Vulvovaginitis

VULVOVAGINITIS (vulvo-vaginitis), inflammation of the external genitalia and vagina. It occurs, mainly, in children. In 1884, Frenkel (Heidelberg) first pointed out the gonorrheal nature of childhood V.-v. Recent research has introduced a number of corrections to both the doctrine of etiology and the definition of the disease itself. Etiology. Many authors consider that the etiological factor in V.-v. in children in 75-90% of cases is the gonococcus. Other researchers, based on their data, believe that the gonococcus is only the causative agent in 35.7% of cases of V.-v. Kushelievsky, based on data from the 1st Moscow Venereal Dispensary, indicates approximately the same percentage (38%). Among other etiological factors, Micrococcus catarrhalis, streptococci, intestinal microbes, pneumococci, and diphtheria bacilli are mentioned. Tsoumaras described a 'paragonococcal' and Kan a 'gonococcoid' V.-v., caused by a Gram-negative diplococcus biologically different from the gonococcus. V.-v. on the basis of Oxyuris vermicularis has long been known. Under the name vulva desquamativa, Epstein describes a physiological catarrh in infants. Among other etiological factors, thermal and medicinal irritation (Kan), foreign bodies, exudative diathesis, neuropathy, endogenous obesity, and asthenia are mentioned. V.-v. in children can be observed after scarlet fever, measles, etc. Solomonovich (State Venereal Institute), based on his research, points to the following factors that may serve as predisposing causes for common V.-v. in children: 1) lymphatic constitution (hypoplastic anomaly), 2) exudative diathesis, 3) uric acid diathesis, 4) endogenous obesity, 5) neuropathy, and 6) asthenia. In general, childhood V.-v. can be divided into two types: simple V.-v. (v. simplex s. vulgaris), which constitutes 60%, and gonorrheal V.-v. (v. infantum gonorrhoica), which accounts for approximately 40% of all cases. Non-gonorrheal V.-v. The etiology of simple V.-v. lies in a number of the constitutional diseases of children mentioned above, then Oxyuris vermicularis. In the discharge from the genitalia, Gram-positive diplococci are found in most cases, sometimes Micrococcus catarrhalis, streptococci, intestinal and diphtheria bacilli. The course of the disease is as varied as its etiology. Forms are not uncommon, especially in young children, when the disease develops slowly and gradually; parents first notice slight itching in the child, and only later do more or less abundant discharge appear, which leaves stains on underwear. More often, especially in older children, right at the beginning of the disease, 3-5 days after infection, purulent discharge of yellow or yellow-green color is noted. The vulva appears swollen and reddened. The duration of the acute period in non-gonorrheal V.-v. can vary, depending on the causative agent of the disease. In V.-v. occurring with measles or chickenpox, the inflammatory phenomena most often disappear almost simultaneously with the child's recovery from the main disease. In scarlet fever, vaginal discharge occurs in 50-70% of cases (Mussliner); they often coincide with the period of desquamation and disappear simultaneously with it; apparently, in these cases there is a process on the vaginal mucosa similar to desquamation on the skin, i.e., there is no true inflammatory process. But, in addition to this, in scarlet fever there are also forms of V.-v. in which all signs of inflammation of the vulva and vagina are present. V.-v. in pinworms usually continues until the pinworms are treated. Diphtheritic V.-v. gives a quite unique clinical picture. The child complains of burning in the area of the vulva, pain during urination. At first, marked redness of the vulva is noted, soon covered with a grayish coating. The labia majora often swell markedly or acquire a dark red hue.--From other individual forms of V.-v., the following should be noted: V.-v. of newborns, which is essentially a physiological phenomenon. Along with intensified peeling of the skin, the same process occurs in the vagina, causing some discharge, i.e., a picture similar to V.-v. V.-v. is also found in infants with improper care of the child, when during washing feces get into the vulva or even into the vagina. As mentioned above, V.-v. in children suffering from exudative diathesis deserves special attention. In these forms, the course of the disease is intermittent. Just as on the face of such children, periods of severe weeping eczema are replaced by periods of only slight peeling of the cheeks, so V.-v. can give a picture of abundant purulent discharge, replaced only by slight redness of the vulva. Such V.-v. can continue until school age, with more or less long periods of well-being. In older girls, V.-v. caused by masturbation is not uncommon. Usually in these cases, redness, swelling of the vulva and gaping of the hymenal orifice are observed. If there are abundant purulent discharges, their cause may be foreign bodies stuck in the vagina during masturbation. It is also necessary to mention the so-called v. aphthosa, described by Heubner. In this disease, aphthae appear on the mucous membrane of the vulva and vagina, similar to the aphthae in the mouth in stomatitis aphthosa, which usually accompanies vulvo-vaginitis aphthosa and is the primary disease. The diagnosis is made based on the presence of the above-mentioned signs of inflammation of the mucous membrane of the vulva and vagina. It is very important to determine the etiology of the disease. First of all, it is necessary to exclude gonorrhea, which is possible with the help of bacteriological examination of the discharge (see below). If there is marked redness, and especially if there are coatings on the mucous membrane of the vulva, it is necessary to examine for diphtheria (culture). In these cases, it is very important to find out if there were cases of diphtheria in the family or apartment. In unclear cases, the possibility of Oxyuris should be kept in mind and appropriate examinations made. It is extremely important to examine the entire child to determine if there is a metabolic disorder or anemia. Establishing the etiology of each case is necessary for determining the diagnosis and prescribing correct treatment. Unfortunately, this is not always possible with complete certainty.--In treatment, first of all, it is necessary to eliminate the cause that caused the V.-v.; at the same time, local treatment should be undertaken. Treatment of V.-v. in girls must be carried out with great caution. On the one hand, one must avoid deep energetic douches, as they can lead to the transfer of infection to higher organs and cause various complications up to peritonitis. On the other hand, one must keep in mind that constant fixation of attention on the genital organs is a psychological trauma and can be a source of masturbation. Non-gonorrheal V.-v. does not require any vigorous local measures for treatment; usually it is sufficient to wash the external genitalia with not strong disinfectant solutions: Kali hypermang. (1:8,000), Liq. alumin. acetici 3% or sitz baths with the same solutions. On the contrary, the use of strongly acting chemical agents contributes to irritation of the mucous membrane and increased discharge. This is especially sharply manifested in vulvo-vaginitis associated with exudative diathesis. General strengthening treatment is always necessary in these cases. Gonorrheal V.-v. In fact, gonorrheal V.-v. is gonorrhea in little girls in general, because with it, in addition to the vulva and vagina, the urethra, rectum, cervical canal, appendages of the uterus, and peritoneum are also affected. Cases of arthritis and general gonorrheal infection in children have also been described (see Gonorrhea).--Frequency. According to Deyll, in Amsterdam schools, 1% of all girls suffer from gonorrheal V.-v. According to Kushelievsky, the 1st venereal dispensary in the last five years examined 3,442 girls aged 2 to 14 years in the Rogozhsko-Simonovsky district of Moscow. Among these children, gonorrheal V.-v. was found in 3.9%, with gonorrheal V.-v. found in 2.3% in nursery age, and in 4.1% in older age. 1927 gave a significant decrease in this percentage. Thus, in 1927, among children of nursery age, gonorrheal V.-v. was found in 1.5%.--Age. Not all ages are affected equally often. The least (about 4%) children get sick under 1 year of age, as well as over 13 years of age. 30% of all patients fall on the age from 1 to 4 years, 37% on the age from 4 to 7, 15% on the age from 7 to 10, and 10% on the age from 10 to 13 years. Thus, 67% of all patients fall on the age from 1 to 7 years.--The routes of infection penetration are quite diverse; children can become infected: 1) during the act of childbirth, with breech presentations, in case of the mother's illness (Koblank); 2) when they sleep in the same bed with sick parents; this so-called family infection, according to the data of most authors, is the cause of childhood V.-v. in 50% of cases (Kan, Shiperskaya, Kushelievsky); 3) when children use underwear, sponges and night dishes from sick adults or children; 4) when using contaminated toilets in schools, children's colonies, etc.

(according to Karicheva and Karetskaya, in 11.5%); 5) on the basis of stuprum (rape; according to Shiperskaya's data, in 2.5%, and according to the data of Karicheva and Karetskaya, even in 17.8%).-The pathological anatomy of childhood gonorrhea is poorly studied. In the wall of the vagina there is always an inflammatory infiltrate, sometimes penetrating to a considerable depth. The glandular epithelium of the cervix was found in a state of intense proliferation. As for the body of the uterus, tubes, and ovaries, some authors have described endometritis and pyosalpinx, followed by local and general peritonitis. Clinical picture and symptomatology. In the acute period, the labia majora are sharply hyperemic, edematous, covered with purulent discharge, which causes an eczematous process on the surrounding skin. If the labia majora are carefully separated, a hyperemic and edematous clitoris, as well as an inflamed introitus urethrae and sulcus nympho-hymenalis, can be seen. By pressing on the perineal area, pus can be seen emerging from the depths of the vagina. The urethra is affected in V.-v. frequently, and according to some authors (Valentin, Scomazzoni, Mattisohn), always or almost always. Bartholin's glands are affected very rarely (Fischer, however, believes that bartholinitis occurs in children in 30% of all cases). Vagina in children is always affected by the gonorrheal process. The delicate epithelium, poor outflow due to the hymenal ring, and the deep folds of the mucosa are the reasons, thanks to which gonorrhea so easily affects the child's vagina. The mucous membrane of the vagina is affected to the very vaults. In acute cases, the mucous membrane is edematous, hyperemic, loosened, and in places covered with purulent coatings. Sometimes hemorrhages and excoriations can be seen. In the folds there is always an accumulation of purulent secretions. In chronic cases, limited hyperemic areas and pinpoint hemorrhages are visible on the wall of the vagina. Often a strong hyperemia can be seen in the vaults, both lateral and anterior and posterior.-The cervix uteri. Regarding the involvement of the cervix uteri in V.-v., opinions differ. Involvement of the cervix is beyond doubt. Edema, pinpoint hemorrhages, and true erosions can be well observed during vaginoscopy. Often a simultaneous involvement of the cervix and vaults can be observed. However, regarding the frequency of cervical involvement, it can only be observed in severe cases. Valentin found cervical involvement in 10%, while other authors (Scomazzoni) found it much more frequently. Zecken (Soecken) found the presence of gonococci in the discharge from the cervix uteri very often, even in the acute form of V.-v. In cases of the so-called "completed" process, the author found gonococci in the discharge from the cervix uteri in 8 cases out of 86, i.e., in 9%.-Ascending gonorrhea, as already indicated above, undoubtedly occurs, but apparently very rarely. In children with V.-v., sometimes sharp pains in the abdomen can be observed for 2-3 days, a tense abdomen, and sometimes an elevated temperature. Whether this phenomenon should be considered as a brief gonorrheal pelveoperitonitis, of course, is difficult to say.-The rectum. Attention has only recently been paid to the importance of rectal gonorrhea in children. It was previously believed that the rectum is affected relatively rarely in vulvovaginitis. More recent research (Stumpke, Valentin, etc.) has shown that the rectum is affected very frequently. Blumenthal even states that rectal gonorrhea is found in all cases without exception. Fraser states that in the cases he observed, rectal gonorrhea did not manifest itself clinically. The course of V.-v. in children occurs in two forms; one runs as an acute infectious disease, resembling the severe form of ascending gonorrhea in adults, and is characterized by the same three main signs, namely: a sudden onset, chronic persistent course, and frequent relapses. The other form begins unnoticed, the discharge is insignificant, there are no acute inflammatory changes, so it immediately takes a chronic course. Such forms are very common in young children. The onset of childhood gonorrhea in the first case is usually characterized by abundant purulent discharge from the urethra and vagina. In case of urethral involvement, there is pain on urination, burning, stabbing pain, and frequent urges. In the area of the genital organs, due to the eczematous process on the outer skin, severe itching and burning appear, and in severe cases the child lies with legs apart, as any kind of movement causes suffering. Sometimes a slight elevation of temperature occurs, which lasts for several days. However, not all cases of V.-v. begin so abruptly. Some cases from the very beginning take a more chronic course. The acute course of the disease usually lasts from 2 to 3 weeks. After the acute period, subjective symptoms usually disappear. The eczematous changes of the external genital organs also disappear by this time, and pain on urination also ceases. The discharge becomes seropurulent or even serous. From this time, the chronic course of the disease begins, characterized mainly by relapses and clear intervals between them. The source of these flare-ups are proctitis, endocervicitis, and sometimes urethritis or paraurethritis. One should know the sources of relapses, as these sources usually do not cause complaints from the child and manifest themselves objectively little. Diagnosis of V.-v. is bacteriological. The discharge from the vulva, vagina, urethra, and rectum should be examined. Examination of the discharge from the cervix uteri should not be performed (danger of ascending infection). A single examination of the secretion is far from sufficient. Before deciding to exclude gonorrhea, at least 3-4 examinations of the secretion from each organ should be performed. If Gram-negative diplococci that do not resemble gonococci are found, the discharge should be cultured for gonorrhea. Secretion from the vagina is taken with a blunt spoon. Secretion from the urethra should be taken 2-3 hours after the last urination. To obtain reliable material for examination from the rectum, it should be irrigated through a double-current catheter. The irrigation water is collected in a glass, the floating flakes are skimmed off, and they are subjected to microscopic examination. If necessary, provocation with Lugol's solution or a 1% solution of silver nitrate should be performed. American authors (Mazer) propose a similar method for examining vaginal discharge. The irrigation water is centrifuged, and the sediment is examined for gonococci. If diphtheria is suspected, a culture for diphtheria bacilli should be performed. Therapy. In the acute period of V.-v., no specific treatment is required. The child should observe bed rest throughout the acute period. Sitz baths with an infusion of chamomile or sage, compresses with a 1% solution of resorcinol, a 1% solution of boric acid, or a 3% solution of aluminum acetate very quickly lead to the disappearance of external eczema. Prolonged use of compresses is not recommended. Powders made from hygroscopic starch act well in the subacute stage. The use of ointments is not recommended. The principle of treating V.-v. in the acute period consists in maintaining strict cleanliness and in the child wearing closed pants.-With the transition of the disease to a chronic state, systematic treatment of V.-v. should be undertaken, based on two principles: first, on increasing the resistance of the child's organism, and second, on ensuring proper drainage for the purulent discharge from the vagina. But since the mucous membrane of the vagina has many folds and pockets, and thus promotes the retention of secretions, the physician should keep in mind that the treatment of childhood V.-v. is a difficult and lengthy matter. It is further complicated by a number of complications that occur in this disease. In the treatment of chronic V.-v., clinicians' opinions differ. Some clinicians hold the view that the child should be spared any kind of trauma, and therefore limit all treatment to systematic daily (2 and 3 times a day) sitz baths with astringent substances (infusion of chamomile or sage) and avoid the use of vaginal douches. Other clinicians, on the contrary, strongly recommend the use of vaginal irrigations to prevent retrohymenal stagnation of discharge. Irrigation of the urethra is usually not resorted to so often. In cases of persistent urethritis, the therapy should be the same as for urethritis in adults (see Gonorrhea, Urethritis). As for irrigation of the vagina, it should be kept in mind that douches should be done through a soft rubber catheter, and the pressure of the liquid should not be strong. Every physician working in this field knows how often shocks occur in children who are douched from a highly hanging irrigator or in a position with the pelvis elevated. For douching, the same solutions are recommended as for adults, but their concentration should be 4 times weaker than for the latter. The first place is taken by a solution of potassium permanganate, which should be taken in a concentration of 1:10,000, followed by a solution of rivanol in a concentration of 1:1,000. A 0.6-0.8% solution of protargol (not stronger) or of hegonon, argyrol, etc., is also recommended.

The disinfectant is albargin in a 1:1,000 solution. Very prolonged douching with a protargol solution is not recommended. Sometimes suppositories made of 1-2% protargol have a good effect. The suppositories are inserted after douching has been performed. Tampons and insufflations of powders into the vagina have also been recommended. When the discharge not only disappears of gonococci, but also of pus, and microscopic examination reveals a predominance of epithelial elements and the appearance of Gram-positive rods, it is necessary to switch to the use of astringent agents, such as a 0.2% solution of Zinc sulf. or alum (1 dessert spoon per 5 glasses of water). Gonococci do not survive on a dry surface, and therefore the vulva after thorough washing or after a sitz bath should be wiped with cotton wool and dusted with hygroscopic powders (tannin, talc, dermatol, etc.). Complications, such as paraurethritis and others, are treated in the same way as in adults. For the treatment of gonorrheal proctitis, see Proctitis. Other methods of treatment, such as hot baths according to Weiss (Weiss), gonococcal vaccine, or gonococcal broth culture according to Bezedko are still little studied. Dembsky strongly recommends the use of anti-gonococcal serum. Treatment should be carried out continuously for six months, constantly checking its results by bacterioscopic and microscopic examinations of the discharge. Examinations should be performed every 1-2 weeks. If for three consecutive months gonococci are not found in the child, then after six months from the start of treatment, a break in treatment is made and the child is observed for 3 months every 2 weeks, each time performing a very thorough bacterioscopic analysis. If during this period nothing is found in the child, then the child should be under supervision for another whole year and appear for examination every 3 months. In case of relapses, the urethra, paraurethral ducts should be carefully examined, the entire vagina and cervix examined with a colposcope, and the rectum should also be examined (see Colposcopy). Prognosis. According to data from the 1st Moscow Venereal Dispensary, the average duration of treatment for childhood V.-v. is from 6 to 18 months. Complete and long-lasting recovery is obtained in 70%. In 25-30% relapses occur, which can sometimes repeat twice, and sometimes three times. In isolated cases, childhood V.-v. drags on until sexual maturity. There are very few studies on the remote consequences of gonorrheal V.-v. Prevention. Prevention for a newborn consists (Epstein) in instilling a few drops of a 2% solution of Arg. nitr. into the vulva. Each sick woman should be explained in detail all the dangers of transferring infection to the child and methods of preventing it. Each sick child should always wear closed panties to prevent the transfer of infection to the eyes or to other children. Particularly careful prevention is required in nurseries, children's homes, and schools. In these institutions, measures to prevent gonorrhea should be observed with special scrupulousness: each newly admitted girl should be examined in this direction; if there is discharge, it is necessary to perform a bacteriological examination of the mucus not only from the vagina, but also from the rectum and urethra. Subsequently, during medical examinations of young children, attention should be paid to the genital organs. When caring for girls, it is necessary to exclude everything that can lead to the transmission of infection: common sponges, towels, etc. Baths should be disinfected. Along with this, periodic examinations of the staff are very important. Nurses and nannies suffering from gonorrhea should not be admitted to children's institutions. Sanitary-educational work among mothers and staff of children's institutions also plays a major role. Leukorrhea, eczema of the external genitalia, intertrigo or vulvitis require immediate quarantine and thorough examination.