Professor Sonia Grover Paediatric and adolescent gynaecologist ; pain medicine specialist ; director , department of gynaecology , Royal Children ’ s Hospital , Melbourne ; consultant gynaecologist , Mercy Hospital for Women , Melbourne , and Bass Coast Health ; clinical professor , University of Melbourne , Victoria .

First published online on 15 December 2023

INTRODUCTION

THE care of the reproductive and genital

tract in infants and young girls , as well as young people with menstrual problems , often falls between the cracks during medical education and training — not quite fitting into paediatrics and not quite part of women ’ s health .

Some problems may be identified antenatally , at birth , during infancy or childhood or in adolescence , including issues in transgender patients .

There are now gynaecologists Australia wide who have undertaken further specialist training in this field ; however , many of the conditions seen by these subspecialists are relatively straightforward and can be managed by a GP .

This How to Treat covers paediatric and adolescent gynaecological conditions and aims to ensure GPs can recognise and manage these problems but are aware of the red flags regarding when to refer on .

PAEDIATRIC PROBLEMS

THESE MAY include vulvovaginitis ,

labial adhesions , PV bleeding and vulval pain .

Consider child sexual abuse when the presentation includes vulval or genital symptoms , although other symptoms — such as behavioural changes — usually accompany this presentation .

Before examining young girls , it is essential to try to establish some rapport . The examination itself should not be traumatic .

A ‘ frog leg ’ position , with the young child on their carer ’ s knees or on the bed , usually provides a good view .

Vaginal swabs are never required , with introital swabs only occasionally indicated .

Vulvovaginitis

Vulvovaginitis is the most common gynaecological problem in pre-pubertal girls , although the precise incidence is unknown . 1

Several factors , including low oestrogen levels , contribute to the inflammation of the genital region in this age group . The thin , atrophic vaginal mucosa is more susceptible to irritation , thus causing a lowgrade discharge that then irritates the thin , atrophic external labial skin . This external thin skin is also more susceptible to other irritants , such as soaps and moisture . The presentation may be with redness ( 82 %); soreness , including burning with micturition ( 74 %); vaginal discharge or odour ( 62 %); and itch ( 58 %). 1

These symptoms tend to fluctuate , with good and bad weeks . The natural history is complete resolution with the onset of puberty when oestrogen alters the vaginal flora and thickens the vaginal and external genital skin .

Any presentation with genital symptoms does necessitate the exploration of possible sexual abuse , so it is essential to carefully

assess risk factors and identify any associated behavioural changes .

A study examining the normal flora of the low introital area in girls with and without symptoms ( 50 girls in each arm ) demonstrated that the flora was largely the same in each group and no infectious agent was identified in most cases . 1 The exceptions were girls who had profuse discharge and / or erythema extending beyond the contact surface of the opposing labia . Candida albicans was identified in only one peripubertal girl with breast development .

Swabs are only indicated where there is profuse discharge or erythema extending beyond the contact surfaces of the labia majora . Antibiotics are largely not necessary for the management of vulvovaginitis , with the focus on simple measures of bathing in vinegar , salt or bicarb baths in an effort to advantageously alter the vaginal flora , combined with the use of barrier cream to protect the thin skin . Antifungals