The management of nonspecific vulvitis in children

THE

MANACMWEiNT

OF NONSPECIFIC

VULVITIS

IN CHILDMEN

JOSEPH B. TETON, M.D., AND NANCY C. TREADWELL, M.D., CHICAGO, ILL. (From

the

Departments

of Obstetrics and Gynecology, University Medicine and Henrotin Hospital)

of Illinois

College

of

OST of the available literature on vulvitis and vulvovaginitis in children This is a familiar still deals with that caused by gonorrhea1 infection. subject but, with the widespread use of antibiotics, more and more children presenting themselves with vulvitis show negative cultures. The normal characteristics of the immature vulvovaginal tract include a thin-walled epithelial surface, the cells of which secrete minimal amounts of glycogen which is broken down into lactic acid. As a result, there is a high pH, 7.0 or 8.0, as compared to that of the mature state. The bacterial flora are different, especially in the relative absence of Doderlein’s bacillus which characteristically thrives on lactic acid in the adult vaginal tract. The normal smear contains vaginal epithelial cells but no pus cells. Endocervicitis per se is rarely seen in the child, since there are only rudimentary cervical glands. Nonspecific vulvitis and vulvovaginitis are generally, if not always, due to an exaggeration of the normal hypoestrogenism of childhood, resulting in a true senile vaginitis.l In support of this etiology is the finding of leukoplakia and, rarely, even kraurosis in some of these children.2 The standard treatment for this condition was first that of gonorrhea1 vulvovaginitis, on the theory that many of these cases were simply gonorrhea1 infections not demonstrable on culture .3 The diagnostic characteristics of this ‘ ‘ senile ’ ’ vaginitis are thin, watery, yellowish discharge, slightly reddened, sore or itchy vulva, adhesions between the labia minora, and pale atrophic vaginal wall. As this was recognized, the local use of estrogen suppositories and cream became popular. In cases with severe and dense adhesive sealing across the vestibule surgical intervention has been advised.4 All these therapeutic regimes present a certain amount of psychic and physical trauma to the child by involving the parent and the gynecologist in procedures usually accompanied by pain, with consequent fear and resistance on the part of the child, over some period of time. In addition to this direct effect, we have the normal response of the immature female from age 3 to puberty, interpreting even light tactile stimuli in the genital area by another person as pain, fear, or anger. This is a sidetracking of the adult sensory responses from the genital area which may represent a natural protective If this is aggravated so as to become persistent after puberty, mechanism.5 it may present a definite negative factor in later sexual adjustments. Last, there are the complex and unreasonable reactions of the parents, especially the

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NONSPECIFIC

VT;LVITIS

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mother who generally takes direct responsibility for the treatment, to the presence 3 of genital pathology in the child. These reactions, which take thtr form of fear, shame, or horror, may easily be passed on to the child.”

Fig. Fig.

1.--S. 2.-S.

T. T.

Fig.

1.

Fig.

2

Adhesive vulvitis. One month after

Lcefore beginning

treatment. treatment.

and surg We wish to report two cases in which local manipulations of were av oided and excellent results obtained by the oral administration trogens. The agent was enteric-coated diethylstilbestrol in the dosage of or 0.25 mg. daily for ten to fourteen da,ys, or until complete lysis of the

ery es-

0.1 ad-

676

TETON

AND

TREADWELL

Am. J. Obst. & Gynec. September, 1956

hesions occurred, followed by a tablet every other or every third night for an additional month or two to ensure against recurrence. We have found this treatment to have been completely effective (Figs. 1 and 2). In one child, R. P., aged 7, we had initially felt that the density of the adhesions would require surgery and had given the medication as a preoperative measure. The other child, S. T., aged 4, had had many types of therapy over a period of three years with no lasting success until oral estrogens were tried. Each child has been free of recurrence now for a year. The only side effects in each child were slight darkening and enlargement of the nipples and areolae and a fine scanty growth of pubic hair. These effects disappeared after a few months and were never marked enough to cause the children concern. Since the enteric-coated tablets are small, red, and candy covered, we encountered no difficulty in persuading the children to take them. The parents, too, found the condition, the therapy, and the minimal side effects readily acceptable. In conclusion, we suggest small oral doses of enteric-coated diethylstilbestrol as a simple and effective therapeutic measure for hypoestrogenic adhesive vulvitis in children between the age of 3 years and puberty.

References 1. Schauffler, Goodrich C.: Pediatric Gynecology, ed. 3, Chicago, 1953, Publishers, Inc., p. 121. 2. Ibid., p. 127. 3. Schauffler, Goodrich C.: Pediatric Gynecology, Chicago, 1942, The Year Inc., p. 101. 4. Greenhill, J. P.: The 1954-1955 Year Book of Obstetrics and Gynecology, The Year Book Publishers, Inc., p. 306. 5. Sehauffler, Goodrich C.: Pediatric Gynecology, ed. 3, Chicago, 1953, Publishers, Inc., p. 19. 6. Ibid., p. 22. 30 NORTE

MICHIGAN

AVENUE

The

Year

Book

Publishers,

Chicago, The

Year

Book

1955, Book