Vaginal bleeding in prepubertal females: a case of Shigella vaginitis and review of literature.

Shigella vulvovaginitis is an uncommon aetiology of prepubertal vaginal bleeding that should be considered in the differential diagnosis, especially in patients who have travelled to developing countries. A young girl presented with prepubertal vaginal bleeding, pelvic pain, occasional dysuria and no gastrointestinal symptoms. After a year-long extensive workup, including vaginoscopy and biopsy, genital culture and Gram stain revealed vulvovaginitis due to Shigella flexneri After review of bacterial sensitivity, the patient was given a 30-day course of sulfamethoxazole-trimethoprim. The patient returned to the clinic 1 month later with no signs of vaginal bleeding, discharge or pelvic pain. This case prompted review of the indicated evaluation and differential diagnosis of prepubertal vaginal bleeding, including infectious aetiologies such as Shigella vulvovaginitis with the authors' goal to expedite diagnosis and treatment in paediatric patients.

Prepubertal Vaginal Bleeding: An Inpatient Series from a Single Center in Fujian China.

STUDY OBJECTIVE: This study characterizes the etiology, clinical features and outcomes of prepubescent vaginal bleeding and summarizes our experience. DESIGN: The data of patients who were hospitalized with vaginal discharge or bleeding treated from January 2012 to December 2018 were retrospectively reviewed. SETTING: A provincial Grade III Level A Maternity and Children's Hospital. PARTICIPANTS: Prepubertal patients with vaginal discharge or bleeding. MAIN OUTCOME MEASURES: Patient age, bleeding duration, etiology, treatment and prognosis were recorded. Physical examinations and color Doppler ultrasonography were also performed. RESULTS: There were 158 patients aged from 1 month to 10 years (mean age 5.2 years). Bleeding duration ranged from 1 to 98 days, with an average of 13.3 days. Sixty patients were diagnosed with vaginal foreign bodies, 34 with vulvovaginitis, 34 with vulvar trauma, 13 with ovarian granulosa cell tumors, 8 with urethral mucosa prolapse, 5 with vaginal yolk sac tumors and 1 each with pituitary tumor, hypothyroidism, McCune-Albright syndrome, and short-term intake of a large number of strawberries. All the children were treated according to their different disease etiologies. CONCLUSION: Prepubertal vaginal bleeding is caused by a variety of different conditions. In our study, the most common causes were vaginal foreign bodies, vulvovaginitis, trauma, vaginal malignant tumors and urethral mucosa prolapse. Careful medical histories and targeted examinations are needed. Vaginoscopy could be considered. Considering the different causes, different treatments should be administered to achieve a good prognosis.

Prevention of recurrent lower urinary tract infections in postmenopausal women with genitourinary syndrome: outcome after 6 months of treatment with ospemifene.

Aim of this study was to evaluate the efficacy of ospemifene in the prevention of recurrent lower urinary tract infections in postmenopausal women with vulvovaginal atrophy. The study have a retrospective design. Thirty-nine patients were enrolled. Patients underwent clinical examination and urine culture. The urinary symptoms and the quality of life were evaluated with UTISA score, PUF and SF-36 questionnaires before and after treatment. All 39 patients received ospemifene 60 mg one tablet/daily for 6 months. Adverse effects and complications were assessed. Thirty-nine patients were enrolled in the study. Two patients experienced one new UTI episode and the mean number of positive urine culture decreased significantly after 6 months (3.65 ± 2.12 vs 0.25 ± 0.17, p < .0001). The mean number of urinary infection symptoms decreased significantly after treatment; dysuria reduced (4.76 ± 2.45 vs 0.89 ± 1.12). PUF score and SF-36 showed a statistically significant change (22.43 ± 5.89 vs 12.14 ± 3.21) and (52.86 ± 9.21 vs 83.43 ± 10.76). No adverse effects were reported and the total success rate was the 92.3% after 6 months at PGI-I. Ospemifene is a valid alternative with excellent tolerability for the UTIS prevention in postmenopausal patients.

Current review of prepubertal vaginal bleeding.

PURPOSE OF REVIEW: Prepubertal vaginal bleeding raises many concerns and evaluation and diagnosis may prove difficult for many providers. We aim to provide a comprehensive review and recent updates for those practitioners who care for these patients. RECENT FINDINGS: Prompt management in the case of prepubertal vaginal bleeding is indicated, especially to rule out malignancy or abuse. If a child is reluctant to undergo examination, or if the extent of injury or source of bleeding cannot be determined, examination under anesthesia and vaginoscopy is recommended. Use of vaginoscopy allows for clear visualization of the vagina and cervix without distorting hymenal anatomy, as well as diagnosis and removal of a foreign body and evaluation of mucosal damage caused. In the case of sexual abuse, providers specifically trained in pediatrics need to be present, and safety of the patient should always be ensured. SUMMARY: Careful history taking and targeted examination may lead to diagnosis in the case of prepubertal vaginal bleeding. However, in more difficult cases, practitioners should not hesitate to examine a patient in the operating room using general anesthesia to elicit the cause. Although sexual abuse and malignancy are always on the differential, most causes of bleeding are benign and easily treated.

Recurrent vaginal discharge in children.

BACKGROUND: Childhood vaginal discharge remains a frequent reason for referral from primary to secondary care. The Pediatric and Adolescent Gynecology (PAG) service at Kettering General Hospital was established in 1993 and provides a specialized service that meets the needs of children with gynaecological conditions. AIM: To investigate recurrent vaginal discharge noting symptomatology, defining pathogens, common and rarer causes, exploring management regimes, and any changes in practice over time. METHOD: Retrospective review spanning 15 years identifying prepubertal children attending the outpatient PAG clinic with recurrent vaginal discharge. We reviewed the medical notes individually. RESULTS: 110 patients were identified; 85% were referred from primary care. The age distribution was bimodal at four and eight years. Thirty-five percent of our patients were discharged after the initial consultation. The commonest cause of discharge was vulvovaginitis (82%). Other important causes included suspected sexual abuse (5%), foreign body (3%), labial adhesions (3%), vaginal agenesis (2%). 35% of patients were admitted for vaginoscopy. CONCLUSION: Vaginal discharge is the most common gynecological symptom in prepubertal girls and can cause repeated clinical episodes. Vulvovaginitis is the most common cause and often responds to simple hygiene measures. Awareness of the less common causes of vaginal discharge is essential.

Voiding dysfunction: another etiology of vulvovaginitis in young girls.

OBJECTIVE: To determine the prevalence of voiding dysfunction (VD) in patients with persistent vulvovaginitis (PVV), and to evaluate the clinical response of PVV in the treatment of VD. PATIENTS AND METHODS: Girls four years or older who consulted for PVV for at least one month and who did not respond to general measures. A physical examination was performed with visual inspection and colposcopy; vaginal samples for culture and vaginoscopy were carried out. On every patient urodynamic studies were performed. Girls who were diagnosed with VD were treated. A pediatric gynecologist did the follow-up; a successful response was considered when inflammatory symptoms and vaginal discharge ceased. RESULTS: Twenty patients were included, mean age 8.6 years (range: 4.6-14 years); 75% prepubertal symptoms lasted for 1.8 years; 19 (95%) had urodynamia, 10 (52.6%) had an overactive bladder, 8 (42.1%) external bladder sphincter dyssynergia, 1 (5.2%) hypotonic bladder, and 13 (65%) showed improvement. CONCLUSION: VD is an important cause when considering the etiology of PVV.

Vulvovaginal chronic graft-versus-host disease with allogeneic hematopoietic stem cell transplantation.

OBJECTIVE: To describe the diagnosis and management of female genital chronic graft-versus-host (GVH) disease, a complication of hematopoietic stem cell transplantation. METHODS: From 1999 to 2006, 33 women with vulvar symptoms or undergoing systematic evaluation for chronic GVH disease were referred 267 (median, range 29-6,117) days after transplantation for gynecologic evaluation. Pertinent histories, laboratory tests, and skin and genital area-directed examinations were performed. Vulvar disease was treated with superpotent topical glucocorticoids and topical estrogen. Sexually active, menopausal women used vaginal dilators, topical glucocorticoids and estrogen, and estrogen vaginal rings for vaginal synechiae. RESULTS: At presentation, most patients complained of vulvar pain during urination and pain that prevented sexual intercourse. Twenty-nine of 33 presenting with vulvovaginal chronic GVH disease had vulvar erythema, with additional signs including vulvar vestibulitis syndrome (n=9), vulvar erosions (n=12), vulvar scarring (n=2), and vaginal scarring (n=6); over time, eight additional patients developed vaginal scarring. Topical glucocorticoids improved vulvar symptoms, and estrogen decreased vulvar mucosal friability. Eleven of 12 patients, who wanted to resume having intercourse, responded to nonsurgical treatment for vaginal synechiae. CONCLUSION: A combination of topical superpotent glucocorticoids and estrogen was effective in the treatment of vulvovaginal chronic GVH disease. In those with vaginal scarring, use of a vaginal dilator and estrogen ring was helpful. Early identification and treatment of vulvovaginal chronic GVH disease ameliorates vulvar pain by healing eroded vulvar mucosa and may prevent the need for surgery for hematocolpos. LEVEL OF EVIDENCE: III.

Signs of chronic stress in women with recurrent candida vulvovaginitis.

OBJECTIVE: The purpose of this study was to determine whether there is an association between recurrent vulvovaginal candida and chronic stress. Chronic stress affects the hypothalamus-pituitary-adrenal axis, which influences the immune function. Recurrent candida vulvovaginitis is increasing. STUDY DESIGN: Women with recurrent vulvovaginal candida (n = 35) and age-matched healthy control subjects (n = 35) collected saliva for the analysis of cortisol. Hormone analyses of blood samples and vulvovaginal examinations were performed. A questionnaire was completed. RESULTS: Morning rise cortisol level was significantly blunted among patients compared with control subjects (P < .002). Mean levels of salivary cortisol were lower the first 45 minutes after awakening in women with recurrent vulvovaginal candida, compared with control subjects. More patients than control subjects reported a history of condyloma, bacterial vaginosis, and herpes genitalis. No differences were seen between patients and control subjects regarding sexual hormone binding globulin, dihydroepiandrosterone, testosterone or Hemoglobin A1c. CONCLUSION: Morning rise salivary cortisol level is blunted in women with recurrent vulvovaginal candida, which indicates signs of chronic stress. The higher incidence of vulvovaginal infections in these women compared with control subjects may reflect impaired immunity, which may be due to chronic stress.

Vestibulectomy for vulvar vestibulitis.

OBJECTIVE: To determine if surgery is an effective therapy for vulvar vestibulitis. STUDY DESIGN: A retrospective chart review of all patients having vestibulectomy at the Mayo Clinic, Rochester, Minnesota, from 1992 to 2001 was performed. A scoring system measuring objective and subjective findings was used both preoperatively and postoperatively to assess the effects of surgery. A paired t test was used to analyze the difference between preoperative and postoperative symptom scores. The Wilcoxon signed-rank test evaluated changes in symptom scores. RESULTS: Thirty-eight of 42 patients (90%) with "pure" vulvar vestibulitis, as determined by physical findings and pathologic confirmation, had a significant improvement (P < .01) in their symptoms. The remaining 4 patients had confounding factors that may explain their lack of improvement. CONCLUSION: Vestibulectomy is a simple and very effective treatment for vulvar vestibulitis.

Coalescencia de labios menores en niñas premenárquicas / Labial adhesions in premenarchial girls

Introducción: La coalescencia de los labios menores es una patología frecuente. Existen diversas etiologías propuestas. La frecuente aparición en niñas de primera infancia ubica a esta patología dentro de las adquiridas. El objetivo de este trabajo fue evaluar el motivo de la derivación al ginecólogo infantil de las niñas que presentaron coalescencia de labios menores, su forma de presentación y los resultados de los exámenes complementarios efectuados, para recalcar la importancia del examen genital en las niñas por parte de los pediatras. En esta presentación se destaca la importancia del examen genital de las niñas durante la consulta pediátrica. Material y métodos: Se analizaron los datos de las historias clínicas de niñas con coalescencia de labios menores. Se evaluaron el motivo de consuelta y la forma de presentación. Se efectuaron muestras de flujo vaginal, urocultivos y parasitológicos de materia fecal. Se instauró tratamiento con estrógenos conjugados locales. Resultados: Se analizaron las historias clínicas de 19 niñas entre 3 meses y 12 años. El 47 por ciento presentó fusión parcial. El motivo de derivación más frecuente fue por vulvovaginitis. Se halló 15 por ciento asociado a parasitosis intestinales y 15 por ciento asociado a infecciones urinarias. En el 80 por ciento de las pacientes estudiadas, el cultivo de la flora vaginal fue inespecífico. Conclusiones: La derivación al ginecólogo infantil fue a través de Pediatría, siendo el 53 por ciento por vulvovaginitis. La presentación más frecuente fue completa. Los gérmenes hallados en el cultivo fueron inespecíficos en 80 por ciento de los flujos vaginales estudiados

Aislamiento de Staphylococcus xylosus, asociado con vulvo-vaginitis pediatrica / Isolation of Staphylococcus xylosus associated with pediatric vulvovaginitis

A traves de procedimientos bacteriologicos sencillos pero conlcuyentes, se aisla el 13-07-1994 estaphylococcus excylosus en un proceso cronico de vulvo-vaginitis (muestra 442/1994) siendo la base de este procedimiento el esquema propuesto por Kloos y Schleifer. El antibiograma (KIRBI-BAUER) demostro sensibilidad a Rifampicina, Cefradina, Ciprofloxacina, Gentamicina, Oxacilina y resistencia a la ampicilina, lincomicina y eritromicina, en concordancia con otros resultados internacionales previos. Es pertinente desarrollar este tipo de pruebas en Bolivia para delimitar el espectro epidemiologicos de este y otros ESTAPHYLOCOCCUS COAGULASA NEGATIVOS (CNS)

Vulvitis and vulvovaginitis: cutaneous considerations.

Vulvar dermatoses (previously dystrophies) include psoriasis, allergic or irritant reactions, lichen sclerosus, lichen simplex chronicus, lichen planus, and tinea. Some of these have bullous or erosive forms, but they differ from the immune-mediated vesiculobullous disease group, which includes vulvar pemphigus, benign familial pemphigus, pemphigoid, linear IgA disease, and dermatitis herpetiformis. Vulvar ulcers can occur in dermatoses resulting from systemic disease (Behçet's syndrome, lupus, pellagra, and Reiter's disease) or malignancies resembling dermatoses (extramammary Paget's disease, squamous cell carcinoma, and vulvar intraepithelial neoplasia). Many vulvar dermatoses itch or burn. Vulvodynia occurs with irritant and allergic dermatitis, vulvar dermatoses, complications of steroid use, candidiasis, papillomatosis, vestibulitis, or essential (dysesthetic) vulvodynia. Diagnostic tests (potassium hydroxide, cultures, and biopsy) should establish the diagnosis and therapy should be specific. Few skin diseases are curable but all are treatable; effective management is defined by whether a medication reliably controls outbreaks or symptoms when it is used. Patience is recommended, because treatment may take weeks or months.

Vulvovaginitis sifilítica: a propósito de un caso infrecuente / Syphilitic vulvovaginitis: a propos of an uncommon case

Por lo poco frecuente que resulta la aparición de las manifestaciones múltiples de la sífilis en la vulva y/o vagina, se decidió estudiar un caso que llegó a nosotros con un dignóstico diferente al que realmente correspondía. Se procede a describir detalladamente la historia clínica de esta paciente de 15 años de edad, estudiante, quien presentó esta entidad

[Vulvovaginogingival syndrome. New characteristic grouping of plurimucous erosive lichen planus]. / Le syndrome vulvo-vagino-gingival. Nouveau groupement caractéristique du lichen plan érosif plurimuqueux.

The triple association of a chronic painful erosive vulvitis, an erosive or desquamative vaginitis and an erosive vestibular gingivitis constitutes a hitherto unreported syndrome. The first 19 cases of this affection seen in the Hôpital Tarnier over the last three years are presented and analyzed, the etiology of these erosive mucosal lesions, limited to three body regions, being lichen planus in each case. Detection of mucosal erosion at one of these three sites now requires clinical investigation of the other two, and biopsy of least one of them from the edge of an eroded zone, as well as search for other-possible mucocutaneous areas of lichen planus. Clinical onset is often asynchronous, one lesion appearing before the others, the simplest to recognize being gingival erosive lichen. In one case, however, peri-erosive lamellar detachments suggested chronic desquamative gingivitis of possible benign pemphigoid origin. Erosive lichen planus of vulva and vagina has not been reported previously. Knowledge of this syndrome allows correlation between lichen planus and certain cases of erosive gingivitis, erythroplastic vulvitis and desquamative vaginitis.

The clinical importance of vaginal discharge in childhood.

The characteristics of vaginal discharge in childhood are outlined and the causes tabulated. Necessary instruments and techniques for examination of children are described together with suitable formats for treatment.