Pressure in Vagina

Dear Lisa,

My 10 year old daughter for years has complained of a "bubble" or vaginal pressure that annoys her greatly, however without pain. She has had ultra sounds of the kidney, bladder and abdomen, an MRI, and vaginoscopy and cystoscopy, all of which were normal. She does have a history of chronic UTI's and constipation and is on a laxative and antibiotic now for those. Any ideas of what could be causing her this pressure, that would not appear on any of these exams? We are very frustrated and desperate for any more ideas to explore.

Thanks so much!

“Bubble in Vagina”

Dear “Bubble in Vagina”,

It must be so frustrating to go on for years listening to your daughter complain and not know the reason. It sounds like she has had an extensive work-up to determine the cause. It is also very concerning that she has chronic Urinary Tract Infections for no known reason.

For some children, chronic constipation can cause Urinary Tract infections. The large, hard stools that are present in the abdomen of a constipated child can impede the normal flow of urine through the urinary tract. This can cause the urine to pool or be pushed upwards back into the kidney. This pooling of urine and retrograde movement can put a child at risk for developing a Urinary Tract Infection. Constipation and large, hard stools can also lead to bloating and abdominal discomfort which may be the cause of the pressure that your daughter is feeling in her vaginal area.

The treatment in this case is to address the constipation. Dietary management and laxatives should loosen and clear out the bowels and prevent symptoms from occurring. You did mention that your daughter is on a laxative, but did not mention if it is working or not. If constipation is still an issue, this problem should be addressed first because many times once the constipation resolves the other symptoms go away too. If your daughter’s vaginal symptoms persist even after her constipation has resolved then a different cause should be investigated.

If constipation was the cause of your daughter’s Urinary Tract Infections, then the infections should also be alleviated with the resolution of her constipation. If your daughter still develops Urinary Tract Infections even after the constipation has resolved, then there may be a different reason for her recurrent infections.

Most practitioners agree that young children with a Urinary Tract Infection need a diagnostic work-up to determine the cause. This work-up typically includes a Renal Ultrasound and a Voiding Cystourethrogram(VCUG). (1,2) A Renal Ultrasound can determine if there is an obstruction in the urinary tract, renal stones, or lower tract abnormalities. This test also assesses the size and contour of the kidneys. (1) Since your daughter’s ultrasound was normal these conditions should have been ruled out.

You did not mention if your daughter had a Voiding Cystourethrogram (VCUG) performed, unless the cystoscopy you mentioned was a VCUG. The purpose of the VCUG is to evaluate the lower urinary tract and determine if there are any anatomical abnormalities such as Vesicoureteral Reflux. (3)

The advantage of having a Voiding Cystourethrogram performed is two-fold. Not only can it determine if a child has an anatomical anomaly of the urinary tract, it can assess the walls of the vagina. During a Voiding Cystourethrogram, dye is injected into the urinary tract. This injected dye tends to collect in the vaginal vault. If there is an abnormal opening between the vagina and rectum such as a Rectovaginal fistula this dye can seep through the opening and cause dye to appear in the rectum.

A Rectovaginal fistula is an abnormal communication between the rectum and the vagina. During a bowel movement, pieces of stool can pass through this abnormal opening allowing the vagina to be contaminated. Microorganisms from the stool can travel into the urethra, up into the urinary tract and cause an infection. Therefore children with Rectovaginal fistulas can have stool come out of their vagina and also can develop recurrent Urinary Tract Infections. If a Rectovaginal fistula is suspected a test called a retrograde Urethrocystogram is performed in order to determine if the abnormality exists. (1)

The appearance of a bubble or protrusion upon examination of a child’s vagina can be due to an Imperforate hymen. The hymen is a layer a tissue that surrounds the vaginal opening of a child. It usually ruptures during the perinatal period. If the hymen fails to rupture an Imperforate hymen develops.

An Imperforate hymen is a rare finding, occurring once in every 1,000 to 2,000 females. (4) When it does occur, it tends to go undetected until a female reaches early adolescence. (5) The typical symptoms include abdominal pain, constipation, low back pain, urinary retention, painful urination or frequent urination. (4)

In some cases an Imperforate hymen is not diagnosed until a young girl is old enough to have her period. When a girl with an Imperforate hymen menstruates, menstrual blood accumulates behind the closed hymen and gives it a blue, bulging appearance. (5) Other conditions that may present with similar symptoms include vaginal atresia, transverse vaginal septum, hymenal cyst, hymenal skin tag, or labial adhesions.

Since your daughter’s complaints include “feeling” a bubble and not “seeing” a bubble an Imperforate hymen is not likely the cause of her symptoms. In addition the vaginoscopy that she had performed should have ruled out an abnormality of the hymen and the external genital structures.

Since your daughter is still complaining about pressure in her vaginal area it might be a good idea to have her evaluated by a Pediatric Gynecologist, unless you have already done this when she had her vaginoscopy. A Pediatric Gynecologist has the expertise to diagnose and treat genital abnormalities in children. A Pediatric Gynecologist can also identify normal variations that may be responsible for your daughter’s complaints. It is important that a genital evaluation be performed by an expert in the area because genital abnormalities are quite difficult to diagnose.

Studies have shown that Family practitioners, Pediatricians and Surgeons generally do not excel in this area. Two studies using surveys of Family Practitioners, Pediatricians and Surgeons demonstrated physician difficulty in correctly labeling and identifying basic genital structures on a photograph of a prepubertal child’s genitalia. (6,7) The inability to correctly label basic anatomy on a photograph questions their ability to correctly interpret and diagnose clinical findings.

The vagina tends to be a very sensitive area which frequently causes young girls to complain. Some girls have normal anatomical variations that may cause more complaints than others. These normal variations can lead to different sensations and complaints. For example a high or microperforate hymen may trap drops of urine or mucus and lead to vaginal symptoms. (1)

Another common condition that I found in many of my female patients was Vaginal Adhesions. Vaginal Adhesions occur when tissue in the vaginal area known as the Labia minora sticks together. This causes the vaginal opening to become partially covered and in some cases a pocket to be formed which can trap urine, air or mucus. Vaginal Adhesions also can cause various vaginal complaints.

For girls with vaginal complaints it is a good idea to avoid activities that may contribute to vaginal irritation. Items and activities that can cause vaginal irritation include bubble baths, perfumed soaps, dyes found in colored underwear or colored toilet paper, tight fitting clothes, sitting in tight fitting jeans for prolonged periods and wearing stockings. (1)

I hope this information helps and I hope your daughter finds relief from her discomfort soon.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Constipation

Urinary Tract Infections

Vaginal Odor

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1526,1470, 1710-1715.
(2)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:534.
(3)Moore J. Oral and IV Treatment similar to urinary tract infections. Infectious Diseases in Children. 2006. Dec. 64.
(4)Wall EM, Stone B, Klein BL. Imperforate hymen: a not-so-hidden diagnosis. Am J Emerg Med. 2003.21:249-250.
(5)McAlhany A, Popovich D. Girl, 13, With Swollen Uterus and Pelvic Pain. Clinician Reviews. 2006. 16(10):53-58.
(6)Ladson S, Johnson CF, Doty RE. Do physicians recognize sexual abuse: Am J Dis Child. 1987. 141(4):411-415.
(7)Lentsch K, Johnson C. Do physicians have adequate knowledge of child sexual abuse: The results of two surveys of practicing physicians. 1986 and 1996. Child Maltreat. 2000;5(1)72-78.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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