Vaginal Discharge
Albert A. Meyer
Vaginal symptoms, especially discharge, are responsible for 10% of all physician visits by women. Each year, approximately 12 million women in the United States are treated for vaginitis (1).
Approach
An irritation or inflammation of the vagina with or without discharge occurs in all age groups and has a variety of causes. Of vaginitis, 90% occurs in women of reproductive age; it is caused by one of three types of infections: an overgrowth of yeast, usually Candida albicans; sexually transmitted Trichomonas vaginitis; or an excessive growth of anerobic microorganisms [bacterial vaginosis (BV)].
Many women with a vaginal complaint, itching, soreness, dysuria, or discharge, self-medicate with over-the-counter (OTC) preparations before seeking medical attention. Because many OTC preparations help symptomatically, the diagnosis can be clouded. The OTC products should be avoided for 3 days prior to the office visit.
A key element in the evaluation of a woman with a vaginal complaint is the awareness that many factors other than the three aforementioned infections can cause vaginitis. These include medications, repeated douching, foreign bodies, systemic illness, and sexually transmitted disease.
History (2)
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.
Testing (5)
A. Vaginal fluid pH. Immersing pH paper in the vaginal discharge or the lateral wall of the vagina will give the vaginal pH.
A pH greater than 4.5 indicates BV or T. vaginalis.
B. Saline wet mount. Obtain a drop of vaginal discharge from the posterior fornix; place it on a slide with a drop of saline and apply a cover slip.
1. Clue cells, which are bacteria-coated, stippled epithelial cells, are characteristic of BV.
2. Trichomonads, which are mobile, oval flagellated parasites, confirm the presence of trichomoniasis.
C. Potassium hydroxide (KOH) preparation. Place a second drop of vaginal secretions on a slide containing a drop of KOH; “a positive whiff test” indicates the presence of BV. Threadlike hyphae and budding yeast observed microscopically are characteristic of a candidal infection.
D. Cultures for gonorrhea and chlamydia are not routinely indicated, but should be taken with a history of a new sexual partner, prurulent cervical discharge, or cervical motion tenderness.
Diagnostic assessment
BV causes 40% to 50% of vaginitis, followed by candidiasis (20% to 25%) and trichomoniasis (15% to 20%). Together, these infections account for more than 90% of vaginitis diagnoses.
When evaluating a woman with a vaginal complaint, be sure to hear her true concern. Evaluate and treat appropriately those with acute symptoms (e.g., pain or swelling) and be careful to understand the effect of pretreatment with OTC preparations in the presumptive diagnosis. It is wise to be mindful of the possibility of sexually transmitted diseases with any vaginal complaint and to test appropriately for these diseases. If a vaginitis, presumably infectious, does not respond to initial therapy, consider other causes including trauma, herpes, menopause, contact dermatitis, toxic shock syndrome, steroid-responsive inflammatory vaginitis, and collagen-vascular or other systemic disease.
References
1. Lash DJ, Garcia TA. Diagnosis and treatment of vaginitis. The Female Patient 1998;23:25–41.
2. Carr PL, Majeroni BA, Robinson JC, Talarico LD. Vaginitis: solid diagnosis means effective treatment. Patient Care 1999;33(2):86–106.
3. Miller KE. Sexually transmitted diseases. Prim Care 1997;24(1):179–193.
4. Chan PD, Winkle CR, eds. Gynecology and obstetrics’ 1999–2000 edition. Laguna Hills, CA: Current Clinical Strategies Publishers, 1999:73–79.
5. Sabel JD. Vaginitis. N Engl J Med 1997;337:1896–1903.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Vaginal symptoms
» Next page: Vaginal Discharge (Field Guide to Bedside Diagnosis)
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