Diagnosis of Pelvic Inflammatory Disease

Diagnostic Test list for Pelvic Inflammatory Disease:

The list of medical tests mentioned in various sources as used in the diagnosis of Pelvic Inflammatory Disease includes:

• Physical exam
• Test for vaginal discharge
• Test for cervical discharge
• Culture of discharge to identify bacteria
• Sonogram
• Endometrial biopsy
• Laparoscopy

Pelvic Inflammatory Disease Diagnosis: Book Excerpts

• Ask the following questions - DYSMENORRHEA
• Ask the Following Questions - PELVIC PAIN
• Ask the Following Questions - VAGINAL DISCHARGE
• Differential Diagnosis - Dysmenorrhea
• Differential Diagnosis - Vaginal Discharge
• Differential Diagnosis - Pelvic Pain - Female
• Differential Diagnosis - Vaginal Discharge
• Approach to the Diagnosis - DYSMENORRHEA
• Approach to the Diagnosis - PELVIC PAIN
• Approach to the Diagnosis - VAGINAL DISCHARGE
• History and physical examination - Dysmenorrhea
• History and physical examination - Vaginal discharge
• Diagnosis - Dysmenorrhea
• Diagnosis - Pelvic inflammatory disease
• History and physical examination - Dysmenorrhea
• History and physical examination - Vaginal discharge
• History (2) - Dysmenorrhea
• History (2) - Vaginal Discharge
• History - Chronic Pelvic Pain
• Differential Overview - Abdominal/Pelvic Mass
• Differential Overview - Vaginal Discharge
• Diagnosis - Pelvic inflammatory disease
• History - Vaginal discharge
• Clinical Features and Diagnosis - Vaginal Discharge
• History and physical examination - Dysmenorrhea
• History and physical examination - Vaginal discharge
• Approach to the Diagnosis - DYSMENORRHEA
• Approach to the Diagnosis - PELVIC PAIN
• Approach to the Diagnosis - VAGINAL DISCHARGE

Tests and diagnosis discussion for Pelvic Inflammatory Disease:

PID: DSTD (Excerpt)

PID is difficult to diagnose because the symptoms are often subtle and mild. Many episodes of PID go undetected because the woman or her health care provider fails to recognize the implications of mild or nonspecific symptoms. Because there are no precise tests for PID, a diagnosis is usually based on clinical findings. If symptoms such as lower abdominal pain are present, a health care provider should perform a physical examination to determine the nature and location of the pain and check for fever, abnormal vaginal or cervical discharge, and for evidence of gonorrhea or chlamydia infection. If the findings suggest PID, treatment is necessary.

If more information is necessary, the health care provider may order other tests to identify the infection-causing organism or to distinguish between PID and other problems with similar symptoms. A pelvic ultrasound is a procedure that may be helpful in evaluating someone for PID. An ultrasound can view the pelvic area to see whether the fallopian tubes are enlarged or whether an abscess is present. In some cases, a laparoscopy may be necessary to confirm the diagnosis. A laparoscopy is a minor surgical procedure in which a thin, flexible tube with a lighted end (laparoscope) is inserted through a small incision in the lower abdomen. This procedure enables the doctor to view the internal pelvic organs and to take specimens for laboratory studies, if needed. (Source: excerpt from PID: DSTD)

Pelvic Inflammatory Disease, NIAID Fact Sheet: NIAID (Excerpt)

PID can be difficult to diagnose. If symptoms such as lower abdominal pain are present, the doctor will perform a physical exam to determine the nature and location of the pain. The doctor also should check the patient for fever, abnormal vaginal or cervical discharge, and evidence of cervical chlamydial infection or gonorrhea. If the findings of this exam suggest that PID is likely, current guidelines advise doctors to begin treatment.

If more information is necessary, the doctor may order other tests, such as a sonogram, endometrial biopsy, or laparoscopy to distinguish between PID and other serious problems that may mimic PID. Laparoscopy is a surgical procedure in which a tiny, flexible tube with a lighted end is inserted through a small incision just below the navel. This procedure allows the doctor to view the internal abdominal and pelvic organs, as well as take specimens for cultures or microscopic studies, if necessary.

Treatment

Because culture of specimens from the upper genital tract are difficult to obtain and because multiple organisms may be responsible for an episode of PID, especially if it is not the first one, the doctor will prescribe at least two antibiotics that are effective against a wide range of infectious agents. The symptoms may go away before the infection is cured. Even if symptoms do go away, patients should finish taking all of the medicine. Patients should be re-evaluated by their physicians two to three days after treatment is begun to be sure the antibiotics are working to cure the infection.

About one-fourth of women with suspected PID must be hospitalized. The doctor may recommend this if the patient is severely ill; if she cannot take oral medication and needs intravenous antibiotics; if she is pregnant or is an adolescent; if the diagnosis is uncertain and may include an abdominal emergency such as appendicitis; or if she is infected with HIV (human immunodeficiency virus, the virus that causes AIDS).

Many women with PID have sex partners who have no symptoms, although their sex partners may be infected with organisms that can cause PID. Because of the risk of reinfection, however, sex partners should be treated even if they do not have symptoms.

Consequences of PID

Women with recurrent episodes of PID are more likely than women with a single episode to suffer scarring of the tubes that leads to infertility, tubal pregnancy, or chronic pelvic pain. Infertility occurs in approximately 20 percent of women who have had PID.

Most women with tubal infertility, however, never have had symptoms of PID. Organisms such as C. trachomatis can silently invade the fallopian tubes and cause scarring, which blocks the normal passage of eggs into the uterus.

A women who has had PID has a six-to-tenfold increased risk of tubal pregnancy, in which the egg can become fertilized but cannot pass into the uterus to grow. Instead, the egg usually attaches in the fallopian tube, which connects the ovary to the uterus. The fertilized egg cannot grow normally in the fallopian tube. This type of pregnancy is life-threatening to the mother, and almost always fatal to her fetus. It is the leading cause of pregnancy-related death in African-American women.

In addition, untreated PID can cause chronic pelvic pain and scarring in about 20 percent of patients. These conditions are difficult to treat but are sometimes improved with surgery.

Another complication of PID is the risk of repeated attacks of PID. As many as one-third of women who have had PID will have the disease at least one more time. With each episode of reinfection, the risk of infertility is increased.

Prevention

Women can play an active role in protecting themselves from PID by taking the following steps:

• Signs of discharge with odor or bleeding between cycles could mean infection. Early treatment may prevent the development of PID.
• If used correctly and consistently, male latex condoms will prevent transmission of gonorrhea and partially protect against chlamydial infection.

Research

Although much has been learned about the biology of the microbes that cause PID and the ways in which they damage the body, there is still much to learn. Scientists supported by the National Institute of Allergy and Infectious Diseases (NIAID) are studying the effects of antibiotics, hormones, and substances that boost the immune system. These studies may lead to insights about how to prevent infertility or other complications of PID. Topical microbicides and vaccines to prevent gonorrhea and chlamydial infection also are being developed. Clinical trials are in progress to test a suppository containing lactobacilli – the normal bacteria found in the vaginas of healthy women. These bacteria colonize the vagina and may be associated with reduced risk of gonorrhea and bacterial vaginosis, both of which can cause PID.

Rapid, inexpensive, easy-to-use diagnostic tests are being developed to detect chlamydial infection and gonorrhea. A recent study conducted by NIAID-funded researchers demonstrated that screening and treating women who unknowingly had chlamydial infection reduced cases of PID by more than 60 percent. Meanwhile, researchers continue to search for better ways to detect PID itself, particularly in women with "silent" or asymptomatic PID.

(Source: excerpt from Pelvic Inflammatory Disease, NIAID Fact Sheet: NIAID)

Diagnostic Tests for Pelvic Inflammatory Disease: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Pelvic Inflammatory Disease.

DYSMENORRHEA: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Are there abnormalities on pelvic examination? A tubo-ovarian mass on pelvic examination should suggest salpingo-oophoritis, endometriosis with a chocolate cyst, or ectopic pregnancy. Perhaps the uterus is abnormal, in which case one should suspect fibroids, endometrial carcinoma, uterine pregnancy, retroverted uterus, endometrial cast, or cervical polyp. A normal examination should suggest ovarian dysfunction, endocrine imbalance, and psychogenic causes.
2. What is the age of the patient? If the patient is young, she probably has a virginal uterus and may be considered to have primary dysmenorrhea. These cases are usually due to uterine hypoplasia, congenital malformations, ovarian dysfunction, or psychogenic causes.

DIAGNOSTIC WORKUP

Routine studies should include a CBC, sedimentation rate, chemistry panel, and thyroid profile. If there is vaginal discharge, a smear and culture should be done for gonorrhea and chlamydia. A cervical and rectal culture for these organisms may also be necessary. If there is a tubo-ovarian mass or enlarged uterus, abdominal ultrasound may help in differentiating the cause. A pregnancy test should be done. The pregnancy test of choice is radioimmunoassay for the beta subunit of human chorionic gonadotropin (HCG), which will be positive within a week of fertilization. If a ruptured ectopic pregnancy is expected, a peritoneal tap or culdocentesis may help if abdominal ultrasound is not conclusive. Laparoscopy may also be helpful in the diagnosis. A fern test and basal body temperature may help diagnose endometriosis. An exploratory laparotomy may be the only way to make a diagnosis in cases of a pelvic mass. If the pelvic examination is perfectly normal, sometimes a course of progesterone hormones is useful in alleviating the problem. A dilation and curettage may also be done to address the problem. Referral to a gynecologist is usually made before doing expensive diagnostic tests.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PELVIC PAIN: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there a pelvic mass? The presence of a pelvic mass would suggest salpingo-oophoritis, ectopic pregnancy, endometriosis, uterine fibroid, or an ovarian tumor that is twisting on its pedicle.
2. Is there fever or purulent vaginal discharge? The presence of fever or purulent vaginal discharge would suggest PID, diverticulitis, and appendicitis.
3. Is there a history of metrorrhagia or menorrhagia? The history of metrorrhagia or menorrhagia would suggest ectopic pregnancy, threatened abortion, retained secundinae, uterine fibroids, and endometriosis.
4. Is there a positive pregnancy test? The presence of a positive pregnancy test would suggest an ectopic pregnancy or threatened abortion.
5. Is the pain related to the menstrual cycle? If the pain is related to the menstrual cycle, mittelschmerz should be considered.

DIAGNOSTIC WORKUP

Routine studies include a CBC, sedimentation rate, pregnancy test, urinalysis, urine culture, chemistry panel, VDRL test, and Pap smear. A vaginal smear and culture should also be done routinely.

The next step would logically be a pelvic ultrasound, but it is wise to consult a gynecologist before ordering expensive tests. The gynecologist may proceed with laparoscopy, culdocentesis, and, ultimately, an exploratory laparotomy. A CT scan of the abdomen and pelvis may also be necessary.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

VAGINAL DISCHARGE: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it purulent? A purulent vaginal discharge suggests nonspecific bacterial vaginitis and gonorrhea.
2. Is it frothy and yellow? This type of discharge is very often due to trichomoniasis vaginitis.
3. Is it cheesy and associated with itching? These findings suggest candidiasis vaginitis.
4. Is it watery and bloodstained? This type of discharge suggests carcinoma of the cervix or endometrium, polyps, hydatidiform mole, and chronic cervicitis. If a frankly bloody discharge is noted, consult the differential diagnosis discussed on page 309 .
5. Is it offensive smelling? An offensive smelling discharge would suggest foreign body in the vagina.
6. Is there inflammation of the cervix? The presence of cervical inflammation would suggest chronic cervicitis and gonorrhea.

DIAGNOSTIC WORKUP

The most important test is microscopic examination of a saline and potassium hydroxide preparation. This will diagnose most cases of trichomoniasis and candidiasis. Gardnerella vaginalis can be diagnosed if clue cells are found, and the pH of the discharge will be greater than 4.7. If this is unrevealing, a Gram stain for gonorrhea and cultures for trichomoniasis, candidiasis, chlamydia, Gardnerella vaginalis , and gonorrhea may be done. A Pap smear should be done to rule out malignancy. Polyps or inflamed areas of the cervix should be biopsied. Colposcopy may help further differentiate a cervical lesion. A dilation and curettage may be necessary to diagnose endometrial carcinoma and hydatidiform mole. Occasionally, pelvic ultrasound and CT scans are necessary. However, before ordering these expensive diagnostic tests, a gynecologist should be consulted. Patients with documented evidence of gonorrhea should have a VDRL test and HIV testing.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Dysmenorrhea: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Primary dysmenorrhea
  –Symptoms develop before age 25
  –Pain occurs with onset of bleeding, then gradually diminishes

• Secondary dysmenorrhea
  –Endometriosis (uterosacral ligament nodules, severe dysmenorrhea)
  –Adenomyosis (enlarged uterus, menorrhagia, age 40–50, parous)
  –Acute PID (acute adnexal and cervical motion tenderness, fever, discharge, and/or new-onset dysmenorrhea)
  –Chronic PID (due to scarring)
  –Uterine leiomyoma/fibroids (enlarged, mobile uterus, menorrhagia)
  –Ovarian cysts (new dysmenorrhea, unilateral fullness)

• Mental health issues
  –Somatization
  –Substance abuse
  –Depression
  –Sexual abuse
• Extrapelvic disorders
  –Irritable bowel syndrome
  –Appendicitis
  –Urinary tract infection
  –Inflammatory bowel disease
  –Diverticulitis
  –Cholecystitis
• Fibromyalgia
• Malformations of the müllerian ducts
• Interstitial cystitis
• Intestinal or uteropelvic junction obstruction
• Malignancy (e.g., uterine, ovarian)
• Ectopic pregnancy

Workup and Diagnosis

• History, physical, pelvic, and rectal examination will often identify the diagnosis
• Patients unresponsive to an initial trial of NSAIDs and oral contraceptives may have pelvic pathology (secondary dysmenorrhea)
• Initial labs include CBC, urinalysis, β-hCG, wet mount, KOH prep, and gonorrhea and Chlamydia cultures, which may uncover pathology associated with secondary dysmenorrhea
• Abdominal and/or vaginal (with vaginal probe) ultrasound may be used to detect pelvic masses (e.g., ovarian cysts, uterine leiomyoma)
• Hysterosonogram if intrauterine pathology is suspected
• Hysteroscopy should follow abnormal hysterosonogram
• Abdominal and/or pelvic CT scan will evaluate gynecologic and abdominal pathology
• Laparoscopy may be both diagnostic and therapeutic
• Culdocentesis may be indicated if ruptured ectopic pregnancy is suspected; however, rarely used today, because of the advent of ultrasound

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Source: In a Page: Signs and Symptoms, 2004

Vaginal Discharge: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Physiologic
  –Many women will have a consistent, slightly clear, non-odor-producing discharge, either midcycle or premenstrually, particularly if they are on oral contraceptives
  –A change in odor, consistency, or color of discharge may signify that evaluation is necessary
  –Increased discharge is associated with pregnancy
• Sexually transmitted disease
  –Trichomonas vaginalis: “Strawberry cervix” with punctate erythema, flagellated oval organisms on wet mount
  –Gonorrhea/Chlamydia may be associated with pelvic pain/dysmenorrhea and dyspareunia
• Bacterial vaginosis
  –Various organisms and changes in normal flora with a characteristic fishy odor
  –Not considered an STD
  –Increases the risk of preterm delivery in pregnant women

• Alteration of normal vaginal flora and/or inflammatory response
  –Candida albicans overgrowth is more common with recent antibiotic use, poorly controlled diabetes, and/or pregnancy; presents with intensely pruritic, inflamed, and erythematous introitus
  –Doderlein's cytolysis (caused by an overgrowth of lactobacilli)

• Atrophic vaginitis
  –Common in postmenopausal women, especially those not on HRT
  –Poor coital lubrication, dyspareunia
  –Dysuria due to atrophic urethral tissue
• Foreign body vaginitis (e.g., retained tampon)
• Noninfectious irritant/allergic contact vaginitis (e.g., soaps, feminine pads, perfumes)
• Cervicitis (usually due to gonorrhea or Chlamydia)
• Cervical dysplasia, cancer, or polyps
• Vaginal or vulvar trauma or cancer

Workup and Diagnosis

• A focused history and physical examination are crucial, including a complete sexual and exposure history, and full abdominal and pelvic examination
  –A wet mount and KOH of the discharge are imperative
  –pH of the discharge may aid in diagnosis
  –A whiff test is done by smelling the discharge after KOH is added; a positive test reveals a fishy odor characteristic of bacterial vaginosis
• Initial labs may include CBC, urinalysis, urine culture, β-hCG, and gonorrhea and Chlamydia cultures
• Test and treat for other STDs when one STD is found (HIV, hepatitis B and C, syphilis)

pH	Discharge	Odor	Wet Mount
Trich >4.5	yellow-green, copious	present	motile, flagellated
BV >4.5	white-grey	fishy	clue cells
Candida <4.5	white, curd-like	none	pseudo-hyphae
GC/chlamydia	mucopurulent	varies	PMNs
Atrophic vaginitis	thin, gray, watery	none	few epithelial cells

>

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Source: In a Page: Signs and Symptoms, 2004

Pelvic Pain - Female: Differential Diagnosis
(In a Page: Signs and Symptoms)

Acute pain (<6 months)

• Pregnancy-related
  –Ectopic pregnancy
  –Threatened abortion
  –Incomplete abortion
  –Septic abortion
  –Ruptured corpus luteal cyst
• Gynecologic (noncyclic)
  –Ovarian cyst
  –Pelvic inflammatory disease
  –Tubo-ovarian abscess
  –Vaginitis/cervicitis
  –Ovarian torsion
  –Uterine fibroids
  –Pelvic (ovarian, uterine, urinary) neoplasm
  –Pelvic floor prolapse (cystocele/rectocele)
• Gynecologic (cyclic pain)
  –Primary dysmenorrhea
  –Endometriosis
  –IUD
  –Mittelschmerz (midcycle ovulation)
• Nongynecologic
  –Irritable bowel syndrome
  –UTI/pyelonephritis
  –Nephrolithiasis
  –Appendicitis
  –Diverticulitis
  –Sexual abuse/trauma
  –Abdominal aortic aneurysm
  –Mesenteric ischemia/infarction
• 
  Chronic pain (>6 months)
• Very difficult to diagnose; differential includes gynecologic and nongynecologic etiologies (above), as well as the following
  –Pelvic adhesions
  –Interstitial cystitis
  –Inflammatory bowel disease
  –Adenomyosis
  –Leiomyoma (fibroids)
  –Hernia (femoral or inguinal)
  –Depression
  –Irritable bowel syndrome
  –Diverticulosis or diverticular abscess
  –Lymphoma
• Less common etiologies (“zebras”) include pelvic congestion syndrome, mesenteric adenitis, surgical adhesions, Asherman's syndrome, foreign body (e.g., tampon), abdominal wall nerve entrapment, and porphyria

Workup and Diagnosis

• History and physical examination
  –Note the nature, severity, onset, radiation, duration of pain; relation to menstrual cycle, intercourse, or other activities; chronic versus acute; chance of pregnancy
  –Note associated symptoms: Fever, nausea, vomiting, dysuria, frequency, vaginal bleeding/discharge, abdominal or back pain
  –Screen for domestic violence and sexual abuse
  –Full abdominal and pelvic exams, including speculum, bimanual, and rectal exam
• Laboratory studies may include urine pregnancy test, urinalysis, urine Gram stain and culture, cervical cultures for Chlamydia and gonorrhea, and wet mount of vaginal smear
• Consider ultrasound if ovarian cyst, torsion, or mass is suspected, or to evaluate for intrauterine versus ectopic pregnancy
• Diagnostic laparoscopy for acute abdomen or endometriosis

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Source: In a Page: Signs and Symptoms, 2004

Vaginal Discharge: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Physiologic leukorrhea
  –In newborns for 2–3 weeks, due to maternal estrogen effect, and in pubertal girls
  –Discharge typically clear to white, sticky, and nonirritating
  –Newborns may have withdrawal bleeding

• Infections
  –Bacterial vaginosis: Previously known as nonspecific vaginitis; polymicrobial in etiology (coliforms, streptococci, Gardnerella); discharge may be gray and malodorous (fishy smell) but generally nonirritating
  –Candida: Discharge may be cheesy and white with erythematous, pruritic, irritated vulva; typical discharge is rarely seen in prepubertal children; discharge typically has no odor
  –Trichomonas: Discharge may be frothy, malodorous, creamy, green, bloody, or pruritic (or asymptomatic)
  –Chlamydia: Commonly asymptomatic or a nonspecific discharge
  –Gonorrhea: Infection is commonly asymptomatic or has a gray-white, thick, purulent discharge
  –Group A β-hemolytic streptococci: Discharge may be bloody
  –Shigella: Discharge may be bloody

• Irritation/hygiene
  –Due to bubble baths and other chemical irritants, tight clothing, obesity, poor wiping
• Foreign body
  –Commonly includes toilet paper, forgotten tampon
  –Discharge is often bloody and malodorous
• Anatomic
  –Ectopic urethra
  –Rectovaginal fistula
  –Urethral prolapse
• Urinary tract infection
• Masturbation
• Sarcoma botyroides
• Oral contraceptives (estrogen effect)

Workup and Diagnosis

• History
  –Age of girl (pubertal vs prepubertal)
  –Sexual activity and number of partners
  –Possibility of sexual abuse
  –Medications (e.g., steroid, oral contraceptive, antibiotic)
  –PMH of diabetes mellitus or immunocompromised
  –Type of discharge and duration of symptoms
  –Hygiene practices including feminine hygiene products, soaps, wiping techniques
  –Therapy tried at home

• Physical exam
  –Frog-leg or lithotomy position; examine external genitalia for abnormalities; speculum exam in sexually active adolescents
  –Amount, odor, color, consistency of discharge

• Labs
  –pH: Normal in the pubertal female is 3.8–4.4; if >5, consider bacterial vaginosis or Trichomonas
  –Vaginal gram stain and culture
  –Cultures for gonorrhea and Chlamydia (DNA amplification may not hold up in court for abuse cases)
  –Wet prep: Trichomonas has motile trichomonads; bacterial vaginosis has clue cells (vaginal epithelial cells coated with bacteria)
  –KOH for Candida
  –Whiff test (KOH added to discharge yields a fishy smell in Trichomonas)

• Urine culture and pregnancy test as indicated by history

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Source: In A Page: Pediatric Signs and Symptoms, 2007

DYSMENORRHEA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The clinical approach to dysmenorrhea is simply to rule out significant organic disease by a thorough pelvic and rectal examination. A smear and culture for gonococcus and Chlamydia should be done. A course of contraceptives or progesterone in adequate doses may then be tried. Diuretics may be indicated if examination suggests pelvic congestion. When the aforementioned measures fail, a dilatation and curettage (D & C) may be indicated. A gynecologist may decide to do a culdoscopy, a peritoneoscopy, or an exploratory laparotomy.

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Source: Differential Diagnosis in Primary Care, 2007

PELVIC PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

A good pelvic and rectal examination is essential. These will often disclose a mass or other pathology to explain the pain. If there is a vaginal discharge, a smear and culture for gonococcus and Chlamydia need to be done. A pregnancy test will help rule out an ectopic pregnancy, but ultrasonography is most useful.

A gynecology consult should be obtained when there is any doubt. In acute cases, the gynecologist may proceed with an exploratory laparotomy immediately.

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Source: Differential Diagnosis in Primary Care, 2007

VAGINAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

To workup a vaginal discharge, simply examining a fresh wet saline and KOH (10%) preparation will expose the most common offenders, namely Trichomonas and Candida. Some physicians treat all patients with negative findings on these examinations as a nonspecific bacterial vaginitis, but this is not a particularly scientific procedure. It is best to do a smear and culture (especially for gonococci). Cultures are also available for Trichomonas and Candida. If gonorrhea is suspected, material from the endocervix should be cultured. Chlamydia cultures are routinely done in some clinics.

Obviously, if the cervix is eroded and the discharge seems to be coming from there, biopsy and conization may be indicated. Referral to a gynecologist is preferred if this procedure is deemed necessary; however, the primary physician may prefer to cauterize the superficial lesions. Patients with discharges thought to be due to lesions beyond the cervix should probably be referred.

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Source: Differential Diagnosis in Primary Care, 2007

Dysmenorrhea: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it's bilateral. When does the pain begin and end, and when is it severe? Does it radiate to the back? How long has she been experiencing the pain? If it's a recent complaint, obtain a human chorionic gonadotropin level to determine if the patient is or was pregnant, because miscarriage can cause painful bleeding. Explore associated signs and symptoms, such as nausea and vomiting, altered bowel or urinary habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.

Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk of sexually transmitted diseases.

Next, perform a focused physical examination. Take the patient's vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Vaginal discharge: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Also, ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Next, ask if she has had vaginal discharge before or has ever been treated for a vaginal infection. What treatment did she receive? Did she complete the course of medication? Ask about her current use of medications, especially antibiotics, oral estrogens, and hormonal contraceptives.

Examine the external genitalia and note the character of the discharge. (See Identifying causes of vaginal discharge.) Observe vulvar and vaginal tissues for redness, edema, and excoriation. Palpate the inguinal lymph nodes to detect tenderness or enlargement, and palpate the abdomen for tenderness. A pelvic examination may be required. Obtain vaginal discharge specimens for testing.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Dysmenorrhea: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Pelvic examination and a detailed patient history may help suggest the cause of dysmenorrhea.

Primary dysmenorrhea is diagnosed when secondary causes are ruled out. Appropriate tests (such as laparoscopy, dilatation and curettage, and pelvic ultrasound) are used to diagnose underlying disorders in secondary dysmenorrhea.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Pelvic inflammatory disease: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnostic tests generally include:

❑ Gram stain of secretions from the endocervix or cul-de-sac. Culture and sensitivity testing aids selection of the appropriate antibiotic. Urethral and rectal secretions may also be cultured.

❑ Ultrasonography to identify an adnexal or uterine mass.

In addition, patient history is significant. In general, PID is associated with recent sexual intercourse, insertion of an intrauterine device, childbirth, abortion, or a sexually transmitted disease.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Dysmenorrhea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it’s bilateral. How long has she been experiencing it? When does the pain begin and end, and when is it severe? Does it radiate to the back? Explore associated signs and symptoms, such as nausea and vomiting, altered elimination habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.

Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe any vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have any signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk for sexually transmitted diseases.

Next, perform a focused physical examination. Take vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Vaginal discharge: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Also, ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Next, ask if she has had a vaginal discharge before or has ever been treated for a vaginal infection. What treatment did she receive? Did she complete the course of medication? Ask about her current use of medications, especially antibiotics, oral estrogens, and hormonal contraceptives.

Examine the external genitalia and note the character of the discharge. (See Identifying causes of vaginal discharge, page 792.)  Observe vulvar and vaginal tissues for redness, edema, and excoriation. Palpate the inguinal lymph nodes to detect tenderness or enlargement, and palpate the abdomen for tenderness. A pelvic examination may be required. Obtain vaginal discharge specimens for testing.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Dysmenorrhea: History (2)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. It is extremely important to distinguish primary from secondary dysmenorrhea.

B. Primary dysmenorrhea starts at the onset of menarche, and is thought to be the result of prostaglandin-2α, which produces uterine ischemia. It can be treated with antiprostaglandins and oral contraceptives.

C. Secondary dysmenorrhea starts later in a woman’s ovulatory life and may be caused by endometriosis or pelvic pathology.

D. If abnormal bleeding is associated with either type of dysmenorrhea, it is important to elicit symptoms of pregnancy, such as missed or late menses, breast tenderness, nausea, or urinary frequency (Chapter 11.5).

E. If severe pain develops during the first part of the menstrual cycle, ascertain the history of a new sexual partner, abnormal vaginal discharge, or dyspareunia. These symptoms could point toward pelvic inflammatory disease (PID) (Chapter 11.3).

F. Pain that develops during menses, but not related to pregnancy or infection, can also be caused by tumor. In younger women, secondary dysmenorrhea sufficiently severe to affect daily functioning or relationships suggests endometriosis. This condition can affect as many as 10% of women. Deep dyspareunia and sacral backache with menses are common symptoms. Premenstrual tenesmus or diarrhea correlates with endometriosis of the rectosigmoid area, whereas cyclic hematuria or dysuria may indicate bladder endometriosis.

G. Infertility is often a consequence of endometriosis.

Physical examination

As with all menstrual complaints, a thorough physical examination is an essential part of making a diagnosis.

A. The general condition of the patient needs to be assessed. Are the vital signs stable or is the patient showing signs of systemic illness such as fever, which can indicate pelvic infection. Hypotension and pallor can indicate a ruptured ectopic pregnancy.

B. A general physical assessment with attention to the back, sacrum, spine abdomen, and bladder is important.

 C. A thorough pelvic examination is key. The external genitalia may show signs of cyanosis, as is seen with pregnancy, or abnormal discharge, as is seen with infection. Palpate the vaginal area for nodules which may present on the anterior cul-de-sac or on the posterior vaginal fornix on bimanual examination; they could indicate endometriosis. Cervical motion tenderness and cervical leukorrhea may be present in PID. Uterine tenderness is often present and uterine displacement and fixation may be noted. Ovarian enlargement or adnexa fixation, which correlates with endometriosis or adnexal mass from neoplastic or infectious cause, may be found. Nodules may also be palpated along the uterosacral ligaments on rectovaginal examination.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Vaginal Discharge: History (2)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. What is the specific vaginal complaint? Is it soreness, discharge, odor, itching, or dyspareunia? Vaginal soreness correlates with vulvovaginal candidiasis, allergy, contact dermatitis, or atrophy. Yeast, BV, atrophy, and trauma produce significant dyspareunia.

 B. What is the characteristic of the discharge? Is the discharge heavy or light, thick or thin? Does it have an odor? Most women have some physiologic discharge that changes during the menstrual cycle with hormonal flux. BV and T. vaginitis produce malodorous discharge of variable amount. Yeast produces a thick discharge that usually has no odor.

C. What is the sexual history (3)? Is there a new sexual partner in the last year? How does the patient protect herself from sexually transmitted disease? In taking this part of the history, it is key to convey necessary information concerning sexually transmitted disease transmission, both to allay anxiety and to modify behavior, when appropriate.

 D. What is the menstrual history? Ask when was the last period? Are you pregnant? What is your method of contraception? Yeast often overgrows in the vagina premenstrually. Trichomoniasis and BV during pregnancy are associated with premature labor, premature delivery, and septic abortion. Yeast vaginitis is more common during pregnancy and when taking oral contraceptives.

 E. Are you taking any medications? Have you tried any medications for your vaginal problem?

Antibiotics, contraceptive preparations, hormones, vaginal medications, and other OCT preparations often alter the vaginal ecosystem and allow infection to be introduced or normal vaginal flora to become unbalanced. Foreign bodies (e.g., tampons, diaphragms, or condoms) can create vaginal irritations, inflammation, and infections.

 F. If the problem is vaginal irritation, have any substances been used that cause allergic reaction or chemical irritation? Do you douche?

These might include deodorant soaps, feminine hygiene sprays, scented douches, laundry detergent, bath oils, dyed toilet tissue, synthetic clothing, or hot tub or swimming pool chemicals.

At times, only elimination of all possible offending agents, skin testing, or both permit identification of the allergies or irritants.

G. If no obvious infectious, traumatic, or chemical agent is identified, could the vaginal complaint be related to a systemic illness [e.g., diabetes mellitus or human immunodeficiency virus (HIV) infection] or with a life change?

Idiopathic vulvovaginal ulceration can be associated with HIV disease.

Atrophic vaginitis secondary to hormone depletion can cause significant dyspareunia, swelling, and discharge. Collagen-vascular disease, pemphigus, and Bechêt’s syndrome can manifest in vaginal symptoms.

Physical examination (4)

A general physical examination should be performed if systemic illness is suspected. Record vital signs, including temperature, blood pressure, and pulse.

In most cases, a genital examination with the patient in the lithotomy position is adequate.

The external genitalia is carefully inspected for evidence of trauma, blisters, lymph nodes excoriations, swelling, erythema, ulcerations, tenderness or pain.

The amount, color, texture, odor, and location of the discharge should be noted. A complete pelvic examination should be performed with particular attention given to the cervix for evidence of friability or inflammation and a cervical motion test which may indicate pelvic inflammatory disease.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Chronic Pelvic Pain: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 As with any pain, the onset, duration, and pattern of the pain must be assessed. The location, intensity, character, and radiation are important historical elements. Aggravating or relieving factors are important, especially as they relate to the urinary, musculoskeletal, or gastrointestinal systems as well as the relationship of pain to sexual activity or menstruation. Systemic symptoms such as fatigue and anorexia are often present. A medication history (e.g., use of birth control pills or over-the-counter medications) should be obtained. The past obstetric, gynecologic, and general surgical histories are extremely important.

It should be noted that women with a history of pelvic inflammatory disease are four times more likely to develop chronic pelvic pain. The list of possibilities for the condition is substantial. A person with intestinal, sexual, urinary, musculoskeletal, and systemic symptoms may be suffering from a psychiatric disorder (e.g., depression) and an acknowledged or remote history of sexual abuse. Often this information is possible to obtain only when the provider creates an atmosphere of mutual respect and trust.

Dyspareunia is often present. Cyclic pain that is related to menstruation usually points to a gynecologic problem. Pain referred to the anterior thigh, pain associated with irregular uterine bleeding, or new onset dysmenorrhea may have a uterine or ovarian cause. Urethral tenderness, dysuria, or bladder pain suggests interstial cystitis or a urethral problem (Chapter 10.1). Pain on defecation, melana, bloody stools, or abdominal pain with alternating diarrhea and constipation can point toward pelvic floor problems, irritable bowel syndrome, or inflammatory bowel diseases.

Physical examination

 A. The general condition of the patient should be noted. Does the patient look chronically ill, which may suggest a pelvic lesion or an inflammatory bowel disorder? Does the patient appear anxious, stressed, or inappropriate?

 1. Can the patient point to the pain with one finger? If so, this can indicate that the pain may have a discrete source.

2. An examination of the lower back, sacral area, and coccyx, including a neuologic examination of the lower extremities, is necessary. Herniated disc, exaggerated lumbar lordosis, and spondylolisthesis can all cause pelvic pain.

 3. Examine the abdomen, looking for surgical scars, distension, and palpable tenderness, particularly in the epigastrium, flank, back, or bladder.

 B. A thorough pelvic examination is the most important part of the evaluation.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Abdominal/Pelvic Mass: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal Mass

❑ Liver enlargement

❑ Spleen enlargement

❑ Fecal mass

❑ Diverticulitis

❑ Colon cancer

❑ Gallbladder enlargement

❑ Pancreatic pseudocyst

❑ Crohn disease

❑ Abdominal aortic aneurysm

❑ Renal enlargement

Pelvic Mass

❑ Distended bladder

❑ Pregnant uterus

❑ Salpingitis

❑ Ovarian cyst

❑ Uterine fibromyoma

❑ Ovarian cancer

❑ Endometrial cancer

❑ Ectopic pregnancy

❑ Malignant deposit

Diagnostic Approach

Consider the structures in the region of the mass for clues to its origin and the presence of tenderness as an indicator of inflammation/infection. It is possible to miss initially even a relatively large mass unless a systematic four-quadrant examination is performed.

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Source: Field Guide to Bedside Diagnosis, 2007

Vaginal Discharge: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Physiologic discharge

❑ Candida vulvovaginitis

❑ Bacterial vaginosis

❑ Trichomonas vaginitis

❑ Atrophic vaginitis

❑ Irritant dermatitis

❑ Gonorrheal cervicitis

❑ Chlamydial cervicitis

❑ Herpes simplex

❑ Cervical cancer

Diagnostic Approach

Symptoms of vaginitis include vaginal discharge, pruritis, irritation, soreness, odor, and less commonly bleeding, dysuria, or pain with intercourse. It is important to distinguish burning on urination due to cystitis, which is internal and accompanied by irritative signs (urinary frequency), from dysuria due to vaginitis, which feels external as the urine passes over an inflamed vulva. Similarly, it is important to distinguish vaginitis, characterized by discharge and pruritus, from cervicitis, with discharge and pelvic pain.

On examination, the vulva appears normal in bacterial vaginosis, while erythema, edema or fissures suggest candidiasis, trichomonas or dermatitis. An erythematous, friable cervix with a mucopurulent discharge is consistent with cervicitis rather than vaginitis. This must be distinguished from ectropion (normal endocervical glandular tissue visible on the exocervix), which is not friable.

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Source: Field Guide to Bedside Diagnosis, 2007

Pelvic inflammatory disease: Diagnosis
(Handbook of Diseases)

Tests commonly used to diagnosis PID include:

❑ Gram stain of secretions from the endocervix or cul-de-sac; culture and sensitivity testing aids selection of the appropriate antibiotic. Urethral and rectal secretions may also be cultured.

❑ ultrasonography or computed tomography scanning to identify an adnexal or uterine mass. (X-rays seldom identify pelvic masses.)

❑ culdocentesis to obtain peritoneal fluid or pus for culture and sensitivity testing.

The patient’s history is also significant because PID is commonly associated with recent sexual intercourse, IUD insertion, childbirth, or abortion.

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Source: Handbook of Diseases, 2003

Vaginal discharge: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Also, ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Next, ask if she has had vaginal discharge before or has ever been treated for a vaginal infection. What treatment did she receive? Did she complete the course of medication? Ask about her current use of medications, especially antibiotics, oral estrogens, and contraceptives.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Vaginal Discharge: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Prepubertal Onset

Physiologic Leukorrhea

Maternalestrogen passes across placenta and stimulates hypertrophy of glycogen-containingvaginal squamous epithelial cells in the fetus.

Decrease in serum estrogen after birthleads to shedding of these cells and production of whitish vaginaldischarge that may persist for a few weeks.

Some neonates also may have associatedwithdrawal bleeding secondary to decreased estrogen stimulationof the endometrium.

Vulvovaginitis

Nonspecific Causes

Most commoncause of vaginal discharge in prepubertal girls is nonspecific vaginitis, whichis usually due to poor perineal hygiene and contamination with mixedbowel flora.

Chemical irritants (e.g., bubble bathpreparations, shampoos, and harsh soaps) also may cause vaginitis.

Dysuria is sometimes associated finding.

Specific Infections

Some neonatesacquire T. vaginalis during passage through birth canal, and whitish oryellowish vaginal discharge may persist beyond neonatal period.Seeing motile flagellated organism on wet mount (saline) confirmsdiagnosis.

Infection with Candida species mayproduce whitish or yellowish discharge and vulvar inflammation.Risk factors include diabetes mellitus, use of broad-spectrum antibiotics,and immunodeficiency disorders. KOH preparation or culture of dischargeis diagnostic.

Group A Streptococcus, S. aureus, H.influenzae, S. pneumoniae, and Shigella species may produce foul-smellingvaginal discharge. Diarrhea usually occurs with Shigella vaginitis,and in some cases vaginal discharge contains blood. Positive vaginalculture is diagnostic.

E. vermicularis (pinworm) producesintense anal itching, particularly at night when worms move ontoperianal skin. Persistent scratching may produce secondary vulvovaginitis.Seeing white, threadlike worms, which are about 1 cm in length,or identifying eggs under microscope from cellophane tape preparationis diagnostic.

In prepubertal females, infection withT. vaginalis, herpes simplex virus, N. gonorrhoeae, or C. trachomatisimplies sexual abuse until proven otherwise. Infections with thesepathogens are discussed in sections Pubertal and Postpubertal Onset: Vulvovaginitis,and Cervicitis.

Foreign Body

Foreignbody in vagina causes foul-smelling discharge, which is often associated withpain or bleeding.

Toilet paper, pins, beads, and pencilerasers are some of the objects that may be found.

History and physical exam are usuallydiagnostic.

Radiography of pelvis is useful, especiallyif foreign body is radiopaque. Exam under anesthesia may be necessaryin some cases.

Pubertal and Postpubertal Onset

Physiologic Leukorrhea

Most commoncause of vaginal discharge in pubescent girls.

Cyclic ovarian activity with increasedestrogen secretion produces glycogen-containing vaginal epithelium.Desquamated vaginal cells and mucus produce whitish discharge thatusually starts before menarche and may continue for several years.

Wet preparation shows epithelial cellswith no evidence of inflammation.

Vulvovaginitis

Nonspecific Causes

Contributing factors to nonspecific vulvovaginitisinclude poor hygiene, obesity, chemical irritants, and tight-fittingnylon underpants.

Specific Infections

Primary causes of vaginitis in adolescentsare bacterial vaginosis, Candida species, T. vaginalis, and herpessimplex virus. Because of changes in vaginal epithelium and colonizingflora in puberty, vagina is more resistant to infections causedby N. gonorrhoeae and C. trachomatis. In adolescents these 2 pathogenscause cervicitis rather than vaginitis.

Bacterial Vaginosis

Presenceof vaginal Gardnerella and Mobiluncus species does not necessarilysignify a sexually transmitted disease because these bacteria alsocan occur in sexually inactive girls.

Presence of thin, white, homogenousdischarge; characteristic fishy odor when 1–2 drops of 10% KOHare added to specimen of vaginal discharge; neutral or alkalinevaginal pH; and appearance of small refractile bacteria coatingvaginal epithelial cells (clue cells) on saline wet mount or Gramstain confirm diagnosis.

Candida Species

Infectionwith Candida species produces thick, cheesy pruritic discharge.

Positive KOH preparation demonstratingyeast cells and mycelia or positive vaginal culture is diagnostic.

Trichomonas vaginalis

Infectionwith T. vaginalis usually produces frothy, pale yellow to gray-greendischarge with musty odor.

Although pathogen can survive on fomitevectors (damp clothes, towels), usual source of infection is throughdirect sexual contact.

Presence of motile flagellated organismson wet mount is diagnostic. If wet mount is negative, positive cultureor polymerase chain reaction test confirms diagnosis.

Herpes Simplex Virus

Infectionwith herpes simplex virus 1 (HSV-1) or HSV-2 may produce small painful vesiclesand ulcers on vulva, vagina, or cervix. Vaginal discharge, fever,and inguinal adenopathy also may occur.

Herpetic infections can present asprimary genital infections or as recurrent episodes, especiallywith HSV-2.

Fluorescent antibody staining of vesiclescrapings or positive culture from lesion confirms diagnosis.

Cervicitis

Is an inflammationof the ectocervix, endocervix, or both. T. vaginalis, Candida species,and herpes simplex virus can cause ectocervicitis, whereas C. trachomatisand N. gonorrhoeae are most common pathogens causing endocervicitis.

Typical clinical findings of cervicitisare mucopurulent discharge and inflamed cervix.

Chlamydia trachomatis

Infectionis almost always acquired through sexual contact. It is most prevalentbacterial sexually transmitted disease in U.S. and frequently accompaniesgonococcal genital infections.

Can be asymptomatic or produce mildcervical discharge. Associated findings include dysuria and urinaryfrequency.

Positive endocervical culture or identificationby nucleic acid amplification tests is diagnostic.

Neisseria gonorrhoeae

Transmissionoccurs by direct sexual contact.

Cervix is inflamed and tender and vaginaldischarge is thick creamy yellow.

Positive endocervical culture or identificationby nucleic acid amplification tests is diagnostic.

Pelvic Inflammatory Disease

Is an infectionwith spread of organisms from vagina or cervix to endometrium (endometritis),fallopian tubes (salpingitis, tubal abscess), pelvic peritoneum(pelvic peritonitis), or contiguous structures (oophoritis, tuboovarianabscess).

N. gonorrhoeae, C. trachomatis, andendogenous flora of lower genital tract including anaerobic bacteria(Bacteroides, Peptostreptococcus, Clostridium, and Actinomyces species)and facultative bacteria (E. coli, H. influenzae, Streptococcusspecies) are frequent pathogens.

Cervical and vaginal discharge, lowerabdominal pain, cervical motion tenderness, adnexal tenderness,vomiting, and fever are common findings.

Cervical culture for C. trachomatis,N. gonorrhoeae, and other aerobic and anaerobic bacteria shouldbe performed. Laparoscopy may be required to provide definitivediagnosis in equivocal cases.

Foreign Body

In adolescents,most common foreign body is retained tampon.

Discharge is foul smelling and oftenblood streaked.

Foreign body can usually be visualizedby speculum exam.

Diagnostic Approach

Nonspecificvulvovaginitis is most common cause of vaginal discharge in prepubertal girls.If discharge fails to improve with good perineal hygiene or if itis purulent, specific bacterial infection, sexually transmittedinfection, or foreign body should be suspected. Wet mounts (salineand KOH), Gram stain, and vaginal cultures should be performed.Exam under anesthesia may be necessary for suspected foreign body.

In pubertal girls who are not sexuallyactive, most common causes of vaginal discharge are physiologicleukorrhea, bacterial vaginosis, and C. albicans. Wet preparations(saline and KOH) and Gram stain should be performed. Bacterial andfungal cultures also should be considered.

In girls who are sexually active, thesame diagnoses described for pubertal nonsexually active femalesare possible, but sexually transmitted infections also are likely.In addition to wet preparations and Gram stain, cultures for C.trachomatis, N. gonorrhoeae, and other aerobic and anaerobic bacteria shouldbe performed. In some centers nucleic acid amplification technologyis available for detection of C. trachomatis and N. gonorrhoeaefrom endocervical and urine specimens. Laparoscopy may provide definitivediagnosis in suspected pelvic inflammatory disease with negativecervical cultures.

If sexual abuse is suspected at anyage, vaginal, rectal, and throat cultures for N. gonorrhoeae andvaginal and rectal cultures for C. trachomatis should be performed,even in an asymptomatic child. HIV testing should be considered.So should pregnancy prophylaxis, which depends on whether menarche hasbeen reached and on nature of abuse.

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Dysmenorrhea: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it's bilateral. When does the pain begin and end, and when is it severe? Does it radiate to the back? How long has she been experiencing the pain? If it's a recent complaint, obtain a human chorionic gonadotropin level to determine if the patient is or was pregnant, because miscarriage can cause painful bleeding. Explore associated signs and symptoms, such as nausea and vomiting, altered bowel or urinary habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.

Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk of sexually transmitted diseases.

Next, perform a focused physical examination. Take the patient's vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Vaginal discharge: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Ask if she has had vaginal discharge before or has ever been treated for a vaginal infection or sexually transmitted disease. What treatment did she receive? Did she complete the course of medication and were all sexual contacts treated? Ask about her current use of medications, especially antibiotics, oral estrogens, and hormonal contraceptives.

Examine the external genitalia and note the character of the discharge. (See Identifying causes of vaginal discharge.) Observe vulvar and vaginal tissues for redness, edema, and excoriation. Palpate the inguinal lymph nodes to detect tenderness or enlargement, and palpate the abdomen for tenderness. A pelvic examination may be required. Obtain vaginal discharge specimens for testing.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

DYSMENORRHEA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The clinical approach to dysmenorrhea is simply to rule out significant organic disease by a thorough pelvic and rectal examination. A smear and culture for gonococcus and Chlamydia should be done. A course of contraceptives or progesterone in adequate doses may then be tried. Diuretics may be indicated if examination suggests pelvic congestion. When the aforementioned measures fail, a dilatation and curettage (D & C) may be indicated. A gynecologist may decide to do a culdoscopy, a peritoneoscopy, or an exploratory laparotomy.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

PELVIC PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

A good pelvic and rectal examination is essential. These will often disclose a mass or other pathology to explain the pain. If there is a vaginal discharge, a smear and culture for gonococcus and Chlamydia need to be done. A pregnancy test will help rule out an ectopic pregnancy, but ultrasonography is most useful. A gynecology consult should be obtained when there is any doubt. In acute cases, the gynecologist may proceed with an exploratory laparotomy immediately.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

VAGINAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

To workup a vaginal discharge, simply examining a fresh wet saline and KOH (10%) preparation will expose the most common offenders, namely Trichomonas and Candida. Some physicians treat all patients with negative findings on these examinations as a nonspecific bacterial vaginitis, but this is not a particularly scientific procedure. It is best to do a smear and culture (especially for gonococci). Cultures are also available for Trichomonas and Candida. If gonorrhea is suspected, material from the endocervix should be cultured. Chlamydia cultures are routinely done in some clinics. Obviously, if the cervix is eroded and the discharge seems to be coming from there, biopsy and conization may be indicated. Referral to a gynecologist is preferred if this procedure is deemed necessary; however, the primary physician may prefer to cauterize the superficial lesions. Patients with discharges thought to be due to lesions beyond the cervix should probably be referred.

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Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Pelvic Inflammatory Disease

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