Jessica Y. Shim, MD, is a clinical instructor in the Department of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School in Boston, Massachusetts. She is also an attending physician of the Division of Pediatric and Adolescent Gynecology in the Department of Surgery at Boston Children’s Hospital.

Danielle T. Cipres, MD, is a clinical instructor in the Department of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School in Boston, Massachusetts. She is also a clinical fellow in the Division of Pediatric and Adolescent Gynecology in the Department of Surgery at Boston Children’s Hospital.

Vulvovaginal complaints make up the majority of gynecologic clinic visits by prepubertal girls.

Vulvovaginal symptoms can be caused by infection, trauma, hygiene, dermatologic conditions, and congenital anomalies. Though these conditions also may present after puberty, this article will focus on common vulvar conditions in the prepubertal pediatric population.

Most pediatric vulvar conditions can be clinically diagnosed with history and physical exam alone, although certain conditions may require additional testing. History taking often requires gathering information from both the child and parent and should focus on the timing, duration, and characterization of the symptoms, including itching, pain, burning, and associated genitourinary and gastrointestinal symptoms such as dysuria, urinary retention, constipation, and stooling habits.

Vulvar hygiene should be elicited, including the use of perfumed soaps, bubbles, detergents, or wipes applied to the external and internal genitalia, as well as who performs these vulvar hygiene practices (child or parent). 

A specific inquiry should address whether the child wipes front to back, has inserted any foreign objects into the vagina, or has experienced any inappropriate touching of their genitals. Symptom triggers and irritants should be investigated, as well as the outcomes of prior palliative measures and interventions. A report of vaginal bleeding, discharge, or malodor is nonspecific but may raise concern for tissue injury, infection, or abuse.

External pelvic examination should be performed to assess the patient’s pubertal development, including Tanner staging and documentation of the degree of estrogenization of the vestibule and vaginal mucosa. 

Genital examination of a prepubertal child can be accomplished by asking the child to make a frog leg or butterfly position, a cannonball position (to better assess the perianal region), or a hands and knees position.

 Skin changes and tissue injuries such as excoriations, abrasions, or bruising are often immediately apparent. 

Of note, the vestibule, hymen, and vaginal mucosa of prepubertal girls commonly appear erythematous, thin, and atrophic due to the poor estrogenization of the tissues. Careful attention should be paid to deviations from normal vulvar anatomy. The patient should always be verbally prepared for the anticipation of touching of the skin and tissue and be reassured that the examination will not hurt. 

Most pediatric gynecology exams will be tailored to the complaints and not require speculum examination. Gentle traction of the labia majora outward allows assessment of hymenal patency and visualization into the lower vagina 

If necessary, further assessment of vaginal patency and length may be performed with a saline-moistened cotton-tipped applicator, which can be used to obtain bacterial cultures if indicated.1 If further intravaginal evaluation is indicated, a vaginoscopy in the office or under anesthesia may be performed.

Nonspecific vulvovaginitis is the most common (75%) cause of vaginitis in young girls.

 Pediatric patients typically describe vulvar discomfort, pruritus, malodor, or vaginal discharge that may be purulent or tinged with blood. 

Signs include erythema, mucoid vaginal discharge, and poor hygiene—or there may be no findings. The prepubertal vulva and vagina are hypoestrogenic and susceptible to irritants such as soaps, detergents, bath bombs, urine, stool, and perfumed products.

In the absence of purulent discharge, antibiotics are rarely indicated. Most symptoms resolve within 2 to 3 weeks after vulvar hygiene measures are instituted, including soaking in plain water without soap, standing up to shower, patting dry, wiping front to back, wearing cotton underwear and loose clothing, and avoiding irritants.

 Barrier emollients such as petroleum jelly or zinc oxide can be applied externally for symptomatic relief.

Additional testing with bacterial vaginal culture and vaginoscopy may be indicated to evaluate for specific causes of vulvovaginitis if symptoms persist or vaginal bleeding or purulent discharge is present, raising suspicion for a specific etiology.

Mixed vaginal flora is a typical culture result in nonspecific vulvovaginitis. Respiratory (eg, 

Streptococcus pyogenes, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Moraxella catarrhalis

coli, Enterococcus faecalis, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas, Shigella, Yersinia

) pathogens are commonly isolated on bacterial vaginal swabs in patients with vaginitis as well as those who are asymptomatic. Therefore they do not always represent an infection.

Colonization is thought to occur by autoinoculation, with group A streptococci accounting for 20% of infectious cases. It should be treated with a 10-day course of oral amoxicillin.3,4 

Other respiratory and enteric flora isolates often resolve with hygiene measures alone but should be treated based on sensitivities if symptoms are persistent or if specific infectious causes such as 

Though approximately 3% to 4% of prepubertal girls are colonized with candida, vulvar candidiasis most frequently occurs in patients wearing diapers.

 Pathogenic vaginal candidiasis is uncommon in healthy, toilet-trained prepubertal girls. Therefore, empiric treatment for vaginal yeast infection should not be performed unless a positive candida test is present in the setting of immunosuppression, recent antibiotics, or diaper use.

 can be isolated even in the absence of sexual abuse, and treatment should be based on culture results and symptoms—vaginal pH testing and microscopy are not reliable testing measures in prepubertal girls.

Sexually transmitted infection testing for chlamydia, gonorrhea, trichomonas, and herpes simplex (if ulcerative lesions present) should be performed if there are concerns for sexual abuse. Empiric treatment for pinworms may be indicated in patients with significant perianal and vulvar itching that does not respond to hygiene measures.

Chronic vulvovaginitis with vaginal discharge, malodor, and bleeding is often secondary to a foreign body such as toilet paper, toys, beads, or other small objects 

If the patient is able to cooperate, visualization and foreign body removal in the office can often be accomplished with the application of topical anesthetic if needed and use of a swab or vaginal irrigation with warmed fluid.

 Small batteries are a rare but serious cause of vaginal burns.

Batteries are radio-opaque on x-ray imaging and require emergent removal under sedation, followed by vaginoscopy to assess the vaginal mucosa for depth of burns and possible damage to the urinary tract or rectal mucosa.

Labial adhesions commonly occur in girls aged 3 months to 6 years due to the prepubertal hypoestrogenic genital tissue 

Other contributing factors may include genital trauma, infection, inflammation, or lichen sclerosus. Adhesions may be asymptomatic or cause vulvar discomfort and urinary symptoms such as postvoid dribbling, difficulty with urination, and recurrent urinary tract infections. 

Small, asymptomatic labial adhesions can be expectantly managed. Most will resolve with endogenous estrogen production at the onset of puberty.

Symptomatic or extensive labial adhesions warrant therapy with topical estrogen (0.01%) cream or high potency (betamethasone 0.05% cream) steroid applied sparingly to the fusion line and continued until resolution. 

These topical treatments have similar efficacy, and the choice of therapy is dependent on the acceptability of potential adverse effects (eg, breast budding, skin atrophy), which can often be mitigated by directed focal application for the minimum duration needed.

Resolution often occurs within 6 weeks of treatment and should be followed by vulvar hygiene measures and daily application of barrier emollients such as petroleum jelly for several months to prevent recurrence. Manual or surgical separation is rarely indicated and reserved for cases of complete urinary obstruction and retention.

Vulvar lichen sclerosus is an inflammatory dermatologic condition affecting the anogenital region with a bimodal incidence in postmenopausal women and prepubertal girls.

Common symptoms include vulvar pruritus, pain, bleeding, and urinary and bowel complaints such as dysuria and constipation or pain with defecation. 

Dermatologic findings include thin, parchment paper–like skin with hypopigmentation frequently in a figure-8 distribution around the anus and vestibule. Lichen sclerosus also can have diverse and subtle presentations including erythema, bruising, punctate hemorrhages, telangiectasias, excoriations, fissures, and hyperkeratotic lesions 

Untreated, severe lichen sclerosus can cause scarring and loss of the vestibular architecture leading to loss of the labia minora, labial agglutination, introital stenosis, and burying of the clitoris under the prepuce. 

Of note, vitiligo of the vulva will demonstrate hypopigmentation but without changes in skin texture or architectural changes.

 Vaginal involvement is uncommon in lichen sclerosus and, if present, should raise concern for an alternative diagnosis such as lichen planus. The etiology of lichen sclerosus is unclear but has been associated with familial inheritance, local trauma, and systemic autoimmune disorders.

Although lichen sclerosus is associated with the development of vulvar carcinoma in postmenopausal women, there is no evidence of this association in young girls.

Skin biopsy is rarely indicated in the pediatric population, and clinical diagnosis based on examination should prompt initiation of topical therapy with a super high potency steroid such as clobetasol propionate 0.05% ointment twice daily.

Medical management is continued until symptoms and skin findings resolve, and then it is tapered over 4 to 8 weeks. 

After resolution, maintenance therapy with a potent topical steroid such as mometasone furoate 0.1% ointment is recommended.

 As lichen sclerosus commonly recurs in 44% to 82% of patients and can persist beyond puberty, repeat treatment courses are often required and long-term follow-up with annual genital exams is recommended.

Vulvar ulcers are distressing for young girls and their parents and can cause significant discomfort. The differential diagnosis for vulvar ulcers is broad and should include testing to exclude infection.

 Herpes simplex virus is characterized by clustered vesicles and painful ulcerations confirmed via viral culture or polymerase chain reaction assay. 

Primary syphilis causes a painless chancre characterized by an isolated ulcer with raised borders with or without regional lymphadenopathy and is diagnosed by dark field microscopy of the chancre fluid. 

Less common infectious etiologies include chancroid (

). These can be diagnosed with bacterial culture of the ulcerative lesion. A positive result of any of these sexually transmitted infections warrants prompt treatment and investigation of suspected
sexual abuse.

Beçhet syndrome is a systemic autoimmune disorder that manifests with arthritis, uveitis, and recurrent ulcerative oral and vulvar lesions.

 Genital Crohn disease can present with “knife cut” genital ulcers along the inguinal or labial folds. A careful history of associated symptoms may prompt referral to specialists to rule out these systemic etiologies.

Lipschütz ulcers are a common cause of acute-onset non–sexually transmitted vulvar aphthous ulcers in both pre- and postmenarchal girls and adolescents.13,19 Lesions are characterized by large, often bilateral “kissing” ulcers with a necrotic-appearing base and gray exudate on the medial aspect of the labia minora 

They are often accompanied by significant edema, pain, dysuria, and occasionally urinary retention due to discomfort. Prodromal symptoms such as fever, malaise, myalgias, lymphadenopathy, and pharyngitis are common, and these ulcerative lesions have been associated with viral and bacterial infections such as Epstein-Barr virus, cytomegalovirus, influenza, mycoplasma, and strep throat, though serologic confirmation of these infections is not required for this diagnosis of exclusion.

The pathogenesis of these ulcers is unclear but it is thought to be secondary to a hypersensitivity reaction to pathogens and has even been reported after vaccinations.

 Lipschütz ulcers are self-limiting, with most symptoms resolving within 10 days, but lesions may take several weeks to heal. Rarely, bladder catheterization is required to relieve urinary retention secondary to severe discomfort with urination. 

Conservative management includes oral pain medications, cleansing with a spray bottle and sitz baths, and application of topical anesthetics and barrier emollients. Antibiotics are reserved for cases with concern for overlying cellulitis. 

There is limited retrospective evidence that use of systemic and high-potency topical corticosteroids may lessen inflammation and pain, though no reduction in duration of symptoms has been demonstrated and this intervention has not been investigated in prospective trials.

 Recurrences may occur in 30% to 50% of cases.

Prepubertal children are more susceptible to vulvar trauma due to the vascularity of the vulva and absence of protective fat pads. In addition to excluding sexual trauma, the nature of the injury should be investigated to consider internal or deep trauma. 

Blunt trauma to the highly vascular anatomy increases risk of hematoma formation, which is typically conservatively managed with pain medications and cool compresses but may require Foley catheter placement for bladder drainage if obstructive symptoms are present.

Surgical drainage is rarely indicated for large or expanding hematomas because the bleeding vessel is rarely identified and drainage raises risk for infection and bleeding due to loss of natural tamponade by the surrounding tissues.

If vulvar lacerations are small, superficial, and hemostatic, they often can be conservatively managed without repair.

 Most injuries are superficial and limited to the mons, clitoral hood, labia, and perineum, and bleeding lacerations can be repaired with a fine absorbable suture with a topical or local anesthetic and sedation. Internal injuries often require examination under sedation with vaginoscopy to assess the depth of the injury and repair.

The majority of vulvar conditions and symptoms in children can be clinically diagnosed with history and examination. Providers should be familiar with these common pediatric vulvar conditions and their initial work-up and management. In cases of unclear diagnosis or failure to respond, referral to a pediatric gynecologist is recommended.

Providers and patients can obtain additional educational information and resources at 

 with specific information relating to clinical presentation, diagnosis, and management of common prepubertal vulvar conditions as well as advice on vulvovaginal hygiene measures.

French A, Emans SJ. Office evaluation of the child and adolescent. In: Emans SJ, Laufer MR, DiVasta AD. 

Emans, Laufer, Goldstein’s Pediatric and Adolescent Gynecology, 7th ed.

Jarienė K, Drejerienė E, Jaras A, Kabašinskienė A, Čelkienė I, Urbonavičienė N. Clinical and microbiological findings of vulvovaginitis in prepubertal girls. 

. 2019;32(6):574-578. doi:10.1016/j.jpag.2019.08.009

French A, Emans SJ. Vulvovaginal problems in the prepubertal child. In: Emans SJ, Laufer MR, DiVasta AD. 

Emans, Laufer, Goldstein’s Pediatric and Adolescent Gynecology, 7th ed

Zuckerman A, Romano M. Clinical recommendation: vulvovaginitis. 

. 2016;29(6):673-679. doi:10.1016/j.jpag.2016.08.002

Jaquiery A, Stylianopoulos A, Hogg G, Grover S. Vulvovaginitis: clinical features, aetiology, and microbiology of the genital tract. 

. 1999;81(1):64-67. doi:10.1136/adc.81.1.64

Beyitler İ, Kavukcu S. Clinical presentation, diagnosis and treatment of vulvovaginitis in girls: a current approach and review of the literature. 

. 2017;13(2):101-105. doi:10.1007/s12519-016-0078-y

Cemek F, Odabaş D, Şenel Ü, Kocaman AT. Personal hygiene and vulvovaginitis in prepubertal children. 

. 2016;29(3):223-227. doi:10.1016/j.jpag.2015.07.002

Alaniz VI, Kobernik EK, George JS, Smith YR, Quint EH. Comparison of short-duration and chronic premenarchal vulvar complaints. 

. 2021;34(2):130-134. doi:10.1016/j.jpag.2020.11.016

Ingram DL, White ST, Lyna PR, et al. Gardnerella vaginalis infection and sexual contact in female children. 

. 1992;16(6):847-853. doi:10.1016/0145-2134(92)90086-7

Huppert J, Griffeth S, Breech L, Hillard P. Vaginal burn injury due to alkaline batteries. 

. 2009;22(5):e133-e136. doi:10.1016/j.jpag.2008.10.009

Bacon JL, Romano ME, Quint EH. Clinical recommendation: labial adhesions. 

. 2015;28(5):405-409. doi:10.1016/j.jpag.2015.04.010

Dowlut-McElroy T, Higgins J, Williams KB, Strickland JL. Treatment of prepubertal labial adhesions: a randomized controlled trial. 

. 2019;32(3):259-263. doi:10.1016/j.jpag.2018.10.006

Trager JD. Vulvar dermatology. In: Emans SJ, Laufer MR, DiVasta AD. 

Bercaw-Pratt JL, Boardman LA, Simms-Cendan JS; North American Society for Pediatric and Adolescent Gynecology. Clinical recommendation: pediatric lichen sclerosus. 

. 2014;27(2):111-116. doi:10.1016/j.jpag.2013.11.004

Casey GA, Cooper SM, Powell JJ. Treatment of vulvar lichen sclerosus with topical corticosteroids in children: a study of 72 children. 

. 2015;40(3):289-292. doi:10.1111/ced.12519

Ellis E, Fischer G. Prepubertal-onset vulvar lichen sclerosus: the importance of maintenance therapy in long-term outcomes. 

. 2015;32(4):461-467. doi:10.1111/pde.12597

Corazza M, Borghi A, Minghetti S, Toni G, Virgili A. Clobetasol propionate vs. mometasone furoate in 1-year proactive maintenance therapy of vulvar lichen sclerosus: results from a comparative trial. 

. 2016;30(6):956-961. doi:10.1111/jdv.13166

Patrizi A, Gurioli C, Medri M, Neri I. Childhood lichen sclerosus: a long-term follow-up. 

. 2010;27(1):101-103. doi:10.1111/j.1525-1470.2009.01050.x

Deitch HR, Huppert J, Hillard PJA. Unusual vulvar ulcerations in young adolescent females. 

. 2004;17(1):13-16. doi:10.1016/j.jpag.2003.11.015

Huppert JS, Gerber MA, Deitch HR, Mortensen JE, Staat MA, Hillard PJA. Vulvar ulcers in young females: a manifestation of aphthosis. 

. 2006;19(3):195-204. doi:10.1016/j.jpag.2006.02.006

Drucker A, Corrao K, Gandy M. Vulvar aphthous ulcer following Pfizer-BioNTech COVID-19 vaccine - a case report. 

2022;35(2):165-166. doi:10.1016/j.jpag.2021.10.007

Dixit S, Bradford J, Fischer G. Management of nonsexually acquired genital ulceration using oral and topical corticosteroids followed by doxycycline prophylaxis. 

. 2013;68(5):797-802. doi:10.1016/j.jaad.2012.10.014

Dowlut-McElroy T, Higgins J, Williams KB, Strickland JL. Patterns of treatment of accidental genital trauma in girls. 

. 2018;31(1):19-22. doi:10.1016/j.jpag.2017.07.007

Iqbal CW, Jrebi NY, Zielinski MD, et al. Patterns of accidental genital trauma in young girls and indications for operative management. 

. 2010;45(5):930-933. doi:10.1016/j.jpedsurg.2010.02.024

McCann J, Miyamoto S, Boyle C, Rogers K. Healing of hymenal injuries in prepubertal and adolescent girls: a descriptive study. 

. 2007;119(5):e1094-e1106. doi:10.1542/peds.2006-0964

Articles

Understanding signs, symptoms helps determine the best treatment regimen

How to identify common pediatric vulvar conditions

It’s a growing specialty within our field and often is underappreciated.

In this issue, you’ll find articles (some of which are detailed below) on gynecologic care for the adolescent, including care of the transgender adolescent patient, common pediatric vulvar conditions, the second part of our pediatric adolescent gynecologic emergencies series, and more.

We tapped experts in the field to address these topics and—appreciating the political nature of some—worked to ensure that the data and expertise were shared across the specialty to provide the best possible coverage.

Appointments specifically for adolescent gynecology are limited in
many areas of the US. As we provide coverage for these needs and topics,
it is essential that we communicate the importance of addressing
concerns, as well as critical support, for the adolescent going through a
medical situation.

Care for transgender patients may need to extend beyond the medical scenario if their care is affected by political agendas. It is vital for obstetrician-gynecologists (ob-gyns) to advocate for the care of our patients and ensure appropriate, evidence-based care.

Pediatric vulvar conditions are often hidden, unrecognized, or unacknowledged. Our advocacy to ensure they are evaluated and addressed is critical.

Adolescent gynecologic care may be provided through pediatric adolescent medicine clinics or ob-gyn adolescent gynecology clinics (after subspecialty training). It is vital to ensure appropriate expertise, interest, and support are provided.

Ultimately for the ob-gyn, these individuals are the future of our
field, and providing the best care now ensures a bright future for the patient population. 

Catherine Y. Spong, MD,editor in chief, is professor and chair in the Department of Obstetrics and Gynecology at UT Southwestern Medical Center in Dallas. She holds the Gillette Professorship of Obstetrics and Gynecology. Email her at cspong@mjhlifesciences.com.

This month we focus on pediatric adolescent gynecologic topics, which are critical to our practices (and our families). 

The world of the pediatric adolescent patient

Part 1 of this series on pediatric adolescent gynecologic emergencies focuses on cases about premenarchal bleeding, urethral prolapse, and the cause of a mysterious vaginal discharge. 

Monica Woll Rosen, MD, is a clinical assistant professor of obstetrics and gynecology at the University of Michigan Medical School in Ann Arbor. She specializes in pediatric and adolescent gynecology.

Elisabeth H. Quint, MD, is a clinical professor in obstetrics and gynecology at the University of Michigan Medical School in Ann Arbor. She is also fellowship director of the Pediatric and Adolescent Gynecology Fellowship and assistant dean for clinical faculty.

Young patients with gynecologic concerns may present to a general obstetrician-gynecologist as their first local contact. But prior to surgical intervention in a child, consultation with or referral to a pediatric and adolescent gynecologist in an academic medical center may be indicated. This review presents several cases of adolescents with genital and pelvic pain, with guidance for work-up and treatment.

You are called to evaluate a 12-year-old girl who fell on the balance beam during a gymnastics class. Her legs landed on either side of the beam. She is unable to void and is in tremendous pain. She was given several doses of pain medication but she continues to experience severe pain (

This patient has extensive vulvar hematoma. Nonobstetric vulvar hematomas are rare, accounting for only 3.7% of all vulvar hematomas.

 They can occur from blunt trauma due to a fall, foreign body insertion, sexual assault, saddle injury, or intercourse. The rich vascular supply from the pudendal vessel branches makes this site vulnerable to hematoma formation.

A hematoma can be managed conservatively unless the hematoma is expanding, the skin is necrotic, or the patient is in too much pain.

 Ultrasound, CT, or MRI can be used to investigate the size, site, and expansion of the hematoma. Cases requiring surgical management involve an incision, evacuation of blood, and ligation of bleeding vessels.

Because this patient’s hematoma prohibited her from voiding, she needed a Foley catheter placed. Her urine was evaluated for hematuria. Because of her extensive hematoma and continued pain despite medication, she required an exam under anesthesia to assess the extent of her injury, insertion of the Foley catheter, and incision and drainage of the hematoma.

A 13-year-old girl presents to the emergency department with several days of worsening vulvar pain that is now severe. A few days ago, she developed a runny nose, fever, and sore throat. She otherwise has a negative review of systems. She is having trouble urinating because of the vulvar pain and has dysuria when she does urinate. Today she noticed a thick, yellow discharge in her underwear. On exam you notice several large painful ulcerations (

Aphthous or Lipschütz ulcers are acute vulvar ulcers that occur mainly in non–sexually active girls and are thought to be viral in nature.

 They commonly appear during or following a prodromal viral illness.

 have been associated with the ulcers, the causative virus often cannot be identified. There have been recent case reports of vulvar ulcers following a COVID-19 infection6 or after receiving the COVID-19 vaccine.

A patient may have black, necrotic, shallow, or deep ulcers in the labia minora or majora.

 There can be overlying purulent discharge. When assessing any ulcers it is important to evaluate for underlying sexually transmitted infections, such as herpes simplex. Other considerations include Crohn disease with multiple tracks and ulceration or Behçet disease, which presents with recurrent vulvar ulcers in conjunction with recurring oral ulcers.

Treatment for aphthous ulcers is supportive, as it is a self-limiting condition. Topical lidocaine gel can be used for pain control, and a topical clobetasol ointment can be used twice daily.

If a patient is severely affected, an oral steroid taper may be considered, as well as an admission for intravenous pain control. If the patient cannot void because of dysuria, a Foley catheter should be placed.

An 11-year-old girl presents after track practice with severe, unilateral right lower quadrant pain. Her last menstrual period was 3 weeks ago. The pain is sharp and radiates to her back. She has associated nausea and vomiting. On exam, she has rebound tenderness and guarding of her lower abdomen. On a pelvic ultrasound, she has a 6-cm simple cyst and a normal appendix. What do you do next?

This patient most likely is experiencing ovarian and/or tubal torsion 

. Ovarian torsion accounts for 2.7% of gynecologic emergencies.

 It occurs when the ovary twists on its attachments, which causes decreased blood flow and eventually leads to necrosis. Ovarian and paraovarian cysts, increased length of ovarian ligaments, and enlarged ovaries are risk factors for this condition. A patient is typically evaluated with an ultrasound to assess for a mass and blood flow to the ovary.

Ovarian torsion can be difficult to diagnose preoperatively—the differential includes appendicitis, hemorrhagic cyst, ovarian rupture, and other bowel etiologies. Absent Doppler flow to the ovary suggests torsion, but torsion may be present even with normal flow. 

A recent study of 87 girls with suspected ovarian torsion found that a preoperative diagnosis was confirmed in 48% of postmenarchal patients.

Treatment involves detorsion of the ovary when possible and cystectomy to prevent recurrence.

 There is limited indication for oophorectomy. Detorsion with cystectomy can almost always be done, regardless of ovarian size. There is insufficient evidence to dictate oophoropexy, although this may be considered, particularly in the case of recurrent torsion.

A 14-year-old girl presents to the emergency department with significant abdominal pain. She is premenarchal but has had pelvic cramping for the past 6 to 9 months. She has Tanner stage V breasts and genitalia. On pelvic exam, there is a bulging hymen with a blue hue (

On rectal exam, there is a large anterior bulge immediately inside her rectal opening. On ultrasound, you see a large mass and have difficulty distinguishing the uterus or ovaries. What is your diagnosis?

This presentation and exam are consistent with an imperforate hymen, which occurs in 0.05% to 0.1% of girls.

Abdominal pain at the time of expected menarche is the most common presenting symptom of this condition (54.2%), followed by urinary retention (20.3%) and dysuria (9.7%).

Of note, this condition can and should potentially be diagnosed in the neonatal nursery, as maternal estrogen allows easy visualization of the vaginal introitus. If the neonate is asymptomatic and voiding without difficulty, surgical management can be deferred until puberty. 

More typical is a missed diagnosis until after menarche. Surgical incision of the hymen is then indicated to relieve the backup of menstrual blood. 

Traditionally, this procedure was performed using a cruciate incision, but many providers now use a circular incision to open the hymen. It is important to suture with interrupted stitches so as not to constrict the hymen. This heals very well and should not recur or cause stenosis. No postoperative dilation is needed. Hormonal suppression of menses may be considered until surgery can be performed. This condition, although urgent, is not emergent, particularly if the diagnosis is in question.

Vaginal agenesis also can present with primary amenorrhea and occasional pain due to obstructed uterine remnants. However, there will usually be some hymenal remnants visible on exam and no bulge will be felt on rectal examination. Further imaging with ultrasound followed by MRI is the next step in distinguishing this condition. Other rare obstructing anomalies include a transverse vaginal septum or cervical agenesis.

A 13-year-old girl presents with significant cyclical abdominal pain and amenorrhea. She has Tanner stage V breasts and genitalia. Her external genital exam is completely normal with an appropriate hymenal opening. There is no bulge on the perineum. A small cotton swab placed through the hymen stops at 4 cm. On rectal exam you feel a bulge anteriorly, approximately 4 cm into the rectal canal. Ultrasound reveals a large blood-filled cavity, so you obtain an MRI (

This scenario is most consistent with a transverse vaginal septum. The septum can be located at different levels of the vagina, but external genitalia appear normal. Septa can vary in thickness, with whole segments of the vagina undeveloped.

Because cases of transverse septa are rare and difficult to repair, they should be managed at tertiary centers by experienced pediatric and adolescent gynecologists or other gynecological surgeons. 

Surgery is usually performed vaginally, with assistance abdominally or laparoscopically. Surgery involves resection of the septum, which relieves the obstruction, followed by either a simple pull-through vaginoplasty or by using a skin or buccal graft to cover the defect.

It is imperative that patients perform patient-led vaginal dilation after surgery. A recent study showed that of 21 patients who underwent transverse septum resections and had a postoperative complication of vaginal stenosis or scarring, 14 (56%) either did not dilate afterward or did not dilate correctly.

Therefore, when a transverse septum is diagnosed, menstrual suppression is usually initiated until a patient is old enough to dilate on her own.

The cases above outline gynecological situations and emergencies that are unique to children and adolescents. Pediatric patients may need an exam under anesthesia to thoroughly evaluate anatomy or vaginal complaints. When uncertainties exist, and especially prior to surgical intervention in a child, consider consulting with a gynecologist experienced in pediatric and
adolescent gynecology.

1. Burnham A, Cooke-Barber J, Thacker S, Evans D, Carney D, Boswell W. Non-obstetric vulvar/paravaginal hematoma in an adolescent female with scleroderma: an opportunity for intimate partner violence intervention. 

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2.Kim MS, Lee HJ, Joo E, Kang S, Lee MH, Kim HC. Management of non-obstetric traumatic vulvar haematoma: a retrospective review of 33 cases.

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3.Vismara SA, Lava SAG, Kottanattu L, et al. Lipschütz’s acute vulvar ulcer: a systematic review. 

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4.Lorenzo CV, Robertson WS. Genital ulcerations as presenting symptom of infectious mononucleosis. 

. 2005;18(1):67-68. doi:10.3122/jabfm.18.1.67

5.Martin JM, Godoy R, Calduch L, Villalon G, Jordá E. Lipschütz acute vulval ulcers associated with primary cytomegalovirus infection. 

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6.Krapf JM, Casey RK, Goldstein AT. Reactive non-sexually related acute genital ulcers associated with COVID-19. 

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7.Wojcicki AV, O’Flynn, O’Brien KL. Vulvar aphthous ulcer in an adolescent after Pfizer-BioNTech (BNT162b2) COVID-19 vaccination. 

. 2022;35(2):167-170. doi:10.1016/j.jpag.2021.10.005

8. Rosman IS, Berk DR, Bayliss SJ, White AJ, Merritt DF. Acute genital ulcers in nonsexually active young girls: case series, review of the literature, and evaluation and management recommendations. 

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9. Bandow GD. Diagnosis and management of vulvar ulcers. 

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10. Childress KJ, Dietrich JE. Pediatric ovarian torsion. 

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Part 2 in a series on emergencies in pediatric and adolescent gynecology

Vol 67 No 6

How to identify common pediatric vulvar conditions

The world of the pediatric adolescent patient

Managing genital and pelvic pain in young patients

Get a grip on revenue cycle management

Providing the best care for transgender adolescents

What did you miss at ACOG?

Up close and personal

What impacts a woman’s contraceptive decisions while breastfeeding?

FDA approves first drug for RVVC

FDA warns that NIPS tests may provide false results

Endometriosis and early natural menopause