Sabendra Joshi (Sabin)
MBBS, MD, ECFMG
Diagnostic Tests:
Visual inspection.
• The vulva and vagina should be examined for evidence of an
inflammatory response as well as the gross characteristics of
the vaginal discharge seen on speculum examination. E.g.
thin , thick , gray , white , green , frothy .
Diagnostic Tests:
Vaginal pH.
 Normal vaginal pH is acidic, < 4.5.
 Identification of the pH using pH-dependent Nitrazine paper.
 Normal vaginal discharge leaves the paper yellow, whereas an
elevated pH turns the paper dark.
Microscopic examination.
 Two drops of the vaginal discharge are placed on a glass slide
with a drop of normal saline placed on one, and a drop of
potassium hydroxide placed on the other.
 The two sites are covered with cover slips, and examined under
the microscope for WBC, pseudohyphae, and trichomonads.
Bacterial vaginosis
• the most common (50%) cause of vaginal complaints.
• It is not a true infection but rather an alteration in
concentrations of normal vaginal bacteria.
• The normal predominant lactobacilli are replaced by
massive increases in concentrations of anaerobic
species and facultative aerobes.
• It is frequently seen postmenopausally because of low
levels of estrogen.
• It is not sexually transmitted.
•
Symptoms
fishy odor
(The most common complaint) .
NO Itching and burning .
50% asymptomatic.
Speculum Examination.
 The vaginal discharge is typically homogenous thin,
grayish-white.
• No vaginal inflammation.
• The vaginal pH is elevated > 5.0.
• A positive "whiff" test is elicited when potassium
hydroxide is placed on the discharge. ( mint odor)
Wet Mount:
Microscopic examination - "clue cells" on a saline preparation.
These are normal vaginal epithelial cells with the normally sharp
cell borders obscured by increased numbers of anaerobic bacteria.
WBCs are rarely seen.
Management
 No treatment for asymptomatic patient
 The treatment of choice is metronidazole or
clindamycin orally or vaginally.
 Metronidazole should not be used in the first
trimester of pregnancy. Clindamycin cream is the
treatment of choice.
Trichomonas vaginitis
• the most common cause of vaginal complaints
worldwide and is the second most common sexually
transmitted disease (STD) .
• caused by a flagellated pear-shaped protozoan ,
Trichomonas vaginalis that can reside
asymptomatically in male seminal fluid.
Symptoms.
 The most common patient complaint is itching,
burning, and pain with intercourse.
Speculum Examination
 The vaginal discharge is
typically frothy and
green.
 The vaginal epithelium is
frequently edematous
and inflamed.
 The erythematous cervix
may demonstrate the
characteristic
"strawberry" appearance.
 The vaginal pH is
elevated > 5.0.
Wet Mount
 Microscopic examination - actively motile
"trichomonads" on a saline preparation.
 WBCs are seen.
Management.
 The treatment of choice is metronidazole orally or
vaginally.
 The sexual partner should also be treated with oral
metronidazole.
 Metronidazole should not be used in the first
trimester of pregnancy. Vaginal Betadine is the
treatment of choice.
Yeast vaginitis
 the second most common of vaginal complaints .
 The most common organism is Candida albicans.
 It is not transmitted sexually.
Risk Factors
 diabetes mellitus
 systemic antibiotics
 pregnancy,
 obesity,
 decreased immunity.
•
Symptoms.
The most common patient complaint is itching, burning,
and pain with intercourse.
Speculum Examination
 The vaginal discharge is typically white-curdy .
 The vaginal epithelium is frequently edematous and
inflamed.
 The vaginal pH is normally < 4.5.
Wet Mount
 Microscopic examination - pseudo hyphae on a
potassium hydroxide prep. WBCs are frequently seen.
Management
 The treatment of choice - a single oral dose of
fluconazole or vaginal "azole" creams.
 An asymptomatic sexual partner does not need to be
treated.
Physiologic discharge:
 the result of the thin, watery cervical mucus discharge
seen with estrogen dominance.
 It is a normal phenomenon and becomes a complaint
with prolonged anovulation, particularly in patients
with wide eversion of columnar epithelium.
Risk factors
 chronic anovulatory conditions such as polycystic
ovarian syndrome.
Symptoms
 The most common patient complaint is increased
watery vaginal discharge.
 no burning or itching.
Speculum Exam
 The vaginal discharge is typically thin and watery.
 The vaginal epithelium is normal appearing with no
inflammation.
 The vaginal pH is normally < 4.5.
Wet Mount
 Microscopic examination - absence of WBCs, "clue
cell," trichomonads, or pseudohyphae.
Management
 The treatment of choice is steroid contraception with
progestins, which will convert the thin, watery,
estrogen-dominant cervical discharge to a thick, sticky
progestin-dominant mucus.