Manage common paediatric and adolescent gynaecological problems, including child sexual abuse

In one line

Most paediatric gynaecological complaints are benign consequences of a hypo-oestrogenic, anatomically exposed prepubertal tract — vulvovaginitis, labial adhesions, physiological discharge — and are managed conservatively; the consultant's task is to recognise the small set of presentations that are not benign (a vaginal foreign body, a rhabdomyosarcoma, precocious puberty, and above all sexual abuse), and to know that in South Africa a reasonable suspicion of child sexual abuse triggers a statutory duty to report, a forensic pathway, and time-critical HIV post-exposure prophylaxis.

Mechanism & pathophysiology

The whole of prepubertal gynaecology follows from one fact: the genital tract of a girl between the neonatal oestrogen withdrawal and the start of puberty is unoestrogenised. Maternal oestrogen plumps the neonate's vulva and produces a physiological white discharge and even a brief withdrawal bleed in the first fortnight of life; once that clears, the child enters years of low oestrogen until adrenarche and gonadarche. That hormonal vacuum sculpts an environment that is the mirror image of the adult vagina.

The prepubertal vulvovaginal mucosa is thin, atrophic and red, not because it is inflamed but because the epithelium is only a few cell layers deep and the underlying vessels show through. There is no glycogen-rich superficial epithelium, so there are no lactobacilli and no lactic acid; the vaginal pH is neutral to alkaline (around 6.5–7.5) rather than the protective acid of the oestrogenised tract. The labia minora are flat and the labia majora carry no fat pad and no pubic hair, so the introitus is unprotected and the vagina, urethra and anus sit close together. The result is a short, exposed, alkaline, antibacterially undefended canal a few centimetres from the perineum and the anus — anatomy that explains almost every common complaint. Faecal and skin flora colonise easily, irritants reach the mucosa directly, small objects can be introduced and retained, and the thin skin splits and adheres readily.

Oestrogen reverses all of this at puberty. The epithelium thickens and cornifies, glycogen returns, lactobacilli recolonise and acidify the vagina, the labia develop and protect the introitus, and physiological leucorrhoea appears as a normal sign of impending menarche. The adolescent tract behaves like the adult tract — which is why the adolescent's gynaecological problems (dysmenorrhoea, heavy or irregular bleeding, the early features of polycystic/metabolic ovarian syndrome, PMOS) are diseases of a functioning, cycling, oestrogenised system, while the prepubertal child's problems are diseases of an exposed, atrophic, hypo-oestrogenic one. Holding those two developmental contexts apart is the single organising idea of the topic: the same symptom — bleeding, discharge, an adherent vulva — means something different on either side of puberty.

Assessment

The history is taken largely from the carer but, in an older child, partly from the child, and it is shaped by the developmental context above.

• Discharge — colour, smell, blood-staining, duration, and crucially whether it is recurrent or persistent and offensive (the foreign-body pattern). Ask about hygiene practice, bubble baths and soaps, threadworm symptoms (perianal itch worse at night), and recent respiratory or skin infection (a clue to a specific respiratory or skin pathogen seeding the vulva).
• Bleeding — distinguish true vaginal bleeding from haematuria or rectal bleeding, which carers frequently confuse. Ask about trauma, signs of puberty (breast budding, growth spurt, pubic hair), and any exposure to exogenous oestrogen (the contraceptive pill, oestrogen creams, phyto-oestrogen-containing products).
• Itch and skin change — figure-of-eight white atrophic perianal and vulvar change suggests lichen sclerosus; soreness with normal-looking skin suggests non-specific vulvovaginitis.
• The safeguarding history runs in parallel, not as an afterthought. Behavioural change, sexualised behaviour inappropriate for age, a disclosure, an inconsistent or changing account of an injury, a recurrent or unexplained genital symptom, or a confirmed sexually transmitted infection all raise the question of abuse, and the history must be documented verbatim where a disclosure is made.

Examination of a child is a skill, not a reflex. It is done with explicit consent from the child appropriate to age and from the carer, with a chaperone, in a warm room, usually in the frog-leg or knee-chest position with gentle labial traction or separation — the knee-chest position often opens the lower vagina enough to see a foreign body without instrumentation. The hymen and lower vagina are inspected; the prepubertal hymen is oestrogen-poor, thin and exquisitely sensitive, so a speculum is never used in the clinic on a prepubertal child. A genital examination is never forced: a struggling, distressed child should not be restrained for a non-emergency examination. Where the vagina must be seen properly — a suspected foreign body that cannot be flushed out, persistent bleeding, a suspected tumour, or a forensic examination in a young or traumatised child — the answer is examination under anaesthesia (EUA) with vaginoscopy, which allows full inspection, lavage, biopsy and foreign-body removal in one controlled episode. A failed or traumatic clinic examination teaches the child that the genital examination is something done to her against her will — exactly the lesson a recently abused child must not be taught.

Investigations are targeted, not routine. A vulval/vaginal swab is taken only when discharge is purulent, bloody or persistent — most non-specific vulvovaginitis needs no swab and no antibiotic. Perianal tape for threadworm ova; urine dipstick and culture where urinary symptoms confound the picture. Pelvic ultrasound assesses uterine size and endometrial thickness (a marker of oestrogen exposure in suspected precocious puberty), adnexal masses and, sometimes, a radio-opaque foreign body. Where puberty is precocious, the work-up extends to bone age, basal and stimulated gonadotrophins and oestradiol. In any child where abuse is suspected, the microbiological work-up is also forensic, and the recovery of a sexually transmitted organism in a prepubertal child is a finding of major medico-legal weight, handled through the formal pathway rather than as an ordinary swab result.

Management

Organise the response immediate → ongoing → long-term, and let the developmental mechanism dictate the plan.

The common, benign conditions

Childhood vulvovaginitis is the commonest paediatric gynaecological complaint, and the great majority is non-specific — an irritant/hygiene-related inflammation of the exposed, atrophic vulva rather than an infection needing an antibiotic. Management is hygiene and skin care: loose cotton underwear, avoidance of bubble baths, soaps and biological detergents, wiping front to back, salt or emollient sitz baths, barrier emollient, and treatment of threadworm if present. Most settles with these measures alone. A specific vulvovaginitis — a single organism causing a purulent, sometimes bloody discharge — is treated for the organism: group A Streptococcus and Haemophilus influenzae (often after a sore throat or coryza) with an appropriate oral antibiotic, Shigella (a classically bloody discharge) and the rest as cultured. A persistent, foul, blood-stained discharge unresponsive to hygiene measures is a retained vaginal foreign body until proven otherwise — most often wadded toilet paper — and warrants vaginal lavage or, if not retrievable in clinic, vaginoscopy under anaesthesia. Recovery of a sexually transmitted organism is a different category of finding and is managed as possible abuse.

Labial adhesions are acquired fusion of the labia minora across the midline, a consequence of the low-oestrogen, easily-inflamed vulva, peaking in infancy and early childhood. The default is observation: most are asymptomatic, do not obstruct the urinary stream, and resolve spontaneously as endogenous oestrogen rises at puberty. Treatment is reserved for the symptomatic child — recurrent urinary infection, post-void dribbling from a urine pocket, or near-complete fusion — and is topical oestrogen cream applied along the adhesion line for a few weeks (occasionally topical corticosteroid), with continued bland emollient afterwards to prevent recurrence. Oestrogen is not without effect: transient breast budding, vulval pigmentation and local irritation occur and reverse on stopping. Manual or surgical separation is a last resort for dense, symptomatic adhesions that fail medical treatment, because forcible separation re-traumatises the raw surfaces and adhesions recur. The evidence supports this restraint: a comparative series found near-universal resolution with topical oestrogen but also high resolution with observation alone, and side-effects and recurrences occurred only in the treated group — so the threshold to apply oestrogen is symptoms, not the appearance.

Paediatric lichen sclerosus is a chronic inflammatory dermatosis presenting with a white, atrophic, figure-of-eight vulval and perianal change, intense itch, soreness, fissuring and — importantly — subepithelial haemorrhage and ecchymosis that can be mistaken for the bruising of trauma or abuse. The two must not be confused: lichen sclerosus is a recognised mimic of abuse, and equally abuse can coexist, so the skin diagnosis does not close the safeguarding question. Treatment is a potent topical corticosteroid (clobetasol propionate) in a reducing regimen, with emollient maintenance; childhood lichen sclerosus often improves around puberty but frequently persists into adult life and needs long-term dermatological follow-up, with the small adult malignancy risk borne in mind.

Prepubertal vaginal bleeding — the differential that must be worked through

Bleeding before puberty is never normal beyond the neonatal withdrawal bleed, and the consultant rule is to exclude the dangerous causes before settling on the common ones. The differential, roughly common to dangerous:

• Vulvovaginitis with excoriation, and trauma (straddle injury, accidental or — if the injury does not fit the history — inflicted).
• A vaginal foreign body — the persistent, offensive, blood-stained discharge pattern.
• Urethral prolapse — a friable, doughnut-shaped ring of red-purple mucosa around the urethral meatus, classically in young girls (more common in those of African descent), which bleeds and is frequently mistaken for vaginal bleeding; managed with topical oestrogen and sitz baths, surgery only if it strangulates.
• Lichen sclerosus with fissuring and subepithelial bleeding.
• Precocious puberty — if bleeding is accompanied by breast development, a growth spurt or pubic hair, the bleeding is endometrial and the work-up shifts to the puberty axis; isolated exogenous oestrogen exposure causes the same picture without true puberty.
• The must-not-miss tumour: sarcoma botryoides (embryonal rhabdomyosarcoma of the vagina) — a soft, grape-like polypoid mass protruding from the vagina, presenting with bleeding or a blood-stained discharge in infancy and early childhood. It is rare but lethal if missed, and any child with a visible vaginal mass or unexplained persistent bleeding needs vaginoscopy and biopsy under anaesthesia, not reassurance. Other rarer tumours (clear-cell adenocarcinoma, germ-cell tumours, oestrogen-secreting ovarian tumours causing peripheral precocity) sit alongside it.
• Sexual abuse — present in the differential of every unexplained prepubertal bleed and discharge, and not a diagnosis of exclusion to be reached only when nothing else fits.

Ovarian masses and torsion in children

Most paediatric ovarian masses are benign (simple cysts, mature teratoma), but the prepubertal ovary is mobile on a long pedicle and torsion presents with acute pain, vomiting and an adnexal mass. The operative principle has reversed from historical practice: at laparoscopy the torted ovary is detorted and conserved, not removed, even when it looks dusky and ischaemic, because the prepubertal ovary recovers function remarkably well and a girl's future fertility and endocrine life depend on it; oophorectomy is reserved for a frankly necrotic or clearly malignant gonad. Oophoropexy of a recurrently torting or abnormally mobile ovary is considered. A solid or complex mass, raised tumour markers for age, or precocity from a hormone-secreting tumour shifts the plan towards staged, fertility-sparing surgical management with paediatric oncology.

Adolescent menstrual problems

Across puberty the tract becomes the adult one, and the adolescent's problems are those of a newly cycling system. Dysmenorrhoea is usually primary and prostaglandin-driven, treated with NSAIDs (mefenamic acid, ibuprofen) and, where contraception is also wanted, a combined hormonal method; pain that is severe, progressive or unresponsive raises endometriosis even in this age group. Heavy menstrual bleeding in an adolescent is frequently anovulatory (an immature hypothalamic–pituitary–ovarian axis in the first gynaecological years), but a teenager who has flooded since menarche, especially with a personal or family bleeding history, must be screened for an inherited bleeding disorder — von Willebrand disease above all — before the bleeding is dismissed as hormonal. Management ranges from tranexamic acid and NSAIDs through combined hormonal methods to the levonorgestrel intrauterine system. Irregular bleeding and androgenic features in adolescence may be early PMOS (previously PCOS), diagnosed cautiously in this age group because anovulatory cycles and acne are common in normal puberty; management is lifestyle-led with cycle regulation as needed. Heavy or irregular bleeding severe enough to cause symptomatic anaemia is managed acutely with high-dose hormonal therapy and iron, with transfusion reserved for haemodynamic compromise.

Child sexual abuse — the immediate, the forensic and the safeguarding response

Child sexual abuse is core paediatric-gynaecology work in South Africa, where the burden is among the highest in the world, and it is approached with gravity and a clear framework rather than improvisation.

Recognition rests on history, examination and their limits. A disclosure by a child is the single most important piece of evidence and is documented in the child's own words. Physical signs may include acute genital or anal injury, but the central, examined fact a consultant must hold is that a normal anogenital examination does not exclude sexual abuse — most sexually abused children, particularly those examined non-acutely, have a normal or non-specific examination, because much abuse leaves no lasting physical mark and the elastic, healing prepubertal tissues recover. A normal examination must therefore never be reported or recorded as evidence that abuse did not occur. Conversely, certain findings (a confirmed sexually transmitted infection beyond the neonatal/vertical window, pregnancy, or a clear penetrating injury) carry strong diagnostic weight, and the structured classification of findings (the Adams/Kellogg approach) exists precisely to keep clinicians from over- or under-reading equivocal genital appearances.

The acute, time-critical interventions in a child presenting after a recent assault, run in parallel with the safeguarding and forensic process:

• HIV post-exposure prophylaxis (PEP). Offered after penetrative exposure if the child presents within 72 hours — this is a hard window. The SA first-line regimen is TLD (tenofovir/lamivudine/dolutegravir) once daily for a full 28 days for a child of at least 10 years and ≥30 kg; younger or smaller children are dosed on a weight-banded paediatric regimen (zidovudine + lamivudine + dolutegravir). Baseline HIV testing is done, the full 28-day course is dispensed at initiation, and adherence support is built in. PEP is started without waiting for the forensic process to conclude.
• Emergency contraception for a post-menarcheal girl presenting within 120 hours (5 days) of a penetrative assault.
• Presumptive STI treatment and hepatitis B (and HPV) immunisation per national guidance, with baseline microbiology where feasible — recognising both its forensic value and that many children do not return for follow-up, so the first contact must do the work.

The forensic and medico-legal pathway is statutory, not discretionary. In South Africa a designated health practitioner conducts the medico-legal examination and completes the J88 medico-legal form, ideally at a dedicated sexual-assault (Thuthuzela) care centre, collecting the evidence kit within the window when it is informative and maintaining the chain of custody of specimens. The examination of a frightened young child is frequently best done under anaesthesia, combining forensic collection with treatment in one episode and avoiding a forced examination. Two pieces of law govern the duty. Under the Criminal Law (Sexual Offences and Related Matters) Amendment Act 32 of 2007, rape is the gender-neutral statutory offence of any non-consensual sexual penetration, the age of consent is 16, and a child below 12 cannot consent in law; sexual offences against a child must be reported. Under section 110 of the Children's Act 38 of 2005, a medical practitioner, nurse or midwife who on reasonable grounds concludes that a child has been sexually abused (or physically injured or deliberately neglected) has a mandatory statutory duty to report, on the prescribed Form 22, to a designated child-protection organisation, the provincial Department of Social Development, or the South African Police Service. The duty is triggered by a reasonable suspicion — it does not require proof, a confession or a confirmatory examination, and failing to report is itself an offence.

The response is multidisciplinary and safeguarding-led. No single clinician manages child sexual abuse alone: the response involves the doctor, a social worker, the police/SAPS family-violence unit, child-protection services, and mental-health support (trauma-focused cognitive behavioural therapy where post-traumatic symptoms emerge), with a non-offending caregiver involved wherever it is safe to do so. The child's immediate safety — whether she can be discharged to a safe home — is assessed before disposition. The clinician's role spans the clinical, the forensic and the protective; treating the HIV and contraceptive risk while neglecting the report, or reporting while neglecting the PEP window, are both failures of the same single duty of care.

Guidelines compared

The major paediatric-gynaecology and child-protection bodies agree on the principles and differ mainly in emphasis and in the legal scaffolding each sits within.

The substantive divergence to know is therefore not clinical but legal-operational: the clinical management of vulvovaginitis, adhesions, bleeding and even the CSA medical work-up is broadly international, but the reporting duty, the forensic documentation (J88, Form 22) and the PEP regimen are South-Africa-specific, and an answer that gives only the international management without the SA statutory and pharmacological framing is incomplete.

The evidence & the controversy

The first evidence point that reorganises clinical behaviour is the weakness of the genital examination as a test for abuse. Across large series, the proportion of sexually abused children with diagnostic physical findings is small — of the order of a few per cent when examined non-acutely, rising substantially only when examined acutely after a recent assault — so the examination's main value is documentation and the detection of acute injury or infection, not confirmation. The practical and medico-legal consequence is sharp: the clinician must resist the pull to "clear" a child on a normal examination, and must phrase findings as the structured classification allows (normal, non-specific, concerning, diagnostic) rather than as a verdict on whether abuse happened. This is the most commonly mishandled point in the whole topic and the one with the gravest consequences when it is got wrong.

The second is the steady de-escalation of intervention in the benign conditions. Non-specific vulvovaginitis does not need antibiotics; labial adhesions do not need oestrogen unless symptomatic and many resolve with observation alone; the torted paediatric ovary is conserved, not removed. The direction of travel is consistently towards doing less to the child, and the comparative data on adhesions — high spontaneous resolution, side-effects confined to the treated arm — is representative of why.

A live, genuinely contested thread worth holding is the question of endocrine-disrupting chemicals and the developing reproductive tract. There is real and growing concern, and active debate, about environmental oestrogenic exposures — bisphenols and phthalates in plastics and personal-care products, and more recently the question of chemical residues in disposable sanitary products and the phyto-oestrogen content of some products marketed to girls — as possible contributors to trends in earlier puberty and to vulval irritation. The honest consultant position is that the mechanistic plausibility is real but the clinical evidence in children remains contested and largely associational; it is presented as an area of legitimate uncertainty and ongoing surveillance, not as established causation, and it does not currently change management of the child in front of you.

How this is argued in practice: when a normal examination is set against a clear disclosure, the disclosure and the documented history carry the weight, the examination is reported in the structured language of the classification, the statutory report is made on a reasonable suspicion regardless of examination findings, and the time-critical interventions (PEP within 72 hours, emergency contraception within 120 hours) are delivered without waiting for forensic certainty.

Landmark trials & key evidence

The arithmetic in the Adams 2018 figures is itself instructive: with diagnostic findings in only 2.2% of non-acutely examined abused girls, the examination's sensitivity for abuse is so low that a normal result moves the post-test probability almost not at all — which is the quantitative reason a normal examination cannot be allowed to reassure, and why the disclosure and the statutory duty, not the examination, drive the response.

Exam traps & red flags

• Recording a normal examination as evidence against abuse. Most sexually abused children examine normally; a normal anogenital examination never excludes abuse and must never be phrased as if it did — findings are reported in the structured classification.
• Missing the statutory reporting duty. A reasonable suspicion of child sexual abuse triggers a mandatory report (Children's Act s110, Form 22) — it does not require proof, a confession or a confirmatory examination, and not reporting is itself an offence.
• Missing the 72-hour PEP window. HIV PEP after penetrative assault is time-critical (within 72 h, TLD for 28 days); it is started immediately and not delayed for the forensic process — and the 120-hour emergency-contraception window is the separate clock.
• Treating a persistent offensive discharge as simple vulvovaginitis. A persistent, foul, blood-stained discharge unresponsive to hygiene is a retained vaginal foreign body until proven otherwise — and recovery of an STI organism is possible abuse, not an ordinary swab result.
• Reassuring a child with a vaginal mass or unexplained persistent bleeding. Sarcoma botryoides (vaginal rhabdomyosarcoma) presents this way — any visible mass or unexplained persistent prepubertal bleeding needs vaginoscopy and biopsy under anaesthesia.
• Confusing lichen sclerosus with the bruising of abuse. Lichen sclerosus produces subepithelial haemorrhage that mimics trauma; it is a known mimic, but it can also coexist, so the skin diagnosis does not close the safeguarding question.
• Over-treating the benign conditions. Antibiotics for non-specific vulvovaginitis, oestrogen for asymptomatic labial adhesions, oophorectomy for a torted prepubertal ovary — each does the child unnecessary harm; observe, conserve, and reserve intervention for symptoms.
• Using a speculum or forcing the examination of a prepubertal child. A clinic speculum examination is never done on a prepubertal child, and a non-emergency examination is never forced — where the vagina must be seen, the answer is examination under anaesthesia with vaginoscopy.
• Dismissing adolescent heavy bleeding as hormonal. Flooding since menarche, particularly with a bleeding history, must be screened for an inherited bleeding disorder (von Willebrand disease) before being attributed to anovulation.

Evidence anchors

• Kellogg ND, Farst KJ, Adams JA. Interpretation of medical findings in suspected child sexual abuse: an update for 2023. Child Abuse Negl. 2023;145:106283.
• Adams JA, Farst KJ, Kellogg ND. Interpretation of medical findings in suspected child sexual abuse: an update for 2018. J Pediatr Adolesc Gynecol. 2018;31(3):225-231.
• Bloomfield V, Iseyemi A, Kives S. Clinical review: prepubertal bleeding. J Pediatr Adolesc Gynecol. 2023;36(5):435-441.
• Kim SW, Han JY, Han SJ, Kim H, Ku SY. Effect of topical estrogen cream compared with observation in prepubertal girls with labial adhesions. J Pediatr Urol. 2023;19(4):403.e1-403.e6.
• McGreal S, Wood P. Recurrent vaginal discharge in children. J Pediatr Adolesc Gynecol. 2012;26(4):205-208.
• WHO. Responding to children and adolescents who have been sexually abused: WHO clinical guidelines. Geneva: WHO; 2017.
• Horak J, Venter WDF, Wattrus C, et al. Southern African HIV Clinicians Society 2023 guideline for post-exposure prophylaxis: updated recommendations. South Afr J HIV Med. 2023;24(1):1522.
• Intermediate counterpart: examination of a child with vaginal discharge.
• South Africa, Children's Act 38 of 2005 — section 110 (mandatory reporting of abuse; Form 22, Regulation 33).
• South Africa, Criminal Law (Sexual Offences and Related Matters) Amendment Act 32 of 2007 — statutory rape, age of consent 16, mandatory reporting of sexual offences against a child; the J88 medico-legal form.