ORLANDO – Infectious processes, such as those associated with vulvar abscesses and aphthous ulcers, are among the more common culprits in young patients who present to the emergency department with pelvic pain, according to Dr. Heather Appelbaum.
Vulvar abscesses should be distinguished from Bartholin’s gland abscesses and cysts (which tend to occur more medially) and should be treated to cover for methicillin-resistant Staphylococcus aureus; Bactrim and clindamycin are good choices, Dr. Appelbaum, director of the division of pediatric and adolescent gynecology at Long Island Jewish Medical Center, New Hyde Park, N.Y., said during a workshop on pediatric gynecologic emergencies at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
Similarly, aphthous ulcers of the vulva should not be confused with herpes. These ulcers are deep, with irregular borders. They usually occur in non–sexually active individuals and are exquisitely tender, she said.
They look different than herpes and have “a totally different history associated with them,” she said, adding that even in girls who don’t seem to be giving an honest history, keep in mind that aphthous ulcers don’t look anything like herpes.
Aphthous ulcers are usually associated with a viral syndrome. A good history will typically reveal a preceding viral-type illness or sore throat. Parvovirus, Epstein-Barr virus, and cytomegalovirus all can be associated with aphthous ulcers, but in most cases the virus is unknown.
“In any case, recognizing this is very important, and for a primary lesion like this, it is important to look for ulcers in other locations,” she said.
Ulcers in the mouth, for example, also can be associated with a viral syndrome, but could be a sign of Behçet’s disease, Crohn’s disease, or some other autoimmune disorder, especially if the ulcers are recurrent, she noted.
Treatment for aphthous ulcers of the vulva is generally supportive. The lesions can weep and become necrotic. They often are associated with a lot of discharge and are purulent.
“They scare mom, they scare the kid, and they scare the clinician, but they really just need to be treated with supportive therapy, because they generally go away in 7-10 days,” Dr Appelbaum said, adding that because the lesions are exquisitely tender, she recommends that patients sit in a warm bath multiple times daily.
Warm baths are really the most soothing thing for these patients, she added, noting that topical lidocaine can be used, but sometimes it burns and doesn’t help much.
“But Percocet does, Tylenol does, and sitting in that warm bath frequently really does. And a lot of hand holding of parents is obviously essential. But it does go away and it resolves without any structural defect or, typically, any long-term sequelae or recurrence,” she said.
The characteristics of genital ulcers were further explored in an unrelated study presented in a poster at the meeting. Dr. Amy Sass and her colleagues from the University of Colorado and Children’s Hospital Colorado, Aurora, reviewed a series of 110 cases of acute genital ulcers (AGUs) in adolescents presenting between March 2002 and August 2014.
None tested positive for bacterial infection, herpes simplex virus, or cytomegalovirus, and six were positive for Epstein-Barr virus (EBV). An additional 18 had a past EBV infection; 34 tested negative for EBV.
Symptoms included vulvar pain and painful urination in all patients, fever in 89%, pharyngitis in 67%, cough in 63%, and headache in 57%.
Nine patients experienced one recurrence, nine had two recurrences, two had three recurrences, and one had five recurrences; 73% of the 38 recurrences occurred in the setting of viral illness, and 27% occurred in the setting of physical exhaustion or emotional stress. The timing of recurrence ranged from 2 weeks to 7 years after the initial episode.
Case patients had a mean age of 13.6 years, and 48% were postmenarcheal, 29% were premenarcheal, and menarcheal status was unknown in 33%. The vast majority (99%) were not sexually active, 36% had a history of oral aphthous ulcers, and 10 had concurrent oral aphthous ulcers at the time of diagnosis.
The mean number of days before AGU onset following prodromal illness was 3 days, and the mean number of days to AGU resolution was 13 days.
Treatment was most often oral NSAIDS, topical lidocaine jelly or lidocaine-epinephrine-tetracaine gel, and sitz baths.
“Acute genital ulcers in sexually inexperienced adolescent are painful and distressing,”the investigators wrote, noting that the differential diagnosis for AGUs includes sexually transmitted infections, autoimmune disease, genital manifestations of systemic illness, and drug reactions.
“Unfortunately, a causative etiology is often not identified, they added.