Vulval Disorders - Paediatric CPC

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Women's and Children's Health Network

• Women’s and Children’s Hospital (08) 8161 7000

Exclusions

• concerns of ‘childhood non-accidental injury’ – refer to Child Protection Services for further information
• vulval disorders without trial of first-line treatment

Triage categories

Category 1 (appointment clinically indicated within 30 days)

• unexplained vulval lump/ulceration/bleeding
• immunosuppressed person with vulval lesion

Category 2 (appointment clinically indicated within 90 days)

• nil

Category 3 (appointment clinically indicated within 365 days)

• vulvovaginitis with failed first-line treatment
• recurrent vulval infections
• suspected vulval dystrophy
• vulval dermatoses, including lichen sclerosus

All referrals for people less than 16 years of age, or those less than 18 years with intellectual disabilities, complex medical conditions, primary amenorrhea, pubertal delay, or Mullerian anomalies are to be sent to Women’s and Children’s Hospital (WCH).

Central Adelaide Local Health Network only accept referrals for people greater than 18 years of age.

Due to limitations in infrastructure and resources, the WCH cannot accommodate referrals for individuals with a body mass index (BMI) equal to or greater than 45, as well as individuals over the age of 69 years of age.

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

• past medical/surgical/psychosocial history
  
• current medications and allergies
• onset, duration and course of presenting symptoms:
  • pain
  • swelling
  • pruritus
  • localised lesions, pigmented or non-pigmented lesions
  • vaginal discharge
  • trauma where appropriate
  • medical management to date
• external vulval examination findings

Sexually active people

Complete a sexually transmitted infection screen, including:

• human immunodeficiency virus and syphilis serology
• chlamydia and gonorrhoea which requires:
  • endocervical swab for culture and
  • endocervical polymerase chain reaction (PCR) swab or urine sample

vulval ulceration present

• wound swab (microscopy, culture and sensitivity)
• PCR screen for herpes simplex virus and varicella-zoster virus
• exotic travel history including location, date and length of stay

vulval dermatitis present

• allergy skin testing results
• fungal swab if suspicion of candidiasis

Clinical management advice

Vulvovaginitis in paediatric cases is commonly caused by irritants such as bubble baths, infections, worms, or dermatological conditions. Yeast infections are rare before the onset of menstruation. In most cases, these disorders can be effectively managed with first-line therapies provided by a general practitioner.

Lichen Sclerosus (LS) often begins with subtle symptoms, making it challenging to diagnose in its early stages. The most common symptom observed in children with LS is intense itching, which may lead to discomfort and difficulty with daily activities. Children may also experience pain or discomfort while urinating or having bowel movements.

It is important to note that relying solely on antibiotics may not result in complete resolution of Bartholin's cysts, particularly when they are large or recurring. Surgical marsupialisation, a procedure to drain the cyst and prevent future recurrences, may be necessary. Therefore, it is recommended to seek medical advice for accurate diagnosis and treatment.

It is important to consider the possibility of sexual abuse in girls presenting with vulval disorders. Please be aware that any concerns of childhood non-accidental injury should be reported and investigated by Child Protection Services.

Clinical resources

• Australian Indigenous Health Info Net - Central Australian Aboriginal Congress: Women's Business Manual for Remote and Rural Practice 7th Edition
• Australian Medical Association - New Stolen Generation resources for GPs
• DermNet – Lichen Sclerosus
• Royal Children’s Hospital Melbourne - Lichen Sclerosus
• Royal Children’s Hospital Melbourne - Vulvovaginitis

Consumer resources

• Jean Hailes for Women’s Health - Lichen Sclerosus (LS)
• Royal Children’s Hospital Melbourne - Vulval Skin Care for Children
• Royal Children’s Hospital Melbourne - Vulval Skin Care for Teenagers
• Royal Children’s Hospital Melbourne - Vulvovaginitis

Reason for request

• to establish a diagnosis
• for treatment or intervention
• for advice and management
• for specialist to take over management
• for a specified test/investigation the General Practitioner cannot order
• for other reason (e.g. rapidly accelerating disease progression)
• transfer of care from another tertiary service
• clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

• full name, including aliases
• date of birth
• residential and postal address
• telephone contact number/s – home, mobile and alternative
• Medicare number, where eligible
• name of the parent or caregiver, if appropriate
• preferred language and interpreter requirements
• identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

• impact on employment
• impact on education
• impact on home
• impact on activities of daily living
• impact on ability to care for others
• impact on personal frailty or safety
• identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

• Willingness to have surgery, where surgery is a likely intervention.
• Choice to be treated as a public or private patient.
• Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
• Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
• Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  
• Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
• A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
• All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The General Practitioners role in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the General Practitioner once the transfer of care has occurred.