Article written By Sherry Bushnell with Dr. Anne Camber, OBGYN in Libby, Montana

Research for this article came from a publication called  Special Populations, published by the American College of Obstetricians and Gynecologists.   www.acog.org

A relationship with your child's doctor is very important.  Best case scenario:  your personal OB is willing to work with your child.  It is in your best interest to understand that part of a doctor's care includes screening for sexual abuse.  If you have a child that is unable to truthfully answer coherently or may be confused with questioning along this line, please make this a topic to share with your doctor ahead of time. 

Vulvovaginitis is the most common problem in pre-puberty girls.  (Symptoms may be redness, itching, and irritation.)

Non-specific vulvogaginitis:  girls may be having symptoms such as itching, burning, irritation and sores involving the vulva.  Girls that are pre-puberty aged will not normally have infections inside the vagina itself, including yeast infections.  Outside irritations can be caused from chemicals such as soaps and lotions or even bubble bath.  Also tight-fitting or nylon clothing, sub-optimal hygiene with even the normal rectal flora, can irritate the mucosa or cause allergies.  Another very common cause of vulva infection is the pinworm.  Itching may lead to scratching until the skin is broken or maybe even bleeding.  Most often all that can be seen is irritation/scratch caused redness on the vulva.

        Other non-infectious irritations may include:

                 Labial agglutination (where the labia grows together) - found in 5% of pre-puberty aged girls and 10% of babies younger than 12 months.  Usually no symptoms, but may cause urine-irritant to vulva, or infection of the urethra.

                 Litchen sclerosis, an auto immune disorder, produces a parchment-like, scaly plaque with an hour-glass shape, that itches or is sore. The skin under the infected area bleeds easily.  There may be crack-like sores and can be misinterpreted as "sexual abuse signs".   There can be secondary infection from the itching.  Medication is available. Help her avoid scratching the area.  Most little girls experience improvement when their period starts.

                Psoriasis - inherited skin disorders, occurring at any age, are most likely associated with other areas of the skin, not just the vulva.

                Dermatitis - Caused by irritations such as soaps (shampoos, creams, perfumes, soap or bubble bath). Moisture sealing lotions or creams can be used to help rehydrate skin.

Infectious vulvovaginits:  Did you know that the common respiratory strep infection, can be transferred from the nose to the vagina?  Other causes of infection can be Shigella (often having blood-tinged discharge) and a bacteria called Yersinia.  Once again, vagina infections are not normally seen in girls that are pre-puberty age, because the pH of the vagina does not support fungal infections.  (Children that are on antibiotics for a long period of time or who are immune-compromised may be an exception.)  Infections such as gonorrhea or Chlamydia infections strongly suggest sexual abuse. 

          Testing for various vaginal infections do not require a speculum exam.  A simple quick cotton swab in the vaginal area is all that is needed. No cervial sample need be taken.  Treatment of non-specific vulvovaginitis includes sitz baths, and avoidance of chemical irritant or tight clothing.  Anything that rubs against the skin should not be worn, including tights, bathing suits, sweat pants or even jeans or panties. External creams such as diaper rash cream containing zinc oxide may be helpful.  Proper cleaning is critical for long-term care.  Teaching to wipe from front to back is essential and wearing 100% cotton underpants are life-long habits we teach our girls when they are young.

                     External treatment of specific infectious vulvovaginitis should be directed at whatever is causing the infection.  Ecoli infections from improper wiping may be helped by a broad spectrum antibiotic, but only when the other measures to help clean and cure the specific infection has not worked.

Children that have been adopted from overseas or who have been exposed to infections may be experiencing:

            Yeast infections -   Girls that wear diapers can have a yeast infections, involving the vulva.  Rarely does it travel into the vagina.

            Umbilicated lesions - Also called molluscum Contagiosum are skin-colored, dome-shaped, smooth areas about 1mm - 5 mm.  They may have redness surrounding the sides or be infected around the edges. These are common in school-aged children, especially those who have lived in very crowded areas or have poor hygiene.  These usually go away by themselves and are not worth the hassle of cutting them out (because that is what has to happen to get rid of them). Average out-break lasts 6 - 9 months.

            Warts - also called condyloma accuminata can be acquired by a baby when she passes through the birth canal or close sexual (or even non-sexual) contact with an infected individual.  Non-intervention is a reasonable approach in children who are not bothered by the warts. They will probably go away on their own or get smaller as time goes on.  Removal can be painful and does not guarantee they will not come back.

            Herpes -  Beyond the newborn baby period (passed on by the birth mom), the presence of the herpes virus indicates the need for sexual abuse evaluation.  Herpes looks like clusters of painful little blisters that are red around the edges.  For an initial outbreak, a child will usually be sick with fever, and have muscle aches.  Rupture of the little blisters brings a weeping, yellowish-gray crust.  Culture of the open blisters are important to accurately diagnose.  There is medication for children over the age of 2.

             Actual Vaginal bleeding in pre-puberty age girls is a big warning sign.  Most of the time the small amount of bleeding that occurs as a smear or drops that can be seen in the panties, is caused from external irritation or itching to the point of breaking the skin.  If it continues consider these possibilities:

                 Foreign body inside her vagina causing infection and irritation - Most commonly toilet paper, coins or plastic marker caps. Can become imbedded in the tissue and need to be removed under anesthesia.

                 Vaginitis infections as mentioned above - Strep group A is almost always a respiratory infection.  With a vaginal opening that is bright red and bleeds easily with rubbing.  Shigella is a bloody, mucousy vaginal discharge.  Commonly thought to be only a kind of diarrhea, actually only 24% of the cases are associated with that.

                Uterthral Prolapse - The mucosa of the urethra can actually come outward through the vagina.  A cherry-red doughnut shaped tissue or mass 2 - 3 cm in diameter can be seen.  Although is appears to be coming from the vagina, it is actually comes from the urethra (hole where urine comes from).  Symptoms usually resolve with sitz baths.  Sometimes estrogen cream can be applied.  Should be looked at by a physician.

                 Growths or tumors - Usually arise from the wall of the vagina and expand to create a visible mass.  Rarely, bleeding can be secondary to leukemia or a birth mark.

                  Trauma - Genital trauma can be caused from accidental injury or sexual abuse.  Bike riding accidents or straddle-style injuries are common and usually only involve small cuts, scrapes or bruises.  Mostly the hymen is not injured.  Suspicion of sexual abuse arises when cross cuts or fissures in the hymen are present. Penetrating trauma to the vagina, from a penis, fingers or an object, can cause serious injury to the walls of peritoneal muscle inside the vagina. close examination requires anesthesia with possible exploration of the abdomen with special instruments.

                  Early puberty - may occur with early development of pubic hair or the breasts.  Vaginal bleeding may be a symptom. Suspicion of an ovarian or central tumor is a concern and should be referred to a specialist.

A Word about Sexual Abuse - All physicians must consider sexual abuse as a possibility when a young child presents with vaginal bleeding, unless the cause of bleeding is obvious.  This is not to scare you, but to prepare you.  If your child is not being abused, then relax.  Answer questions matter-of-factly and don't be offended.  If you were a physician, wouldn't you want to be sure the child you are treating is safe? 

            Once again, a personal relationship of trust with your provider before going in, will go a long way.  Findings that will be suspicious to a care provider are:  lacerations of the vulva, posterior forchette or anus, or cuts across the hymen.  However, most children that are sexually abused will have a normal exam.  Most physicians are not skilled in interviewing a child about sexual abuse, but can use nondirective questions to see if they can get direct responses from them to help get details.  These might be the name of the person, the time, the location, and exactly what happened.  If your child does have some of these symptoms and is not able to correctly answer questions such as these in a manner that is appropriate for what is happening, please use caution with the care-giver you choose.

            Actual sexual abuse:  A physical examination should be done as soon as possible, or within 72 hours if a child has bleeding or injury. The focus is on collecting evidence such as skin cells, hair or other details from linens or clothing. Your care giver should be knowledgeable about your state's laws regarding reporting and what the protocol is.

             Both I as a midwife and Dr. Anne Camber, a wonderful OBGYN in Libby, Montana, (who also has a heart for helping disabled women and their care-givers find the help they need) are willing to share with you suggestions in a general sense.  We’d like to help you get the courage to confidently get going in a positive direction.

       Some of the issues you might need addressed may be beyond our ability, without personally seeing a patient.  However, suggestions for managing a period or ideas of helping a family cope with issues surrounding getting appropriate help, can be addressed to “Dr. Camber or Sherry” and sent to Sherry’s private e-mail  questions@blessingcatcher.com