BERKELEY, CA (UroToday.com) - As pediatricians at the gynecology pediatric unit of a public children´s hospital in Santiago, Chile we see about 2,000 cases a year.
Of these, 50% are prepubertal girls, and vulvovaginitis is the most common cause for consultation.
This investigation began because a large group of patients with vulvovaginitis did not have any detectable etiology. The patients had symptoms for 2.5 years on average and as long as six years in one case. Multiple vaginal cultures with commensal bacterias were found. On average 4 vaginal samples for microbiologic study were taken from each patient, although some had 8 vaginal microbiological studies. Only 47.5% of the vaginal microbiology studies were positive, and 74.3% of those were positive for commensal bacterias. Vaginoscopy was normal or showed erythema in the vaginal mucosa, and tests for sexually transmitted diseases were also normal. Psychological evaluations performed by a professional psychologist suggested that many of these girls had not been sexually abused.
So we asked the question, “does another etiology of vulvovaginitis exist that could explain these persistent symptoms?” Our previous experience made us look for voiding dysfunction since we believe that urine acts as a permanent chemical trigger on vaginal mucosa causing persistent inflammation.
One case was of an 8 year old patient who was brought in for compulsive masturbation. Her genital evaluation showed hyperpigmentation of labia mayora and intense erythema of the introitus. Screenings for sexually transmitted diseases, pinworm test and psychological evaluation were normal while urodynamics showed an overactive bladder with sphincter dyssynergia. Her symptoms ceased completely when she was treated with oxibutinine acid and biofeedback.
When we met with pediatric nephrologists and designed this study, they proposed urodynamics as the best method to diagnose voiding dysfunction. Although it is an invasive method that causes discomfort to the patient, it is the best tool for diagnosis. However, it is necessary to continue to look for other methods and we have begun evaluating voiding dysfunction in girls with vulvovaginitis by performing bladder ultrasound - a non-invasive method. When we asked about urinary symptoms, we were surprised that 90% of cases had urinary symptoms, (13) 65% with urinary incontinence and 19 (95%) with voiding dysfunction. Thirteen (65%) improved with treatment. Ten of the 13 were treated with oxibutinine acid and biofeedback and 3 of the13 with biofeedback only.
Biofeedback seems to be a good tool for the management of external sphincter dyssynergia. In these cases it was performed by a physiotherapist during the course of ten 30 minute sessions. The physiotherapist taught the patients and caregivers how to modify voiding habits; the girls were required to pass all the urine from the bladder and to perform perineal exercises at home. Patients who improved hygiene habits and participated in biofeedback achieved normal status of genital mucosa and ceased to have vaginal discharge.
A diagnosis of voiding dysfunction must be considered when consulting for vulvovaginitis in pediatric patients, and questions about urinary symptoms must be asked. If patient symptoms do not improve with hygiene measures and no other etiology is found, voiding dysfunction must be evaluated. It is also important to incorporate other medical disciplines in order to obtain positive results in this patient group.
Written by:
Patricia Romero, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Voiding dysfunction: Another etiology of vulvovaginitis in young girls - Abstract
UroToday.com Pediatric Urology Section