- Email: [email protected]
Constipation presenting as recurrent vulvovaginitis in prepubertal children
718 Brief reports
J AM ACAD DERMATOL OCTOBER 2000
Constipation presenting as recurrent vulvovaginitis in prepubertal children P. A. F. A. van Neer, MD,a and C. R. W. Korver, MD, PhDb Roermond, The Netherlands Vulvovaginitis is the most common gynecologic problem in premenarcheal girls. We describe 3 patients with recurrent vulvovaginitis caused by bacterial infection who responded to treatment of constipation with resolution of the vulvovaginitis. There were no recurrences during the follow-up period of 15 to 36 months. We propose that underlying constipation should be added to the list of possible causes of recurrent vulvovaginitis. (J Am Acad Dermatol 2000;43:718-9.)
V
ulvovaginitis is the most common gynecologic problem in premenarcheal girls.1 The literature outlines several causal factors such as inadequate protective mechanisms, poor perineal hygiene, the presence of foreign bodies within the genitalia, sexual abuse, and infection. We report 3 cases in which recurrent vulvovaginitis due to bacterial infection resolved with treatment of constipation, leading to full recovery of the vulvovaginitis with no recurrences during the follow-up period of 15 to 36 months.
CASE REPORTS Case 1. A 5-year-old girl presented to the dermatology outpatient clinic in June 1995 with recurrent vulvar itching and vaginal discharge over a period of several months. On examination there was no discharge, but marked vulvar erythema and excoriation was noted. Vaginal swabs grew Escherichia coli, Streptococcus pyogenes, and Enterococcus faecalis. The patient was treated with amoxicillin/clavulanate, and the symptoms resolved only to recur a week later. Again S pyogenes was cultured, this time sensitive to erythromycin. This cycle continued until finally a pediatrician was consulted for advice on further management. He found the child to be constipated. In other aspects, the child was deemed to be healthy. The child was treated with lactulose 6 g 3 times a day, and the parents were advised about general hygiene and appropriate diet for the child. For several
From the Departments of Dermatologya and Pediatrics,b Laurentius Hospital Roermond. Reprint requests: P. A. F. A. van Neer, MD, Laurentius Hospital, PO Box 960, 6040 AX Roermond, The Netherlands. Copyright © 2000 by the American Academy of Dermatology, Inc. 0190-9622/2000/$12.00 + 0 16/54/107738 doi:10.1067/mjd.2000.107738
months the child remained symptom free. Six months later she presented with abdominal pain due to constipation together with pruritus. She was again treated for constipation and infection. Three years later she was completely symptom free. Case 2. An 11-year-old girl presented to the dermatology outpatient department in March 1997. She had been suffering from vulvar redness and purulent discharge for several years. Repeated treatment with antibiotics and antimycotics resulted in resolution of the symptoms for a period of 11⁄2 years. She had also suffered from recurrent abdominal pain and constipation, which had been diagnosed by a pediatrician in January 1995. Examination found the vulva to be markedly erythematous and excoriated. Genital swabs grew S pyogenes. Therapy with feneticilline and topical treatment with zinc oxide were started. She was referred to a pediatrician because of her constipation problems. She was found to have an abnormal voiding pattern with urinary frequency and slight urge incontinence. This was believed to be due to constipation, which was confirmed by x-ray of the abdomen. Treatment with lactulose (12 g twice daily) markedly alleviated her symptoms. Nineteen months later her vulvar complaints had disappeared, and her defecation frequency was almost completely normal. Case 3. In July 1997 a 7-year-old girl was seen at the dermatology outpatient clinic. Her presenting complaint was genital itching and soreness of the vulva and vagina. According to the parents her complaints had started immediately after she stopped wearing nappies. She had no history of dermatologic or gynecologic disease. However, she had on occasion had abdominal pain due to constipation. On examination the dermatologist found her vulva to be erythematous but not to have vaginal discharge. Culture of genital swabs grew E coli, sensitive to amoxicillin. The pediatrician consulted found the
J AM ACAD DERMATOL VOLUME 43, NUMBER 4
child to be constipated (evidenced by x-ray of the abdomen). Treatment with high-dose lactulose was started (12 g 3 times a day). Her problems of constipation and vulvovaginitis disappeared completely after treatment. On consultation via the telephone 15 months later, she was found to have no further complaints of vulvovaginitis.
DISCUSSION Vulvovaginitis in prepubertal girls has been attributed to several predisposing factors such as poor personal hygiene, local irritants, the presence of foreign bodies, infection, and child abuse.1 The vaginal mucosa of the child is an excellent medium for bacterial growth. It lacks important protective factors such as estrogen stimulation, glycogen, and Doderlein bacilli. Furthermore, the vulvar skin is thin, the vagina is situated close to the anus, and consequently perineal hygiene is frequently poor. These factors render the patient vulnerable to recurrent episodes of vulvovaginitis.1 Although constipation in infants and children is frequently encountered by general practitioners and pediatricians, reports on the incidence are remarkably scarce. Incidences of constipation of 3% in a pediatric outpatient clinic2 and up to 10% to 25% in a pediatric gastroenterology outpatient clinic have been reported.3 In our experience, 21% of children who visited the pediatric outpatient clinic for the first time were diagnosed with constipation (unpublished observation, 1996). Organic intestinal causes (Hirschsprung’s disease, anal atresia, spinal disease), medication, metabolic disorders (dehydration, hypothyroidism, hypokalemia), and neuromuscular or psychiatric diseases must be excluded as the cause but remain very rare. In most cases, a diagnosis of chronic functional constipation is made.4 We are convinced that characteristic avoidance of regular toilet visits in this age group is the main contributive factor in the pathogenesis of chronic constipation. The diagnosis is based on a typical medical history and supportive physical findings. The former takes the form of one of several of the following problems: recurrent abdominal pain often with crescendo-decrescendo character, encopresis, anorexia, malaise, painful defecation, and altered urinary pattern.
Brief reports 719
If one only relies on the presence of decreased defecation frequency and/or increased consistency of the feces, the diagnosis can be easily missed. Radiologic assessment of constipation is reliable and a scoring system has been proposed.5,6 In our group of constipated girls aged 3 to 10 years, 12% presented with vaginal discharge as the main or only symptom. This particular finding has not been reported before. All these children remained symptom free after adequate instruction regarding hygiene and dietary measures and a prolonged laxative regimen consisting of liquid lactulose or paraffin. We suggest that constipation leads to perianal and vulvar irritation plus pruritus by a mechanism still unknown and that secondary infection causes the vulvovaginitis. Infection can originate from pharyngeal or nasal secretions.7 A relationship between streptococcal vulvovaginitis and constipation is known from the literature.8,9 Our case reports show that girls with recurrent episodes of vulvovaginitis should be examined for constipation because its recognition and treatment could lead to complete resolution of the vulvovaginitis. We propose that underlying constipation should be added to the list of possible causes of (recurrent) vulvovaginitis. REFERENCES 1. Altchek A. Pediatric vulvovaginitis. J Reprod Med 1984;29:35975. 2. Levine MD. Children with encopresis: a descriptive analysis. Pediatrics 1975;56:412-6. 3. Taitz LS,Wales JKH, Urwin OM, Molnar D. Factors associated with the outcome in management of defecation disorders. Arch Dis Child 1986;61:472-7. 4. Keuzenkamp-Jansen CW, Fijnvandraat CJ, Kneepkens CMF, Douwes AC. Diagnostic dilemmas and results of treatment of chronic constipation. Arch Dis Child 1996;75:36-41. 5. Barr RG, Levine MD, Wilkinson RH, Mulvihill D. Chronic and occult stool retention: a clinical tool for its evaluation in schoolaged children. Clin Pediatr (Phila) 1979;18:674-86. 6. Blethyn AJ, Verrier Jones K, Newcombe R, Roberts GM, Jenkins HR. Radiological assessment of constipation. Arch Dis Child 1995;73:532-3. 7. Straumanis JP, Bocchini JA. Group A beta-hemolytic streptococcal vulvo-vaginitis in prepubertal girls: a case report and review of the past twenty years. Pediatr Infect Dis 1990;9:845-8. 8. Figueroa-Colon R, Grunow JE, Torres-Pinedo R, Rettig PJ. Group A streptococcal proctitis and vulvovaginitis in a prepubertal girl. Pediatr Infect Dis 1984;3:439-42. 9. Guss C, Larsen JG. Group A beta-hemolytic streptococcal proctocolitis. Pediatr Infect Dis 1984;3:442-3.
J AM ACAD DERMATOL OCTOBER 2000
Constipation presenting as recurrent vulvovaginitis in prepubertal children P. A. F. A. van Neer, MD,a and C. R. W. Korver, MD, PhDb Roermond, The Netherlands Vulvovaginitis is the most common gynecologic problem in premenarcheal girls. We describe 3 patients with recurrent vulvovaginitis caused by bacterial infection who responded to treatment of constipation with resolution of the vulvovaginitis. There were no recurrences during the follow-up period of 15 to 36 months. We propose that underlying constipation should be added to the list of possible causes of recurrent vulvovaginitis. (J Am Acad Dermatol 2000;43:718-9.)
V
ulvovaginitis is the most common gynecologic problem in premenarcheal girls.1 The literature outlines several causal factors such as inadequate protective mechanisms, poor perineal hygiene, the presence of foreign bodies within the genitalia, sexual abuse, and infection. We report 3 cases in which recurrent vulvovaginitis due to bacterial infection resolved with treatment of constipation, leading to full recovery of the vulvovaginitis with no recurrences during the follow-up period of 15 to 36 months.
CASE REPORTS Case 1. A 5-year-old girl presented to the dermatology outpatient clinic in June 1995 with recurrent vulvar itching and vaginal discharge over a period of several months. On examination there was no discharge, but marked vulvar erythema and excoriation was noted. Vaginal swabs grew Escherichia coli, Streptococcus pyogenes, and Enterococcus faecalis. The patient was treated with amoxicillin/clavulanate, and the symptoms resolved only to recur a week later. Again S pyogenes was cultured, this time sensitive to erythromycin. This cycle continued until finally a pediatrician was consulted for advice on further management. He found the child to be constipated. In other aspects, the child was deemed to be healthy. The child was treated with lactulose 6 g 3 times a day, and the parents were advised about general hygiene and appropriate diet for the child. For several
From the Departments of Dermatologya and Pediatrics,b Laurentius Hospital Roermond. Reprint requests: P. A. F. A. van Neer, MD, Laurentius Hospital, PO Box 960, 6040 AX Roermond, The Netherlands. Copyright © 2000 by the American Academy of Dermatology, Inc. 0190-9622/2000/$12.00 + 0 16/54/107738 doi:10.1067/mjd.2000.107738
months the child remained symptom free. Six months later she presented with abdominal pain due to constipation together with pruritus. She was again treated for constipation and infection. Three years later she was completely symptom free. Case 2. An 11-year-old girl presented to the dermatology outpatient department in March 1997. She had been suffering from vulvar redness and purulent discharge for several years. Repeated treatment with antibiotics and antimycotics resulted in resolution of the symptoms for a period of 11⁄2 years. She had also suffered from recurrent abdominal pain and constipation, which had been diagnosed by a pediatrician in January 1995. Examination found the vulva to be markedly erythematous and excoriated. Genital swabs grew S pyogenes. Therapy with feneticilline and topical treatment with zinc oxide were started. She was referred to a pediatrician because of her constipation problems. She was found to have an abnormal voiding pattern with urinary frequency and slight urge incontinence. This was believed to be due to constipation, which was confirmed by x-ray of the abdomen. Treatment with lactulose (12 g twice daily) markedly alleviated her symptoms. Nineteen months later her vulvar complaints had disappeared, and her defecation frequency was almost completely normal. Case 3. In July 1997 a 7-year-old girl was seen at the dermatology outpatient clinic. Her presenting complaint was genital itching and soreness of the vulva and vagina. According to the parents her complaints had started immediately after she stopped wearing nappies. She had no history of dermatologic or gynecologic disease. However, she had on occasion had abdominal pain due to constipation. On examination the dermatologist found her vulva to be erythematous but not to have vaginal discharge. Culture of genital swabs grew E coli, sensitive to amoxicillin. The pediatrician consulted found the
J AM ACAD DERMATOL VOLUME 43, NUMBER 4
child to be constipated (evidenced by x-ray of the abdomen). Treatment with high-dose lactulose was started (12 g 3 times a day). Her problems of constipation and vulvovaginitis disappeared completely after treatment. On consultation via the telephone 15 months later, she was found to have no further complaints of vulvovaginitis.
DISCUSSION Vulvovaginitis in prepubertal girls has been attributed to several predisposing factors such as poor personal hygiene, local irritants, the presence of foreign bodies, infection, and child abuse.1 The vaginal mucosa of the child is an excellent medium for bacterial growth. It lacks important protective factors such as estrogen stimulation, glycogen, and Doderlein bacilli. Furthermore, the vulvar skin is thin, the vagina is situated close to the anus, and consequently perineal hygiene is frequently poor. These factors render the patient vulnerable to recurrent episodes of vulvovaginitis.1 Although constipation in infants and children is frequently encountered by general practitioners and pediatricians, reports on the incidence are remarkably scarce. Incidences of constipation of 3% in a pediatric outpatient clinic2 and up to 10% to 25% in a pediatric gastroenterology outpatient clinic have been reported.3 In our experience, 21% of children who visited the pediatric outpatient clinic for the first time were diagnosed with constipation (unpublished observation, 1996). Organic intestinal causes (Hirschsprung’s disease, anal atresia, spinal disease), medication, metabolic disorders (dehydration, hypothyroidism, hypokalemia), and neuromuscular or psychiatric diseases must be excluded as the cause but remain very rare. In most cases, a diagnosis of chronic functional constipation is made.4 We are convinced that characteristic avoidance of regular toilet visits in this age group is the main contributive factor in the pathogenesis of chronic constipation. The diagnosis is based on a typical medical history and supportive physical findings. The former takes the form of one of several of the following problems: recurrent abdominal pain often with crescendo-decrescendo character, encopresis, anorexia, malaise, painful defecation, and altered urinary pattern.
Brief reports 719
If one only relies on the presence of decreased defecation frequency and/or increased consistency of the feces, the diagnosis can be easily missed. Radiologic assessment of constipation is reliable and a scoring system has been proposed.5,6 In our group of constipated girls aged 3 to 10 years, 12% presented with vaginal discharge as the main or only symptom. This particular finding has not been reported before. All these children remained symptom free after adequate instruction regarding hygiene and dietary measures and a prolonged laxative regimen consisting of liquid lactulose or paraffin. We suggest that constipation leads to perianal and vulvar irritation plus pruritus by a mechanism still unknown and that secondary infection causes the vulvovaginitis. Infection can originate from pharyngeal or nasal secretions.7 A relationship between streptococcal vulvovaginitis and constipation is known from the literature.8,9 Our case reports show that girls with recurrent episodes of vulvovaginitis should be examined for constipation because its recognition and treatment could lead to complete resolution of the vulvovaginitis. We propose that underlying constipation should be added to the list of possible causes of (recurrent) vulvovaginitis. REFERENCES 1. Altchek A. Pediatric vulvovaginitis. J Reprod Med 1984;29:35975. 2. Levine MD. Children with encopresis: a descriptive analysis. Pediatrics 1975;56:412-6. 3. Taitz LS,Wales JKH, Urwin OM, Molnar D. Factors associated with the outcome in management of defecation disorders. Arch Dis Child 1986;61:472-7. 4. Keuzenkamp-Jansen CW, Fijnvandraat CJ, Kneepkens CMF, Douwes AC. Diagnostic dilemmas and results of treatment of chronic constipation. Arch Dis Child 1996;75:36-41. 5. Barr RG, Levine MD, Wilkinson RH, Mulvihill D. Chronic and occult stool retention: a clinical tool for its evaluation in schoolaged children. Clin Pediatr (Phila) 1979;18:674-86. 6. Blethyn AJ, Verrier Jones K, Newcombe R, Roberts GM, Jenkins HR. Radiological assessment of constipation. Arch Dis Child 1995;73:532-3. 7. Straumanis JP, Bocchini JA. Group A beta-hemolytic streptococcal vulvo-vaginitis in prepubertal girls: a case report and review of the past twenty years. Pediatr Infect Dis 1990;9:845-8. 8. Figueroa-Colon R, Grunow JE, Torres-Pinedo R, Rettig PJ. Group A streptococcal proctitis and vulvovaginitis in a prepubertal girl. Pediatr Infect Dis 1984;3:439-42. 9. Guss C, Larsen JG. Group A beta-hemolytic streptococcal proctocolitis. Pediatr Infect Dis 1984;3:442-3.