It may be difficult for a young child to describe vulvar sensations. Parents may notice the child crying during urination, scratching herself repeatedly, or complaining of vague symptoms. Often, the gynecologic child patient’s pediatrician will have evaluated the child for urinary tract infection. Evaluation for pinworms is also warranted, as pinworms can cause severe itching in the vulvar as well as perianal area. Vulvovaginitis is the most common gynecologic problem of childhood. Prepubertally, the vulva, vestibule, and vagina are anatomically and histologically vulnerable to infection. The physical proximity of the vagina and vestibule to the anus can result in overgrowth of pathogenic bacteria that can cause primary vulvitis and secondary vaginitis. Cultures of these bacteria can be seen and studied using medical microscopes such as a gynecology microscope.

The gynecologist should be familiar with normal prepubertal genital anatomy and hymen configuration. The unestrogenized vulvar vestibule is mildly erythematous and can be confused with infection. In addition, smegma around and beneath the prepuce may resemble patches of candida vulvitis. The prepubertal vulvar area is quite susceptible to chemical irritants.

Chronic skin conditions such as lichen sclerosus, seborrheic dermatitis, and atopic vulvitis may occur in children. Lichen sclerosus, the cause of which is not well established, has a characteristic “cigarette paper” appearance in a keyhole distribution (around the vulva and anus). Lichen sclerosus in the pediatric patient should be treated with reassurance that the condition will regress as the child progresses through adrenarche and menarche. Medications include progesterone in oil (400 mg in 4 oZ. of Aquaphor), applied twice daily; betamethasone valerate (0.1 % ointment, Valisone) or high-potency topical corticosteroids, Temovate (0.05%) cream, applied once or twice daily for 2-3 week until symptoms regress, then tapered to twice per week or less often to minimize use.

Labial agglutination may occur as a result of chronic vulvar inflammation from any cause. The treatment of labial agglutination consists of a brief course (2-4 weeks) externally applied estrogen cream. The area of agglutination (adhesion) will become torn as a result, and separation can often be performed in the office with the use of a topic anesthetic (e.g., lidocaine jelly). Urethral prolapse may present with acute pa or bleeding, or the presence of a mass may be noted by the use of a gynecology microscope.

Vulvovaginal complaints of any sort in a young child should prompt the consideration of possible sexual abuse. Sexually transmitted infections may occur in prepubert children. Sensitive but direct questioning of the parent or caretaker and the child should be a part of the evaluation.

Adolescents with gonadal dysgenesis or androgen insensitivity may present with abnormal pubertal development and primary amenorrhea. Various developmental abnormalities, including vaginal agenesis, imperforate hymen, transverse and longitudinal vaginal septa, vaginal and uterine duplications, hymenal bands, and septa, most commonly present in early adolescence with amenorrhea (for the obstructing abnormalities) or with concerns such as inability to use tampons (for hymenal and vaginal. bands and septa). These developmental abnormalities must be evaluated carefully to determine both exter¬nal and internal anatomy.

A tight hymenal ring may be discovered because of concerns about the inability to use tam¬pons or initiate intercourse. Manual dilation can be successful, as can small relaxing inci¬sions at 6 o’clock and 8 o’clock in the hymenal ring. This can sometimes be done in the of¬fice using sterile gynecologic instruments and sometimes a gynecology microscope under local anesthesia. There are times that the gynecologic procedure may require conduction or general anesthesia in the operating room. The condition of “hypertrophy of the labia minora” has been described, along with surgical procedures to correct this developmental abnormality. This con¬dition is more appropriately considered a variant of normal, with reassurance as the pri¬mary therapy. Genital ulcerations may be noted, when viewed with a gynecology microscope, in girls with leukemia or other cancers re¬quiring chemotherapy. The possibility of sexual abuse, incest, or involuntary intercourse should be considered for young adolescents with vulvovaginal complaints, STDs, or pregnancy.