Mrs. S. made the appointment for her five-year-old daughter Mia, convinced that she had a urinary tract infection. For the past three days Mia has had burning when she urinates. According to mom she runs into the bathroom, starts to urinate, and then stops saying that it burns. Only a trickle of urine comes out. This pattern repeats itself frequently throughout the day. Mom was quick to point out that Mia has been fully potty trained since she was three years old. Normally she voids about four times a day. Since this all started she has been going to the bathroom at least eight to nine times a day.
In obtaining the history I was able to determine there was no fever, abdominal or flank pain, and no bedwetting during the night. Having established this, I was fairly certain that we were not dealing with a kidney infection. Mrs. S. concurred, adding, “I think she has cystitis. I often get cystitis which is a bladder infection myself. This is exactly how it affects me,” she said.
I had Mia collect a urine specimen which she was easily able to do with mom’s assistance. While the nurse was running the specimen I moved to my exam. She had a normal temperature of 98.4 degrees, which was reassuring. Pertinent physical findings revealed an entirely benign abdomen with no suprapubic or flank tenderness. When I examined the vaginal area there was significant redness of the labial region, but no discharge. The nurse brought in the result of the urinalysis and it confirmed what I had suspected. Mia most likely had vaginitis, and not a true urinary tract infection.
The urinalysis measures for the presence of white blood cells (leukocyte esterase), certain bacteria (nitrites), red blood cells and protein. When one has a true urinary tract infection there is usually the presence of white blood cells, red blood cells, blood and protein. The gold standard to determine if there is an actual infection is the urine culture, which takes 48 hours for the results as the bacteria has to be grown in the lab.
In Mia’s case, the urinalysis was positive for only the leukocyte esterase, which goes along with inflammation…not necessarily infection. The blood, protein and red cells were all negative. Mrs. S. asked, “Well, shouldn’t she be on antibiotics because they always work for me within a day?”
I told her that Mia had vaginitis. Since there was no fever or evidence of a kidney infection, and the urinalysis did not suggest a bacterial infection, I was going to treat this conservatively and wait for the urine culture to come back. I then discussed vaginitis with her.
Vaginitis is inflammation of the vaginal area and is very common in young females. Because the vaginal area is inflamed, when they start to void the urine makes contact with the irritated area causing it to sting or burn. As a result, they stop voiding and do not fully empty their bladder. Within a short period of time they feel that they have to void again. Because it again stings they hold it. This explains the frequency and urgency of having to void, much like the symptoms of cystitis.
There are many causes of vaginitis. One of the more common causes is the use of a bubble bath resulting in a chemical irritation of the vaginal area. Another common repercussion is when girls wipe themselves from back to front instead of from front to back. This can contaminate the vaginal area. Young girls often will urinate, take a huge wad of toilet paper the size of a softball, and essentially wipe “nothing”. They then pull up their panties and go off running having not dried the vaginal area at all. The moisture in a warm confined space is a perfect setup for inflammation.
In the summertime it is not uncommon for a girl to spend the better part of a day in a swimsuit going in and out of the pool or the ocean. The constant wetness and drying can be irritating to the vaginal mucosa and set up vaginitis. Finally, it is normal and common for young girls to explore and masturbate. This too can cause irritation and thus vaginitis.
In general the best ways to avoid vaginitis are to insure that young girls properly wipe themselves from front to back and dry the vaginal area well. Bubble baths should be discouraged. In the summertime, it is wise to have a spare bathing suit. When they get out of the water for any length of time they can dry off and rotate the wet suit for a dry one.
I explained to Mia’s mom that I doubted she had a true infection. If there was even a slight suspicion that it was cystitis she would begin taking antibiotics until the culture came back in 48 hours. We did not want to start this program needlessly.
In order to treat the vaginitis Mia was to soak in a warm bath three times a day without soap or chemicals. After the bath mom would dry her well and blow dry the vaginal area with a hair dryer at a cool setting. Some over-the-counter antibacterial ointment would be applied to the labial area where it was inflamed. Mom was to call with an update the next day. If Mia was still having the same symptoms I would consider starting an antibiotic until we got the culture results.
The phone call the next morning brought good news. “Amazing,” she said. “Mia hasn’t complained once since the first tub soaking.” When the lab results came in after the 48 hour period the urine culture report was completely negative.