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).
Assessment
The examination is the heart of this objective. Done well, it is diagnostic and non-traumatic; done badly, it is frightening, unrevealing, and can itself constitute a harmful experience.
History first (often from the caregiver)
Nature, duration, colour and odour of discharge; blood (foreign body, tumour, lichen sclerosus, abuse); itch (threadworm, dermatosis); dysuria; hygiene and toileting habits, bubble baths, clothing; recent sore throat or skin infection (group A strep); systemic illness; and a sensitive, non-leading safeguarding history (who cares for the child, any behavioural change, any disclosure). Let the child speak in her own words; do not ask leading questions.
Preparing for the examination
- Explain and gain assent from the child (age-appropriately) and consent from the caregiver; never proceed against a distressed child's resistance — reschedule or escalate.
- A chaperone is mandatory; a trusted caregiver is usually present for reassurance.
- Warm room, calm unhurried manner, distraction; allow the child to sit on the caregiver's lap if that helps.
- One careful look is the goal — avoid repeated attempts.
The examination itself
Figure E1.2 — The gentle examination: frog-leg and knee-chest positioning, labial separation/traction, no speculum, one calm look, what to inspect, and when to escalate to EUA/vaginoscopy.
- Position: frog-leg (supine, soles together, knees apart) is the standard; the knee-chest (prone) position gives an excellent view of the lower vagina and is useful to confirm or exclude a foreign body or lower-vaginal lesion as the vaginal walls fall open.
- Technique: gentle labial separation and labial traction (grasping the labia majora and drawing gently down-and-out) brings the vestibule, hymen and lower vagina into view.
- Inspect: vulval skin (erythema, excoriation, lichen sclerosus, fissures), the urethral meatus, the hymen and vestibule, the lower vagina (discharge, foreign body, lesion, bleeding point), and the perianal skin (threadworm, fissures, warts).
- Do NOT use a speculum in a prepubertal child in the clinic — it is unnecessary and traumatic.
- Document findings factually and objectively (especially where abuse is possible); use diagrams; avoid interpretive labels.
- Examination under anaesthesia (EUA) with vaginoscopy is the correct route when the upper vagina must be seen — persistent or bloody discharge, suspected foreign body or tumour, trauma, or when an adequate view cannot be obtained awake.
Investigations
- Swabs only if indicated — a specific pathogen is suspected or discharge is persistent/purulent; a charcoal swab for culture (and, where abuse is a concern, the correct medico-legal samples and tests for STIs done through the safeguarding pathway).
- Threadworm: clinical, or the adhesive-tape test for perianal ova.
- Urine dipstick/culture if dysuria (exclude UTI).
- Vaginoscopy at EUA for foreign body, persistent bleeding, or suspected tumour — both diagnostic and therapeutic (removal).
- Blood glucose if recurrent candida.
The safeguarding assessment
Hold the possibility of sexual abuse in mind throughout — not as an accusation but as a duty of care. Red flags include an STI, anogenital injury inconsistent with the history, a child's disclosure, or behavioural change. If suspected, follow the child-protection pathway (below) rather than attempting a forensic examination yourself.
Management
- Non-specific vulvovaginitis — hygiene and barrier measures: wipe front-to-back, avoid bubble baths/soaps, loose cotton underwear, sitz/salt baths, barrier emollients; reassure that it usually settles and recurs less after puberty. Antibiotics are not first-line.
- Specific infection — treat the identified predominant pathogen (e.g. penicillin for group A strep), threadworm with mebendazole + treat the household and hygiene.
- Vaginal foreign body — remove (often EUA/vaginoscopy); discharge resolves rapidly thereafter.
- Lichen sclerosus — potent topical steroid and dermatology/gynae follow-up (lichen-sclerosus).
- Suspected sexual abuse (South African pathway) — this is a mandatory-report matter (Children's Act 38 of 2005; Sexual Offences Act 32 of 2007). Refer to a Thuthuzela Care Centre / designated facility for an integrated forensic and supportive assessment; medico-legal findings are recorded on the J88; provide HIV post-exposure prophylaxis, STI prophylaxis and emergency contraception per protocol where indicated; involve social services and the police. Do not improvise a forensic exam.
- Suspected tumour — urgent referral for EUA, biopsy and paediatric oncology (vaginal-tumours).
Red flags / pitfalls
Figure E1.3 — Red flags and the South African safeguarding pathway: act on bloody/persistent discharge (foreign body, sarcoma botryoides) and STI (abuse), via mandatory report → Thuthuzela → J88 → HIV PEP; hygiene-first for the rest.
- Persistent or blood-stained discharge — actively exclude a foreign body and, rarely, sarcoma botryoides; arrange vaginoscopy.
- An STI in a prepubertal child — sexual abuse until proven otherwise; activate the safeguarding pathway.
- Using a speculum in the clinic — never in a prepubertal child; use position, traction, and (if needed) vaginoscopy under anaesthesia.
- Repeated forced attempts — traumatic and counterproductive; prepare properly for one good look, or examine under anaesthesia.
- Mistaking lichen sclerosus bruising/fissuring for abuse (or vice versa) — examine carefully and involve experts.
- Treating every discharge with antibiotics or antifungals — most is non-specific; candida is rare prepubertally (and if present, look for diabetes).
- Missing the safeguarding dimension — discharge is a moment to consider the child's wider safety, sensitively and without leading questions.
- Over-investigating physiological neonatal or peripubertal discharge.
Evidence anchors
- Paediatric and adolescent gynaecology references / NASPAG / RCPCH — prepubertal vulvovaginitis: ~75% non-specific, hygiene-first management, antibiotics only for an identified pathogen, and EUA/vaginoscopy for foreign body or bleeding.
- South African child-protection framework — Children's Act 38 of 2005 and Criminal Law (Sexual Offences and Related Matters) Amendment Act 32 of 2007 (mandatory reporting), the J88 medico-legal form, and Thuthuzela Care Centres for integrated survivor care.
- South African STI / HIV PEP guidelines — STI prophylaxis, HIV post-exposure prophylaxis and emergency contraception after sexual assault.
- WHO 2020 / clinical sources — embryonal rhabdomyosarcoma (sarcoma botryoides) as the rare bloody-discharge tumour (vaginal-tumours).