A 6-year-old has a yellow vaginal discharge

Let's discuss the evaluation of yellow vaginal discharge in a 6-year-old and a sexually active 16-year-old, highlighting the key differences and similarities in our approach.

Case 1: 6-Year-Old with Yellow Vaginal Discharge

In a pre-pubertal child, vaginal discharge is less common than in adolescents or adults, and the differential diagnosis is different. Our primary concern is to identify non-sexually transmitted causes and consider the possibility of sexual abuse.

• Key Points in the History and Physical Examination:

History:

• Detailed Description of the Discharge:
  • Onset: When did it start? Was it sudden or gradual?
  • Color: Is it truly yellow? Are there other colors (white, green, brown)?
  • Consistency: Is it thick, thin, watery, or mucoid?
  • Odor: Is there a foul odor?
  • Volume: Is it scant, moderate, or heavy?
  • Associated Symptoms:
    • Vulvar itching, redness, or swelling (vulvitis).
    • Pain or discomfort (dysuria, pain with wiping).
    • Fever.
    • Abdominal pain.
    • Bleeding (even spotting).
    • Bowel symptoms (constipation, fecal soiling).
• Hygiene Practices:
  • How does the child wipe after using the toilet (front to back is important)?
  • What kind of soap or bath products are used? Are they scented or harsh?
  • Does the child take bubble baths?
  • What type of underwear does the child wear (cotton is preferred)?
• Foreign Body Insertion:
  • Is there any history or suspicion of the child inserting anything into her vagina (e.g., toys, toilet paper)? Young children are curious and may do this without understanding the consequences.
• Trauma:
  • Any history of falls or injury to the perineal area?
• Medications:
  • Any recent antibiotic use (which can sometimes predispose to yeast infections, although less common in this age group)?
• Past Medical History:
  • Any history of eczema, allergies, or other skin conditions?
• Social History:
  • Who are the primary caregivers?
  • Any recent changes in the household or caregivers?
  • Any behavioral changes in the child?
  • Crucially, we must gently and sensitively inquire about the possibility of sexual abuse. This should be done in a way that is age-appropriate and non-leading, often starting with general safety questions and escalating if concerns arise. This may involve separate interviews with the child and caregiver.

Physical Examination:

• General Examination: Note the child's overall well-being, any signs of fever, or abdominal tenderness.
• External Genital Examination:
  • Careful inspection of the vulva, labia, and perineum for redness, swelling, bruising, lacerations, or signs of trauma.
  • Assess for the presence and characteristics of the discharge (color, odor, location).
  • Look for any obvious foreign bodies.
  • Assess the hymen for any signs of trauma (keeping in mind that normal variations exist, and trauma can occur through non-abusive mechanisms).
• Internal Examination:
  • In most cases of a 6-year-old with discharge, a speculum examination is NOT routinely performed due to the small size of the vaginal opening and potential for trauma and anxiety.
  • If an internal examination is absolutely necessary (e.g., suspicion of a retained foreign body that cannot be visualized externally), it should be done by an experienced clinician, potentially with sedation, and with careful attention to the child's comfort and psychological well-being.
  • A cotton-tipped swab can be gently inserted into the introitus to collect a sample of the discharge for microscopy and culture.  
• Perianal Examination: Inspect for redness, irritation, or evidence of pinworms (though this typically causes itching rather than yellow discharge).

• How would your approach differ if the patient were a sexually active 16-year-old?

The approach to a sexually active 16-year-old with yellow vaginal discharge would be significantly different, with a primary focus on sexually transmitted infections (STIs).

History:

• Detailed Sexual History:
  • Age of sexual debut.
  • Number of sexual partners (lifetime and in the past few months).
  • Gender(s) of sexual partners.
  • Types of sexual activity (vaginal, oral, anal).
  • Condom use (consistency and correct use).
  • History of previous STIs (in the patient or their partners).
  • Symptoms in sexual partners.
• Detailed Description of the Discharge: Similar to the 6-year-old, but with a higher index of suspicion for STI-related characteristics (e.g., copious, purulent, foul-smelling).
• Associated Symptoms:
  • Pelvic pain.
  • Dysuria.
  • Post-coital bleeding.
  • Intermenstrual bleeding.
• Menstrual History: Last menstrual period, cycle regularity.
• Contraceptive Use: Type and consistency of use.

Physical Examination:

• General Examination: Similar to the 6-year-old.
• Pelvic Examination with Speculum: This is a crucial part of the examination in a sexually active adolescent.
  • Visualization of the cervix for inflammation (cervicitis), discharge emanating from the os, and friability.
  • Collection of specimens for:
    • Nucleic Acid Amplification Tests (NAATs): To detect Chlamydia trachomatis and Neisseria gonorrhoeae, which are common causes of yellow/purulent discharge.  
    • Wet Mount and KOH Preparation: To evaluate for bacterial vaginosis (BV) and trichomoniasis, which can also cause abnormal discharge.
    • Pap Smear (if indicated based on age and sexual history): For cervical cancer screening.
• Bimanual Examination: To assess for cervical motion tenderness (CMT), uterine tenderness, and adnexal tenderness, which can indicate pelvic inflammatory disease (PID), a serious complication of untreated STIs.  
• External Genital Examination: Similar to the 6-year-old, looking for signs of vulvitis or other lesions.

• What are similarities and differences in the approach?

Similarities:

• Detailed History of the Discharge: In both age groups, we need a thorough description of the onset, color, consistency, odor, volume, and associated symptoms of the discharge.
• External Genital Examination: Careful visual inspection of the vulva and perineum is essential in both cases to identify local inflammation, trauma, or foreign bodies.
• Importance of Hygiene Practices: Inquiring about hygiene is relevant in both age groups, although the implications differ (irritation vs. a potential contributing factor to non-STI infections).

Sample Solution