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are almost never indicated as
candida prefers an oestrogenised
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Vulval pain
Vulval pain in adult women can be
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laying their eggs in the perianal area at this time . Similarly , the movement |
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environment . 1
Labial adhesions
Labial adhesions ( see figure 1 ), fusion
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divided into pain associated with dermatological problems and pain in the absence of dermatological problems . Depending on the loca- |
of the worms from the vagina over the very sensitive skin of the pre-pubertal hymen appears to provoke a considerable amount of distressing |
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or agglutination are almost invaria- |
tion of the altered sensation , vulval |
pain that wakes the girls at night . |
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bly not present at birth and are most |
pain may be divided into vulvody- |
The distress often lasts a few hours , |
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often noticed by maternal and child |
nia or vestibulodynia . It can also be |
with baths and cool washes to the |
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health nurses or parents when the child is about six months of age . 2 , 3 At this time , the endogenous oestrogen |
classified as a provoked or unprovoked pain or altered sensation : a dysaesthesia . |
perineum often required to relieve the distress . Threadworm is treated with mebendazole once weekly for |
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levels have fallen , and it is thought that some minor irritation of the labia |
The pattern is similar in young pre-pubertal children , where genital |
three weeks , together with the usual measures of treating other family |
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results in the opposing surfaces stick- |
pain may also relate to dermatolog- |
members , washing bed linen and try- |
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ing together . Some degree of labial |
ical problems , such as LS or vulvo- |
ing to encourage good hand hygiene |
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adhesion has been reported in almost |
vaginitis , but can occur as a pain or |
to avoid reinfection . 14 |
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40 % of girls , although more significant |
dysaesthesia in the absence of a skin |
Vaginal pain caused by pelvic |
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adhesions occur in fewer than 5 %. 2 |
problem . Until recently , these altered |
floor muscle spasms or cramps can |
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Although a number of interven- |
skin sensation conditions were rarely |
also occur as vaginal stabbing pain , |
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tions have been advocated , these are |
reported in the literature . 9-13 |
but this is not usually seen in young |
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mostly not required . 4 |
The children who experience |
children . |
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In the past , lateral traction to cause the adhesions to separate was advocated , but this can be traumatic for both the girl and her parents , and |
these symptoms may be quite young , which can make localising or getting an accurate description of the pain challenging . Nevertheless , these |
Vaginal and genital lumps and bumps
The appearance of a lump at the vag-
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there is a high recurrence risk . The |
problems are increasingly recognised |
inal opening or in the genital area in |
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use of topical oestrogen has also been |
in young pre-pubertal girls who pres- |
a pre-pubertal child can raise consid- |
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advocated , but again , there is a high |
ent with distressing genital sensa- |
erable concern . |
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risk of recurrence . Repeated use of oestrogens can potentially result in enough oestrogen absorption for subsequent breast development .
Labial adhesions are not seen in adolescents — except where there is an underlying skin condition , such as
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Figure 1 . Patient ’ s mother is carefully assisting in the demonstration of the labial adhesions , allowing identification of the midline stripe where the adhesion or agglutination has occurred . |
tions . They may also describe the altered sensations as stinging , burning , “ a bubbly feeling ”, “ a tickly sensation ” or a “ funny feeling ”. Some girls are referred regarding potential masturbation , as they have been rubbing their genital area ; however , fur- |
HYMENAL TAGS The simple explanation for a ‘ piece of flesh ’ at the hymenal opening can be a hymenal remnant or tag ( see figure 4 ). Most often these arise in the midline posteriorly and are |
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lichen sclerosus — which suggests the |
ther questioning may reveal that the |
noticed in the neonatal period . They |
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natural history of labial adhesions is of spontaneous resolution . 5 It is very rare for complete fusion and urinary obstruction to occur , and when this does occur , it is in children younger than two years of age .
The major challenge is to reassure the parents , who have invariably been made anxious about the ‘ abnormality ’ of the genital area and the lack of a visible vaginal opening .
|
Mikael Häggström / CC0 1.0 / bit . ly / 3oCUF6I |
rubbing or pressure they have been exerting on their genital region is to relieve an uncomfortable sensation .
In a cohort of nearly 50 girls with genital dysaesthesia , more than 60 % had also experienced , or were currently experiencing , urinary symptoms — most often in the form of urinary frequency and urgency . 13
Examination of the genital area reveals normal skin with no evidence
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remain largely unchanged in size over weeks and months . No action is required . Although hymenal tags will occasionally be a nuisance in a teenager with tampon use or with sexual activity , many tags disappear altogether , presumably when oestrogen levels fall and the tag becomes atrophic .
Thickening and redness of the labia , or a vaginal polyp ( see fig-
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Lichen sclerosus
Lichen sclerosus ( LS , see figure 2 ) is
|
of dermatological conditions . Even very young girls can assist with the diagnosis . A cotton wool – tipped swab |
ure 5 ) — particularly those that are new and have changed over a 4 – 6- week period — are a cause for con- |
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a skin condition that occurs in males |
( usually the same swab used for taking |
siderable concern . Prompt referral |
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and females of all ages but is more |
specimens ) is used to gently touch the |
is required . Although the classic |
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common in females . It may occur in |
inner thighs , the mons pubis and then |
teaching for rhabdomyosarcomas |
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young children as well as around men- |
progress towards the labia majora , |
( see figure 6 ) or botryoides sarcoma |
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opause . It has a distinctive appear- |
labia minora ( outer then inner aspects ) |
has been grape-like lesions and / |
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ance , with white skin changes and |
and then periurethral and perihyme- |
or bleeding , this presentation only |
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splitting or fissuring often between the |
nal areas , looking for areas that repli- |
occurs in 50 % of cases and requires |
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labia minora and labia majora . It may |
cate the altered sensation experienced |
urgent referral . 15 |
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also occur perianally and can result |
by the young person . Repeated testing |
A lump in the labia majora may |
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in significant resorption of genital |
usually provokes the same response |
reflect a number of different diag- |
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skin and loss of architecture . In chil- |
in the same area , suggesting there is a |
noses , including a palpable ovary , a |
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dren , the condition may present with |
specific area that has altered sensation |
testes , a lipoma or simply a pre-pu- |
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a persistent itch , blistering and bruising ( sometimes mistaken for abuse or trauma ) but can also sometimes be asymptomatic . |
or a dysaesthesia . The approach to this problem after exclusion of other possibilities — such as sexual abuse , vulvovagini- |
bertal unilateral fibrous hyperplasia of the labia majora , which usually appears around adrenarche . 16 Referral is appropriate to clarify the |
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The cause is unknown ; however , |
tis and vulval LS — is the use of tricy- |
diagnosis . |
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some girls have a family history of LS . There is thought to be an autoimmune component : LS is associated with other autoimmune diseases , |
clic antidepressants ( amitriptyline ) starting at 5mg at night , increasing to 10mg and occasionally 20mg . 13 Topical 2 % amitryptylline can be used , |
Vaginal bleeding
Brown discharge in the setting of
vulvovaginitis ( on history and clini-
|
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with thyroid disorders the most |
but many young girls find it too dis- |
cal findings ) will usually settle with |
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common . 6 |
tressing to apply this . |
simple vulvovaginitis measures ( see |
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Biopsy is rarely required for a |
Treatment is often required for |
earlier ). |
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diagnosis in children , and if essen- |
a few months , and then the dose is |
Ongoing profuse brown discharge |
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tial , should be performed under |
gradually reduced . Flares of symp- |
is likely to be a foreign body ( see |
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general anaesthetic to avoid the |
toms or relapses tend to occur at |
figure 7 ) — usually a piece of tissue |
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potential trauma of this procedure . |
times of stress , but for most young |
paper . Sometimes this is visible just |
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The treatment is avoidance of |
girls , this approach results in a reso- |
within the introitus , but most often |
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irritants and soaps and use of emol- |
lution of symptoms . 13 |
an examination under general anaes- |
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lients to maintain skin moisture and |
The other , far more distressing |
thesia is required for a vaginoscopy |
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as a barrier to potential irritants . Topical potent steroids are required |
Figure 2 . Lichen sclerosus . |
pain state , seen only in pre-pubertal girls and presenting as noctur- |
and removal of the foreign body .
In the case of bright red vagi-
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( usually in an ointment base as this is less irritant ) to manage both the symptoms and to prevent the loss |
followed by maintenance once to twice weekly . |
with the onset of puberty . 7 Nevertheless , there is undoubtedly a cohort |
nal vaginal shooting pain , is caused by ‘ lost worms ’. 14 Thread worms ( see figure 3 ), which typically infest |
nal bleeding , look for evidence of pubertal development to ascertain whether hormonal blood tests are |
of genital architecture . Methylpred- |
There are limited data on the |
in whom the condition persists ; fol- |
the anal region and cause perianal |
required . In the absence of evidence |
nisolone aceponate 0.1 % is usually |
long-term outcome of LS in chil- |
low-up is essential , particularly in |
itch , can ‘ get lost ’ and wander into |
of oestrogenisation ( that is , in girls |
applied twice daily for two weeks |
dren , with certain opinions that the |
those with significant disease who |
the vagina . The perianal itch is usu- |
with atrophic hymen and genital |
and then once daily for two weeks , |
condition will resolve in some girls |
are asymptomatic . 8 |
ally nocturnal because of the worms |
skin and no breast bud ), consider a |