Personal Hygiene and Vulvovaginitis in Prepubertal Children

Accepted Manuscript Personal hygiene and vulvovaginitis in prepubertal children Fatıma Cemek, Dursun Odabaş, Ünal Şenel, A. Tuba Kocaman PII:

S1083-3188(15)00262-4

DOI:

10.1016/j.jpag.2015.07.002

Reference:

PEDADO 1875

To appear in:

Journal of Pediatric and Adolescent Gynecology

Received Date: 27 November 2014 Revised Date:

12 June 2015

Accepted Date: 10 July 2015

Please cite this article as: Cemek F, Odabaş D, Şenel Ü, Kocaman AT, Personal hygiene and vulvovaginitis in prepubertal children, Journal of Pediatric and Adolescent Gynecology (2015), doi: 10.1016/j.jpag.2015.07.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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ACCEPTED MANUSCRIPT Original article

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Running title: Vulvovaginitis in prepubertal girls

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Personal hygiene and vulvovaginitis in prepubertal children

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Fatıma Cemek1,*, Dursun Odabaş2, Ünal Şenel3, A. Tuba Kocaman3

Department of Pediatrics, Basaksehir State Hospital, Istanbul, Turkey

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Department of Pediatrics, Konya Training and Research Hospital, Konya, Turkey

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Department of Bioengineering, Faculty of Chem. and Met. Eng., Yıldız Technical University,

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1

*

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Istanbul, Turkey,

Correspondence:

Dr. Fatıma Cemek

Department of Pediatrics

Basaksehir State Hospital, Istanbul, Turkey Tel: 0202 383 46 32 Fax: 0212 383 46 25; E-mail: [email protected]

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ACCEPTED MANUSCRIPT Abstract.

Objectives: To determine and compare clinical and microbiological features of vulvovaginitis in prepubertal girls. Background: Vulvovaginitis is the most common gynecological problem of childhood.

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Methods: This study involves forty-five girls from 2-12 (5.38±2.9) years old; and twenty-six girls from 3-12 (5.72±3.1) years old as a control group. Anamnesis and physical examination were followed by vaginal smear, urine culture and stool analyses from both groups, and the

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personal hygiene status and education level of the mother were determined.

Results: The most common symptoms among the patients were vaginal discharge (44.4%),

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vulvar erythema (37.8%), and vaginal itch (24.4%). Microorganisms, isolated from vaginal smears, were detected in 48.9% of the patients. Escherichia coli was shown in the urine culture of three patients with vulvovaginitis (6.70%). In microscopic stool analysis parasites were detected (45.9%). We found some relevant personal hygiene factors, such as wiping

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back to front (42.9%), cleaning by herself after defecation (89.3%), using toilet paper (60.7%) and wet wipes (21.4%), having bath by standing (14.3%) and by sitting (46.4%), among patients. The questionnaire also showed that the children wear tight clothing (35.7%).

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Conclusion: Our findings suggest that vulvovaginitis in prepubertal girls is related not only to microorganisms but also poor personal hygiene, the educational status of mothers and specific

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irritants.

Key words: Prepubertal girls, vaginal discharge, vulvovaginitis, personal hygiene

Introduction

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Although the actual incidence is unknown, vulvovaginitis is considered to be the most common gynecological problem in children and adolescents. Many factors can contribute to inflammation in the genital area. These factors include introitus less protected by arrangement of the labia majora, irritation of the vaginal mucosa and low estrogen concentration leaving

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the patient susceptible to infection, exposure to irritants (bubble bath), poor hygiene and infection by specific pathogens. If symptoms such as vaginal discharge, dysuria, inflammation, itching and vulvar erythema are present, it is a case of vulvovaginitis (1-4).

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The proximity of the anus and vagina can cause contamination by fecal bacteria. Also,

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prepubertal girls lack protective labial fat pads and pubic hair. In addition, one effect of estrogen in puberty is to thicken the vaginal mucosa and thus reduce the incidence of potential infections and vaginitis (2-7).

Approximately 75% cases of vaginitis in prepuberty are non-specific vaginitis (7). In

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cases of non-specific vaginitis, Coliform bacteria, Escherichia coli, Enterococci, anaerobic Diphtheroids and microorganisms such as bacteria that suggest fecal contamination are the most common microorganisms. Many scientists think that inadequate hygiene and tight

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clothing (nylon underwear, tights and plastic-coated paper diapers) may have a role in the development of non-specific vaginitis. Another common factor is exposure to irritants such as

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perfumed cleaning supplies in laundry and bathing, as well as soap (vigorously rubbing the genital area with soap). Thus, mildly irritating chemicals deposited at the entrance of the vagina cause chemical vaginitis / irritant vaginitis. Then, super-infection with local microorganisms can develop (8-10). The aim of this study is to determine and compare the clinical and microbiological features of vulvovaginitis and to clarify the contribution of clinical and environmental factors and infection to the aetiology of vulvovaginitis in prepubertal girls.

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ACCEPTED MANUSCRIPT Materials and methods

This study was approved by The Human Research Ethics Committee at the Yuzuncu Yıl University Medical School and conducted in accordance with the Helsinki Declaration. Parents were informed about the study, and informed written consent was obtained from each

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before the start of the study.

Patients who presented to the children's health and disease clinic in the faculty of medicine research and training hospital were admitted to this study. Forty-five girls who were

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beyond the diaper stage and who presented with complaints such as redness in the genital area, pain, burning, tenderness, itching, and vaginal discharge were diagnosed with

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vulvovaginitis and admitted as a patient group. Girls aged 2-12 years at prepubertal status Tanner stage I with absence of secondary sexual characteristics, and showing typical complaints and symptoms of vulvovaginitis, were enrolled in the study. The control group was randomly selected for this study. Girls included in the control

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group were of prepubertal age and at Tanner stage I.

The twenty-six girls had no

gynecological complaints, no history of sexual abuse and no systemic antibiotic therapy. The families of the children included in this study were informed about the study. The

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required permissions were obtained for the examination and laboratory tests. The detailed

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histories of individuals in both groups were taken and clinical information and laboratory findings were recorded. The urine, vaginal cultures and stool samples were collected carefully from children.

Precautions were taken in the prepubertal girls to prevent contamination of the urine

with vaginal discharge. When urine was collected from small children who could not control their bladder sphincter, special sterile containers were used. Any contact with the container’s interior walls was avoided. A midstream sample was the appropriate specimen for a urine culture: urine was collected after the first brief miction was discarded and before the miction

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was completed. The container was immediately sent to the laboratory for analysis. The samples were inoculated onto 5% sheep blood-brain heart infusion agar (DIFCO-USA), and eosin methylene blue agar (DIFCO) medium in the microbiology laboratory. Pathogen identification and antimicrobial susceptibility tests were examined using Sceptor panels

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(Becton-Dickinson, USA).

Stool samples were collected from all the asymptomatic girls and the symptomatic girls. After being placed into stool containers, the samples were examined by direct

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microscopy in the parasitology laboratory. In the early morning of three consecutive days, a

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tape test for pinworms was taken from the perineal area of every child with anal itching, spread on a slide, and examined under a microscope.

The vaginal cultures were taken by establishing with the child and the child’s family good relations and trust for the examinations and investigations. Then the patient was laid on

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the examination table with legs open in the supine position. In the physical examination, without use of auxiliary tools like speculum and otoscope, the child’s prepubertal status, skin disease, type of stream, and the condition of the vulva and vagina were determined. The

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assistance of child’s mother was provided during this process. The swab cultures were taken to detect ureaplasma and mycoplasma using specially prepared cotton-tipped sterile, wooden

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swabs as a transport medium. The resulting samples were immediately sent to the microbiology laboratory for cultivation. The data obtained from the patient and control groups were compared. Statistical

analysis was performed with SPSS ver. 20.0. Chi square test was used to compare categorical variables and Student t test was applied for continuous variables of the treatment groups. For statistical significance p value of 0.05 was accepted. The average of the data and standard deviation of patients and control subjects were shown as X ± SD.

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The patient group was composed of forty-five girls from 2-12 years who complained of vaginal discharge; the control group was composed of twenty-six girls from 3-12 years.

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The mean age of children belonging to the patient group was 5.38±2.9 years, whereas in the control group this value was 5.72±3.1 years. A statistically significant difference was not determined between the ages of patient and control groups included in this study (p>0.05). Clinical symptoms of patients who were diagnosed with vulvovaginitis are shown in Table 1.

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Microorganisms isolated from the cultures are summarized in Table 2. The stool microscopy

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results of stool samples obtained from patients and control groups are shown in Table 3. Giardia intestinalis was detected in six children (13.3%) in the patient group and two children (7.7%) in the control group. Blastocystis hominis was determined in 3 (6.7%) diseased children and two children (7.7%) in the control group. Enterobius vermicularis and Ascaris lumbricoides, were found in 10 children (22.2%) and one (2.2%) child respectively in the

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patients group, whereas these parasites were not found in the control group. Trichuris trichiura and iodamoeba butschlii were not detected in the patient group. However, it was

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seen in one child (3.8%) in the control group. The educational status of the children’s mothers is shown in detail in Table 4. Hygiene information on patients whose cultures contained

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microorganisms are shown in Table 5. Microorganisms were detected in vagina and/or urine cultures of 10 girls (35.7 %) who use tight underwear and tights, in 12 girls (42.9 %) who clean themselves from the back to the front, in 25 children (89.3 %) who clean themselves after the toilet, in 4 children (14.3 %) who have a bath while standing, in 13 children (46.4 %) who have a bath while sitting, in 6 children (21.4 %) who have a bath in a bathtub-basin, in 6 children (21.4 %) who use wet wipes and in 17 children (60.7 %) who use toilet paper. Discussion

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Prepubertal girls are anatomically, physiologically, and behaviorally exposed to an increased risk of developing vulvovaginitis. Vaginal discharge is the most common gynecological complaint in prepubertal girls. Vulvovaginal inflammation is seen in 40 to 50% of patients who are admitted to the pediatric clinic (5-7). The families and children have

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difficulty in expressing discomfort because of undue fear and anxiety caused by society’s apprehensions about privacy, by traditional upbringing and by ignorance about the disease. The most common complaints of patients are vaginal discharge, vulvar infection signs

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(redness, itching, and burning) and fusion of labia minora (3,4,11,12). Piippo et al. detected 32% vaginal discharge, 21% itching, 22% burning-pain, 13% genital redness, 10% bleeding,

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29% urinary symptoms, 3% sensibility, and 7% pain symptoms in 68 prepubertal girls with vulvar symptoms (13). In a study conducted in Spain, the most common symptoms of vulvovaginitis such as discharge, itching, and dysuria were determined in 74 girls between the ages of 2 and 12 (14). In our study, the most common signs and symptoms detected in patients

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with vulvovaginitis were: 44.4% vaginal discharge, 24.4% vaginal itching, 37.8% vulvar erythema, 33.3% dysuria, 6.3% perineal pain-burning during urination, 13.3% enuresis, 2.1%

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encopresis, 35.6% anal itching.

Such pathogenic microorganisms as β-hemolytic streptococci, H. influenzae, and, S.

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pneumoniae are frequently responsible for vulvovaginal infections in children (5, 15-17). Sexually transmitted infections such as Neisseria gonorrheae and Chlamydia trachomatis are important causes of vulvovaginitis following child sexual abuse, and screening of these infections should be undertaken in all children evaluated for possible sexual abuse (17-19). Some researchers have determined that many bacteria such as coliforms and streptococci constitute mixed infections in vulvovaginitis in prepubertal girls. Also, cheesy vaginal discharge is seen in vaginal candidiasis. Generally, infection is facilitated by use of

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antibiotics in patients with diabetes mellitus and increased moisture and heat in the perineal region caused by tight clothing (5-7, 20). In our study, Mycoplasma hominis and Ureaplasma were examined because of being

colonization only in one patient, six years old.

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member of colonization and inducing vulvovaginitis. We detected Ureaplasma urealyticum

75% of women are subject to vulvovaginal candidiasis at least once during their

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lifetime (20, 21). Candida is usually not isolated in prepubertal girls, but it may be found in girls with predisposing factors, such as a recent course of antibiotics, diabetes or the wearing

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of diapers (7, 16). Basic complaints are itchiness, sensitivity and vaginal discharge forming a yellow-white curd. We detected only one Candida infection in the patients group. This patient, who attends the pediatric nephrology unit, used prophylactic antibiotics at low doses following diagnosis of recurrent urinary tract infection and enuresis.

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In our study, prepubertal girls whose ages were from 2-12 were included in the patient group. This group of children is not sexually active. No sign or symptom of sexual abuse was detected in their physical examination or history. For this reason, we did not perform any

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culture for microorganisms of sexually transmitted diseases. In our study, microorganisms including Streptococcus bovis D-II (6.7%), Enterococcus faecalis D (4.4%), E. coli (4.4%),

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Non A-Non B hemolytic Streptococcus (4.4%), Diphtheroid bacilli (8.9%), S. epidermidis (2.2%), Ruminococcus productus (6.7%), Candida spp. (2.2%), Actinomyces israelii (6.7%), Ureaplasma urealyticum (2.2%) were isolated from cultures of patients with vulvovaginitis. Recently, many studies have emphasized the importance of checking for foreign bodies in the etiology of vaginal discharge in prepubertal girls. The main clinical symptoms of a vaginal foreign body are vaginal bleeding, bloody spotting in underwear and a foul-smelling discharge. The researchers emphasize that this cause is rare but it should be considered in the

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presence of ongoing bloody discharge in girls who are considered to have an infection. The most common foreign body is toilet paper. After removal of the foreign body, the recommended treatment is sitz baths and application of local estrogen cream (22-24). In our study, a foreign body was not considered in any of the cases because of the duration and

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character of discharge.

Enterobius vermicularis is a common etiologic factor in vulvovaginitis. Increased itching of perianal/perineal region at nights, crowded and poor hygiene conditions should

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make us consider infestation with E. vermicularis (16, 23, 25). Yilmaz et al. detected it in two

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prepubertal girls among 27 prepubertal girls in their patient group (26). E. vermicularis was found in 32.3% of cases of vulvovaginitis in study by Pierce and Hart, and Williams et al. reported it as an etiological factor in 20% of cases of prepubertal vulvovaginitis (27-28). In our study, E. vermicularis was detected in 10 (22.2%) cases of 45 symptomatic prepubertal girls. The high incidence of patients with parasites may be explained by patients’ low

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sociocultural level and poor hygiene conditions. Many researchers have defined the most common cause of vulvovaginitis as allergic

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reaction to bubble bath and given some recommendations to the families of patients about allergens and the possible role of hygiene in vulvovaginitis (1,24). All of our patients use soap

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in the bathroom, as stated by their families. Use of bubble bath was not detected. Allergic vulvovaginitis was not encountered in patients, possibly because patients used only cotton underwear and had no exposure to irritant substances such as bubble bath. In our study, non-infectious vulvovaginitis was detected in approximately 80% of symptomatic girls. The majority of microorganisms indicated in our study belong to the normal vaginal and intestinal flora. This finding suggests colonization caused by fecal contamination due to the proximity of anus and vulva, and fecal contamination due to

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inadequate and incorrect cleaning after using the toilet (back-to-front cleaning). Because normal vaginal flora isolated from patients’ vaginal cultures responded to conservative treatment in 2-4 weeks, the etiology of the vulvovaginitis in these cases is thought not to

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derive from a specific infectious pathogen. In the present study, a similar flora was isolated both in studied girls and in controls. However, a statistically significant difference was found in the number of samples with positive microbiological findings between symptomatic girls and controls (p<0.05) (Table 2).

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Moreover, we found that wearing tight clothing and cleaning from back to the front after

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using the toilet were associated with increased risk of having a positive urine and vaginal culture or of having symptoms. In contrast, bathing while standing and using wet wipes to clean were associated with decreased risk of infection and symptoms (Table 5). We determined that, vulvovaginitis not only depends on infectious agents but also

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poor hygiene and improper cleaning (35.7%) (cleaning from back to front), and the cleaning habits of girls after toilet by themselves (89.3%). In addition, use of wet wipes (21.4%) and toilet paper (60.7%) can contribute to fecal contamination of the vulva and increase the risk of

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vulvovaginitis. The bath type was also important; bathing while standing (14.3%) was found to be healthier than while sitting (46.4%) or in a basin (21.4%). The use of tight clothing like

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tights was another risk factor for vulvovaginitis. Wearing tights and tight clothing (35.7%) was determined as an important risk factor for vulvovaginitis in children in our study group. We concluded from our research that the mother’s education level was another

important factor for this disease. Mothers of the children with vulvovaginitis and of children in the control group graduated from primary school or had a lower level of education (57.8% and 23.1%, respectively) (Table 5). Children of mothers with low educational level do not receive an adequate level of toilet training or it may be considered that they do not show

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sensitivity to this issue. The results of another study also showed a significant correlation between bacterial vaginosis and educational status; it was evident that the lack of education was significantly associated with bacterial vaginosis (p<0.05) (29).

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In another study, the most common sources of vaginal irritation and discharge were respiratory bacteria which were manually transmitted to the perineum, local irritants induced by bubble bath or nylon underwear, and fecal contamination induced by poor perineal hygiene (1,5,24,30). Indeed, in our study, some of the microorganisms isolated from cultures were

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members of the intestinal flora. This indicates the inadequacy of cleaning after toilet.

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Our study had several limitations. We had great difficulties to create the control group due to social and cultural perceptions. Therefore, the number of children in the control group was relatively small. Moreover, we did not compare vaginal cultures with cultures from the nasopharynx. At the same time, symptomatic girls treated with antibiotics or other meds. All

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Conclusion

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of the patients and the control group improved hygiene habits.

Our findings suggest that vulvovaginitis in prepubertal girls is related not only to

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microorganisms but also to poor hygiene, educational status of mothers and specific irritants. General recommendations should be given about personal hygiene and avoidance of irritants to the mothers of girls. A specific pathogen is not isolated in 25-75% of girls with vulvovaginitis. This may be due to non-specific irritation resulting from the use of bubble bath, soaps, or shampoos; poor hygiene; tight clothing; or fecal contamination (7). Nevertheless, the presence of symptoms such as redness, itching or discharge mostly indicates an infectious etiology. Organisms such as N. gonorrhea, Chlamydia and Trichomonas are the strongest predictor of sexual abuse in children. The possibility of sexual abuse should always

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be considered when a child presents with genital symptoms. Although Candida is not common in children, it can be seen in children who use antibiotics. Atrophic vaginitis may be present in some children with recurrent infections due to reduced resistance of vaginal mucosa

References

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to infection.

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2. Cuadros J, Mazo´n A, Martinez R et al. The aetiology of paediatric inflammatory

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Dev. Basel, Karger, 2012;22:72-83. 5. Ranđelović G, Mladenović V, Ristić et al. Microbiological aspects of vulvovaginitis

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7. Joishy M, Ashtekar CS, Jain A, Gonsalves, R. Do we need to treat vulvovaginitis in prepubertal girls? BMJ 2005;330:186–188. 8. Fischer G. Chronic vulvitis in pre-pubertal girls. Australasian Journal of Dermatology 2010; 51: 118–123.

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9. Hansen MT, Sanchez VT, Eyster K, Hansen, KA. Streptococcus pyogenes Pharyngeal Colonization Resulting in Recurrent, Prepubertal Vulvovaginitis. J Pediatr Adolesc Gynecol 2007; 20: 315-317. 10. Rimoin LP, Kwatra, SG, Yosipovitch G. Female-specific pruritus from childhood to

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postmenopause: clinical features, hormonal factors, and treatment considerations.

11. Hopkins J. The Johns Hopkins Manual of Gynecology and Obstetrics. Ankara: Atlas

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Kitapçılık, 2000.

12. Jones R. Childhood vulvovaginitis and vaginal discharge in practice. Family Practice

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1996; 13: 369-372.

13. Piippo S, Lenko H, Vuento R. Vulvar symptoms in paediatric and adolescent patients. Acta Paediatr 2000; 89: 431–5.

14. Cuadros J, Mazo A, Martinez R, Gonzalez P. The aetiology of paediatric inflammatory vulvovaginitis. Eur J Pediatr 2004; 163: 105–7. 15. Stricker, T., Navratil, F., Sennhauser, F.H. Vulvovaginitis in prepubertal girls. Arch

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Dis Child 2003;88:324–326.

16. Dei, M., Maggio, F.D., Di Paolo, G., Bruni, V. Vulvovaginitis in childhood. Best Practice & Research Clinical Obstetrics and Gynaecology 2010; 24: 129–137.

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17. Heymann WR. Streptococcal vulvovaginitis. J Am Acad Dermatol. 2009; 61:94-5. 18. Cox RA, Slack MPE. Clinical and microbiological features of Haemophilus influenza vulvovaginitis in young girls. J ClinPathol 2002; 55:961–964.

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19. Jaquiery A, Stylianopoulos A, Hogg G, Grover S. Vulvovaginitis: clinical features, aetiology, and microbiology of the genital tract, Arch Dis Child. 1999; 81: 64–67.

20. Zhou X, Westman R, Hickey R et al. Vaginal Microbiota of Women with Frequent Vulvovaginal Candidiasis. Infection and Immunity, 2009; 77(9): 4130–4135

21. Rimoin LP, Kwatra, SG, Yosipovitch G. Female-specific pruritus from childhood to postmenopause: clinical features, hormonal factors, and treatment considerations. Dermatologic Therapy, 2013; 26: 157–167.

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22. Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J. Paediatr. Child Health 2004; 40: 205–207. 23. Sanfilippo JS. Vaginal Discharged Time for a Reappraisal. J Pediatr Adolesc Gynecol. 2013; 26: 203-204.

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24. Smith YR, Berman DR, Quint, E.H. Premenarchal Vaginal Discharge: Findings of Procedures to Rule out Foreign Bodies. J Pediatr Adolesc Gynecol 2002; 13:227-230. 25. Romero P, Rodrıguez E, Munoz M et al. Voiding Dysfunction: Another Etiology of

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Vulvovaginitis in Young Girls. J Pediatr Adolesc Gynecol 2011; 24: 189-191

26. Yilmaz AE, Celik N, Soylu G, Donmez A, Yuksel C. Comparison of clinical and

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microbiological features of vulvovaginitis in prepubertal and pubertal girls. Journal of the Formosan Medical Association 2012; 111: 392-396.

27. Pierce AM, Hart CA. Vulvovaginitis causes and management. Arch Dis Childhood 1991;67:509–12.

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28. Williams TS, Callan JP, Owen LG. Vulvar disorders in prepubertal females. Pediatr Ann 1986;15:588–605.

29. Bahram A, Hamid B, Zohre T. Prevalence of Bacterial Vaginosis and Impact of

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Genital Hygiene Practices in Non-Pregnant Women OMJ. 2009;24, 288-293. 30. Hansen MT, Sanchez VT, Eyster K, Hansen, KA. Streptococcus pyogenes Pharyngeal

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Colonization Resulting in Recurrent, Prepubertal Vulvovaginitis. J Pediatr Adolesc Gynecol 2007; 20: 315-317.

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Table 1. Clinical symptoms of the patients with vulvovaginitis

(%)

20

44.4

Watery discharge from mouth

18

40.0

Vulvar erythema

17

37.8

Anal itching

16

35.6

Dysuria

15

33.3

14

31.1

Vaginal itching

11

24.4

Abdominal pain

12

26.7

Parasite history

12

26.7

History of urinary tract infection

9

20.0

Vaginitis treatment received

5

11.1

Enuresis

6

13.3

Perineal pain-burning during urination

3

6.3

Encopresis

1

2.1

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Vaginal discharge

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Clinical Symptoms

Prepubertal group Average age 5.38 years (range 2–12 years) (n = 45)

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Odor in discharge

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Microorganisms

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Table 2. Microorganisms isolated from the cultures of girls with vulvovaginitis and in controls

Patient

Control

n (%)

n (%)

p-value

4 (8.9)

1 (3.8)

p<0.05

3 (6.7)

0

p<0.05

3 (6.7)

0

p<0.05

3 (6.7)

0

p<0.05

Enterococcus faecalis D

2 (4.4)

1 (3.8)

p>0.05

Escherichia coli

2 (4.4)

1 (3.8)

p>0.05

Non A- Non B hemolytic Streptococcus

2 (4.4)

0

p<0.05

Staphylococcus epidermitis

1 (2.2)

1 (3.8)

p>0.05

Candida spp.

1 (2.2)

0

p>0.05

Ureaplasmaurealyticum

1 (2.2)

0

p>0.05

3 (6.7)

0

The vaginal swab culture Diphtheroid bacilli Streptococcus bovis D-II Ruminococcusproductus

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Actinomycesisraelii

Urine culture Escherichia coli

p<0.05

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Patient group n (%)

Control group n (%)

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Parasites

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Table 3. Stool microscopy findings in girls with vulvovaginitis and control

p-value

10 (22.2)

0

p<0.05

Giardia intestinalis

6 (13.3)

2 (7.7)

p<0.05

Blastocystishominis

3 (6.7)

2 (7.7)

p>0.05

Ascarislumbricoides

1 (2.2)

0

p>0.05

Trichurustrichura

0

1 (3.8)

p>0.05

Iodamoebabutschlii

0

1 (3.8)

p>0.05

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Enterobiusvermicularis

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p<0.05

20 (44.4)

4 (15.4)

p<0.05

Graduated from high school

7 (15.6)

8 (30.8)

p<0.05

Graduated from college

4 (8.9)

7 (26.9)

p<0.05

Illiterate

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Graduated from primary school

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Control group n (%) 1 (3.8)

Educational status of mothers

Patient group n (%) 4 (8.9)

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Table 4. Educational status of mothers of patient and control girls

p-value

19

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Table 5. Hygiene information of study groups

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Symptomatic patients Control (n=45) (n=26) n (%) n (%)

p-value

21 (46.7)

5 (19.2)

p<0.05

22 (48.9)

3 (11.5)

p<0.05

35 (77.8)

15 (57.7)

p>0.05

7 (15.6)

14 (53.8)

p<0.05

28 (62.2)

10 (38.5)

p>0.05

Those who use wet wipes

9 (20.0)

11 (42.3)

p<0.05

Those who use toilet paper

42 (93.3)

22 (84.6)

p>0.05

Narrow clothing, use of tight Cleaning from back to the front

Those who bathe while standing

by

TE D

Those who clean themselves after toilet

AC C

EP

Those who bathe while sitting