Running Head: DIFFERENTIAL DIAGNOSIS – VAGINAL DISCHARGE
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Differential Diagnosis Associated with the Chief Complaint of Vaginal Discharge
Presented to
Dr. Cheryl Juneau
________________________________________
In Partial Fulfillment
Of the Requirements for the Course
GNRS 5669 FNP Adult/Women’s Health
February 18, 2013
________________________________________
By Kaci Burton and Penny Garner
__________________________________________
THE UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON
SCHOOL OF NURSING
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Differential Diagnoses Associated with the Chief Complaint of Vaginal Discharge
The purpose of this paper is to present a patient with the chief complaint of
vaginal discharge. Based on the patient’s presentation, 5 differential diagnoses were
developed: bacterial vaginosis, vaginal candidiasis, allergic vaginitis, gonorrhea, and
chlamydia. These were narrowed down after reviewing the patient’s history and
physical examination that are described in detail later. The 3 most likely diagnoses are
bacterial vaginosis, vaginal candidiasis, and allergic vaginitis.
Subjective
L. B. is a 35 year-old white female that presents to the clinic with the complaint of
vaginal discharge. She has been experiencing vaginal discharge for approximately 2-3
weeks. She explains that the vaginal discharge has been continuous throughout the
day and night. She states that the discharge has remained consistent in quality and
quantity throughout the 2-3 weeks and has a slight odor associated with it. She
describes the discharge as a slight to moderate in quantity, thin, white, and mucous-like.
The physical presentation regarding the vaginal discharge among the differentials are
quite different. During the history taking a patient will describe the vaginal discharge as
thin, white to gray in color, and malodorous with bacterial vaginosis, candidiasis is thick
and curd-like, and allergic vaginitis is expected to be excessive and malodorous
(Johnson, Thomas, & Porter, 2011). L.B. states that she first noticed the odor and
discharge after having sex with her husband, and has not been sexually active since.
She also admits to douching, as she always does, following her menstrual cycle 3
weeks ago. She denies using any new products for douching, such as perfumes or
cleansers. An increase in odor following intercourse is indicative of bacterial vaginosis.
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Vaginal candidiasis and allergic vaginitis have no particular association with intercourse,
except they may cause dyspareunia. Douching may lead to bacterial vaginosis,
whereas douching with new fragrances or cleansers may cause allergic vaginitis
(Hensley & Hollier, 2011). She has tried Monistat 1 day treatment 1 week ago without
improvement or resolution. L.B. states that it is not affecting her work or normal daily
activity, but it is affecting her sex life. She states that she is embarrassed and does not
want to tell her husband what is going on until she finds out what the problem is.
L.B. states that she is in generally good health and denies any significant medical
history. She denies any surgeries, blood transfusions, serious accidents or injuries, or
major illness. She reports that her only hospitalizations were for her 2 vaginal deliveries
that were normal and without complications. She has no allergies to medications and
currently takes a women’s multivitamin daily. She states that her vaccinations are up to
date and has not received the influenza vaccine this season. She denies smoking or
recreational drug use, but admits to drinking 2-3 glasses of wine per week and
consuming 2 cups of coffee every morning before work. Her last complete physical
exam was at her well-women 9 months ago, but her primary care physician saw her 4-5
months ago for a “cold”. Her last PAP was 9 months ago and has no history of any
abnormal results. She has not yet started getting mammograms, but she does do selfbreast exams when she thinks about it. L.B. states that she does not use any type of
birth control method since her husband had a vasectomy 4 years ago. The introduction
of condoms, spermicide, or lubricants leads to allergic vaginitis resulting in inflammation
and edema (Dains, Baumann, & Sheibel, 2012). She is the primary cook in the home
and tries to prepare well-balanced meals, but states she eats worse at work. She walks
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in her neighborhood approximately 3-4 days per week for 30-45 minutes with her
husband and children.
L.B. has been married for 10 years and lives in a single-story home with her
husband and 2 children. She has a son that is 9 years old and a daughter that is 5
years old. She works in the human resource department at Sam’s Club. She does not
express any excess stress, economic concerns or religious considerations that may
affect her care.
L.B. describes her family as being in generally good health. On her maternal
side she has a grandmother with hypertension (HTN) and depression, an aunt with
infertility issues (unknown specifics), and her mother suffers with depression and
restless leg syndrome. On her paternal side she only knows that her father has HTN
and chronic back pain.
The patient’s view and impression on her condition was reviewed by utilizing the
patient explanatory model. L.B. expresses general concern and embarrassment about
her current condition. She explains, “I thought it was a yeast infection because I get
those every now and then. I went to Walgreens and bought some Monistat and when it
did not help my problem I became worried. I don’t think it’s an STD, because my
husband and I are faithful to each other, but I have no idea what it could be. I just want
the discharge to be cleared up because it is embarrassing”.
L.B. describes herself as being in generally good health with no recent major
illnesses or need for antibacterial therapy. She has not had any weight loss or gain in
over a year. She reports her diet as regular with no specific restrictions. L.B denies any
skin lesions, masses, lumps, or nodules. She also denies any swelling or tenderness of
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the lymph nodes. She denies any head or neck pain as well as denies oral lesions or
pain in the mouth. L.B. denies ever having any chest pain, palpitations, or swelling in
the extremities. She states she never experiences shortness of breath or has any
unusual cough. L.B. reports no abdominal pain. She describes her gynecological history
as having two normal, uncomplicated vaginal deliveries, she douches after every
menstrual cycle, and her last menstrual cycle was three weeks ago. L.B. confirms a
malodorous vaginal discharge for approximately 2-3 weeks of thin, white, mucous-like
consistency in minimal to moderate amounts. She denies any burning, painful, frequent,
or malodorous urination. She also denies and pruritus in the vaginal area. She
describes her mental state as “somewhat depressed about this discharge.”
Objective
L.B. can be described as an alert, oriented, well-dressed, well-nourished middleaged white female in no acute distress. Her expression is that of nervousness and
seems genuinely concerned about the reason for her office visit. Her left arm blood
pressure is 118/62 with a regular radial heart rate of 72. Her respirations are 18 and is
afebrile with an oral temperature of 97.2 degrees F. She is 5’ 8” tall and weighs 130
pounds which is equivalent to a body mass index of 19.8 kg/m2. L.B.’s skin is warm
and dry with no rashes, lesions, or skin breakdown present. Her head is normocephalic
with no lesions present. Her neck is supple with trachea midline. No lymph node
swelling or tenderness noted on palpation. The thyroid gland is supple without
enlargement, nodules or bruit. L.B.’s heart has normal S1, S2 with no murmurs, rubs, or
gallops. The capillary refill on L.B. is <3 seconds. The patient’s respirations are even
and unlabored with symmetrical chest expansion. Her lungs are clear to auscultation in
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all lobes anteriorly and posteriorly. L.B has a symmetrical abdomen that is soft, round,
and nontender on palpation without masses or organomegaly. Her bowel sounds are
active over all quadrants. Upon inspection, the patient’s external genitalia is normal in
appearance. There is mild irritation and redness noted around the vulva without lesions.
An inspection of the folds of the labia majora, labia minora, and urethra reveal no
redness or lesions. The Bartholin and Skene glands are not palpable. Upon speculum
exam of the vagina there is noted a moderate amount of thin, grey-white discharge that
is mildly adherent to the vaginal walls with a fishy odor. No mucopurulent or curd-like
discharge noted. The cervix is pink and closed with no lesions visible and no cervical
motion tenderness. The perianal area is normal with no lesions noted. Her uterus is
palpable on bimanual exam and is small and soft with no adnexal or cervical motion
tenderness (CMT) noted. Ovaries are not palpable.
No symptoms alone or findings on physical examination are very conclusive for
vaginal infections, therefore microscopy is most beneficial in definitively diagnosing
these infections when classic findings are present (Domino, 2012). In suspicion of
bacterial vaginosis vs. vaginal candidiasis vs. allergic vaginitis it is decided during the
speculum exam of the vagina to take a swab sample of the discharge from the lateral
fornices in order to prepare several wet mounts for microscopic exam. Two glass slides
are prepared with a smear of the vaginal discharge applied, one using 10% potassium
hydroxide (KOH) and the other using normal saline (NaCl or NS). The whiff test is
positive to the KOH slide and the microscope exam reveals no budding hyphae. It is
only in BV that the whiff test will be positive and only in vaginal candidiasis will there be
budding hyphae present (Dains et al, 2012). This KOH slide does not rule out allergic
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vaginitis. The NS wet mount is viewed under the microscope next and is positive for
clue cells, and few lactobacilli. No WBC’s are seen on this slide. This finding on the NS
wet mount is consistent in BV. This slide rules out allergic vaginitis as you would see the
presence of WBC’s on a NS wet mount (Dains et al, 2012). The vaginal discharge is
then applied to pH paper with a reading of 5.2. This test rules out both vaginal
candidiasis and allergic vaginitis because only in BV is the pH > 4.5 (Dains et al, 2012).
Assessment
1. Bacterial Vaginosis
The medical diagnosis for L.B. is bacterial vaginosis. Bacterial vaginosis (BV) is
the most common cause of vaginal discharge and most commonly found in reproductive
age women (Dains et al, 2012). BV is a disturbance of the normal flora in the vagina
caused when hydrogen peroxide producing lactobacilli are replaced by other bacteria,
usually anaerobes. BV is characterized by a thin white, grey, green, or brownish
discharge that is malodorous and moderately adherent to the vaginal wall. Pelvic
tenderness may be present, but no CMT. Fifty percent of women are asymptomatic, but
most exhibit a musty or fishy vaginal odor, commonly immediately after intercourse. The
most clinically significant diagnostic test for BV is the presence of clue cells on a NS wet
mount. The Amsel criteria for the diagnosis of BV requires that 3 out of 4 indicators be
present: presence of clue cells on a NS wet mount, presence of characteristic vaginal
discharge, pH > 4.5, and a positive whiff test. (Domino, 2012).
L.B.’s presentation confirms the medical diagnosis of BV because of her
characteristic vaginal discharge as that of thin, white and having an odor noticed after
having intercourse with her husband. Upon speculum exam of the vagina it is noted the
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discharge is moderately adherent to the vaginal walls. Upon bimanual exam there is no
CMT noted. Diagnostic tests confirm BV as the medical diagnosis due to the presence
of clue cells and WBC’s on microscopic exam of the vaginal discharge. L.B. has 4 of 4
indicators required in the Amsel clinical criteria to confirm the diagnosis of BV.
2. Vaginal candidiasis
Vaginal candidiasis occurs when an alteration in the balance of microorganisms
in the vagina allow for growth of yeast. The most common organism is candida albicans.
This condition accounts for 33% of all vaginal infections and occurs most commonly in
women from menarche to menopause. Risk factors for this infection include recent
antibiotic use, an immunocompromised state, hypothyroidism, diabetes, anemia, use of
oral contraceptives, wearing tight fitting clothing, previous candidal infection, and
obesity. The patient presentation will include a vaginal discharge that is thick, white,
curd-like and may have white patches on the vaginal mucosa. The discharge does not
have an odor. She will likely be experiencing vulvar itching, erythema, dyspareunia, and
dysuria. The presence of budding yeast and pseudohyphae on a KOH wet mount and a
vaginal pH of < 4.5 would also confirm the diagnosis of vaginal candidiasis. (Hensley &
Hollier, 2011).
The diagnosis of vaginal candidiasis is ruled out because L.B.’s discharge is not
characteristic of thick and curd-like and it has an odor. She denies complaints of vaginal
itching, dyspareunia and dysuria. The KOH wet mount prepared with L.B.’s vaginal
discharge did not have any budding yeast or pseudohyphae and the pH of her vaginal
secretions was > 4.5.
3. Allergic Vaginitis
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A substance that comes into direct contact with the vulvovaginal area is generally
the cause of allergic vaginitis. The causative allergen is usually something that has
been introduced recently such as vaginal lubricants, douches, spermicides, and or
condoms. These particular substances may cause irritation, inflammation, and edema
in some cases, which leads to the allergic vaginitis (Dains et al, 2012). The patient may
present with a malodorous excessive vaginal discharge, pruritus, and dysuria (Johnson,
Thomas, & Porter, 2011). This diagnosis was considered a possibility based on the
patient’s presentation and feminine hygiene practices. L.B. complained of an odorous
vaginal discharge that she subsequently noticed after intercourse with her husband.
Around the same time she had just finished her menstrual cycle and douches
afterwards.
The diagnosis of allergic vaginitis was ultimately ruled out because L.B. did not
have dysuria and denied douching with a new cleaning solution. In addition to the lack
of new allergen exposure, the patient also had no erythema or edema noted on external
inspection or speculum exam. Lastly, the bedside pH strip testing revealed a vaginal
pH greater than 4.5, unlike allergic vaginitis, which causes a more acidic environment
with a pH less than 4.5 (Dains et al, 2012).
Plan
The diagnostic labs indicated for the chief complaint and presentation of vaginal
discharge by L.B. are the wet mount and pH strip. Both of these tests were performed in
the office during L.B.’s visit. Vaginal cultures were considered, but decided not
necessary because both the wet mounts and pH strip were conclusive for the diagnosis
of BV. See Appendix A for further information on the diagnostic lab results. No further
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diagnostics are indicated at this time. First line treatment for BV is Metronidazole
vaginal gel: 0.75% 5 grams intravaginally daily x 7 days (Domino, 2012). The
prescription for Metronidazole was written for L.B. for 7 doses with no refills. Education
was provided to L.B. which included all of the following: Metronidazole produces a
disulfiramlike effect when alcohol is ingested. A disulfiramlike effect is characterized by
severe flushing and may include tachycardia and hypotension. Avoid any alcoholcontaining product while taking metronidazole. Avoid use of panty liners, pantyhose,
and occlusive pants and undergarments. Avoid douching to prevent recurrence. Delay
sexual relations until symptoms clear, discomfort resolves, and treatment is complete
(Domino, 2012). Informed patient of the websites ACOG.org and CDC.gov and that she
may find additional helpful information here to educate herself. There is no indication
for a referral based on L.B.’s presentation and diagnosis. L.B. was informed that no
specific follow-up is needed, but if symptoms persist or recur within 2 months, to make
another appointment for a repeat pelvic exam and possible vaginal cultures. L.B.
verbalized complete understanding of all instructions given.
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References
Dains, J., Baumann, L., & Scheibel, P. (2012). Advanced health assessment and
clinical diagnosis in primary care. St. Louis: Elsevier Mosby.
Domino, F.J. (2012). The 5-minute clinical consultant (20th ed.). Philadelphia, PA:
Lippincott Williams & Wilkins.
Hensley, R. & Hollier, A. (2011). Clinical guidelines in primary care: A reference and
review book. Lafayette: Advanced Practice Education Associates, Inc.
Johnson, J., Thomas, D., & Oscar, B. (2011). Women’s health problems. In L.M.
Dunphy, J.E. Winland-Brown, B.O. Porter, & D.J. Thomas (Eds.), Primary care:
The art and science of advanced practice nursing (pp. 661-734). Philadelphia,
PA: F.A. Davis Company.
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Appendix A
Vaginal Discharge Differential Diagnosis Table
Subjective Data
Bacterial Vaginosis
Vaginal Candidiasis
Allergic Vaginitis
+Vaginal discharge,
+Vaginal discharge,
+Vaginal discharge,
increased odor
dysuria, pruritic
Introduction of
after intercourse,
discharge,
new allergens:
no dyspareunia,
dyspareunia, recent
bubble bath,
recent change in
use of antibiotics
lubricants, or
sexual partner
Objective Data
douche
Thin white to gray
Copious, thick,
Mild to moderate
malodorous vaginal
white, curd-like
malodorous vaginal
discharge,
vaginal discharge,
discharge,
Edema and
Labia are
inflammation and
erythema
erythematous and
edema
edematous,
reddened vaginal
wall
Lab/Diagnostic Data
Vaginal pH >4.5,
Vaginal pH 4-5
Vaginal pH <4.5
Wet mount: +clue
Wet mount:
Wet mount: +WBC
cells, +KOH amine
+pseudophyphae
test “whiff test”
& branching yeast
(Dains et al, 2012).