Green or yellow (purulent) discharge | Burning | Dyspareunia
Exam including inspection of the vulva, vagina and cervix
Inflammation not usually present
Erythema | Edema
Inflammation | Strawberry Cervix
Inflammation | Thin/friable mucosa
Desquamative Inflammatory vaginitis (DIV)
Varying vestibular and vaginal erythema
Appropriate laboratory testing
Collection of and microscopic examination of a 10% KOH and saline prep (wet mount), pH testing and ‘whiff test’ constitute the office-based clinical testing of samples
Culture (if necessary)
Yeast: Obtain if recurrent candidiasis or possible non-albicans Candida (suspect if blastospores ‘only’ or persistent treatment after treatment) | Negative microscopy with signs and/or symptoms of candidiasis
Trichomoniasis:ACOG recommends culture with a negative wet mount in the following circumstances
Persistent symptoms following treatment | high vaginal pH and WBCs on microscopy | Pap suspicious for T. vaginalis | patient desire for screening
Note:CDC considers NAAT screening more sensitive for T. vaginalis then culture (previous gold standard) or wet mount
Mucopurulent cervicitis: Test (DNA or cultures) for gonorrhea or chlamydia
HSV: If any vulvar fissure/lesion suggestive of herpes simplex virus, perform viral culture or PCR assay for HSV DNA by swabbing the lesion
Type-specific HSV serologic assays might be useful in the following scenarios: 1) recurrent genital symptoms or atypical symptoms with negative HSV PCR or culture; 2) clinical diagnosis of genital herpes without laboratory confirmation (CDCSTD Guidelines)
Perform “whiff test” with 10% KOH, and microscopy with saline
Positive whiff test
Negative (-) for WBC: Treat for bacterial vaginosis (BV)
Positive (+) for WBC: Review signs/symptoms for trichomoniasis or mixed bacterial vaginosis or cervicitis
Vaginitis is a general term for disorders of the vagina, but does not indicate the underlying cause. Vaginitis may result from infection, inflammation, or may reflect changes in the normal vaginal microbiome. The disorder is termed vulvovaginosis when the vulva is involved. When patients present with symptoms of itching/burning/irritation/dyspareunia/discharge consider a broad range of possibilities including but not limited to the triad of bacterial vaginosis (BV), trichomoniasis and vulvovaginal candidiasis. Office based tests such as those above also have a low sensitivity. Accurate diagnosis may require a combination of a careful history, vulvar or vaginal biopsy and appropriate culture.
Self-diagnosis and treatment, while convenient, may be unreliable and results in frequent misuse of OTC products
FDA approved commercial tests for BV
ACOG acknowledges that direct DNA probe assays for G vaginalis or chromogenic point-of-care assays for sialidase activity have acceptable performance vs Amsel criteria and Nugent scoring
However, because these tests only pick up one organism (i.e., G vaginalis) “the diagnostic utility of a test that identifies only a single organism (eg G vaginalis) is still being investigated and is not currently supported”
Vaginal pH testing narrows the differential diagnosis of vaginitis for BV and trichomoniasis
Candidiasis: History | Exam | Culture
Obtain vaginal secretions slide for future Gram stain if possible
Incidental findings on Pap test
BV on Pap
Symptomatic: pH, amine test, and wet mount
Asymptomatic: Do not treat
Trichomoniasis on Pap
High false-positive rate (8% standard and 4% liquid-based)
Wet mount for confirmation
If wet mount negative, NAAT or culture
If diagnostic tests not available, can consider metronidazole, but high rate of unnecessary treatment
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