estrogen in the prepubertal child results in thinner, atrophic labia and an alkaline pH, making the vaginal mucosa more susceptible to irritation and infections In this age group, this is potentiated by the higher prevalence of poor local hygiene, the close proximity to the rectum, more frequent use of bubble baths and other harsh soaps, the use of tight, nonabsorbent clothing, and exploratory behaviors including insertion of foreign bodies Vaginitis is the most common gynecologic problem in prepubertal girls, and the differential diagnosis can be quite extensive ( Table 80.1 ) In addition to vaginal discharge, other symptoms can include dysuria, itching, soreness, erythema, and bleeding Nonspecific vaginitis occurs in 25% to 75% of girls presenting with symptoms of irritation and vaginal discharge In these cases, no specific pathogen is isolated The etiology is most likely the result of poor perineal hygiene or mechanical or chemical irritation Symptoms resolve within to weeks with vaginitis treatment Children with infection caused by respiratory and enteric pathogens can present with a purulent, bloody, or mucoid discharge The most common respiratory pathogen associated with this infection is Streptococcus pyogene s A recent history of sore throat is sometimes obtained The vulva and perianal areas have a distinctive beefy red appearance Other bacteria found less commonly include Staphylococcus aureus, nontypable Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitides, and Moraxella catarrhalis These usually cause self-limited symptoms Enteric pathogens that may or may not be associated with diarrhea include Shigella flexneri and Yersinia enterocolitica The possibility of sexual abuse must always be considered in a prepubertal child who presents with vaginal complaints Sexually transmitted infections as a result of sexual abuse in this age group include Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, human papilloma virus, and herpes simplex virus N gonorrhoeae infection causes a purulent vaginal discharge C trachomatis may produce a scant, mucoid discharge, but is often asymptomatic Chlamydia may be transmitted perinatally and may persist for several months up to to years of age However, the possibility of sexual abuse must be thoroughly investigated as it is more common after toddlerhood T vaginalis infection beyond the newborn period is most