two times: the neonate (maternal-oestrogen withdrawal can cause mucoid discharge ± a little bleeding in the first 1–2 weeks) and the peripubertal girl (physiological leucorrhoea as oestrogen rises). Recognising these prevents over-investigation.
Causes of discharge in the prepubertal girl
Figure E1.1 — Causes of prepubertal vaginal discharge: ~75% non-specific/hygiene-related, the specific organisms (group A strep, Haemophilus, threadworm), vaginal foreign body, lichen sclerosus, and STI = consider abuse.
- Non-specific vulvovaginitis (~75%) — mixed faecal/skin flora on a background of poor hygiene and irritants; thin grey/whitish discharge, soreness, dysuria, itch.
- Specific infections — group A β-haemolytic streptococcus (florid, sometimes blood-stained, often after a sore throat), Haemophilus influenzae, Shigella (bloody), and threadworm/pinworm (Enterobius) causing nocturnal perianal itch.
- Vaginal foreign body — classically wads of toilet paper; produces an offensive, often blood-stained, persistent discharge. A foreign body must be actively excluded when discharge is bloody or refractory.
- Dermatoses — lichen sclerosus (figure-of-eight pallor, fissuring, bruising that can be mistaken for abuse), eczema/psoriasis, contact dermatitis.
- Candida — uncommon in this age group; think diabetes, recent antibiotics, or nappies/incontinence if seen.
- Sexually transmitted organisms — gonorrhoea, chlamydia, trichomonas in a prepubertal child are markers of sexual abuse until proven otherwise and trigger the safeguarding pathway.
- Tumour — rare but feared: embryonal rhabdomyosarcoma (sarcoma botryoides) presents with a blood-stained discharge ± a grape-like mass (Vaginal tumours).