WELLONE PRIMARY MEDICAL AND DENTAL CARE
For Medical Provider Staff
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Conducting this test exposes the operator to potentially
infectious material. Standard precautions, including
glove use are required for this procedure.
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Patients with symptoms of bacterial vaginosis generally complain of an increased vaginal discharge with a foul, fishy odor that becomes
Vaginal pH testing and wet mount are indicated
based on patient complaints and symptoms; rarely
is “asymptomatic” pH or wet mount testing
indicated.
The absence of trichomonads or pseudohyphae
does not rule out infections because several studies
have demonstrated the presence of these
pathogens by culture or PCR after a negative
microscopic examination.
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Obtain discharge from the lateral fornices. Avoid
the cervical mucus, which has a higher pH than the
vagina.
Avoid using lubricating jelly (will interfere with PH
and Wet mount results as well as cervical pathology
specimen; speculums can be lubricated with water)
Compare the color to the chart on the container.
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True
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False
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Discharge should be obtained from the lateral
fornices. Cervical mucus should be avoided
since it will interfere with pH testing.
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Normal vaginal pH is 3.8-4.5
pH >4.5 is consistent with BV, trich and
atrophic vaginitis
A normal pH is seen with candida
Limitations: blood, sperm, and cervical
mucus can elevate the pH; acid gels may
lower the pH.
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4.0-6.0
4.5-5.0
3.8-4.5
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3.8-4.5
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Place one smear of discharge
on one side of the slide and
another smear on the other
side of the slide.
Avoid placing too much
discharge on the slide as a
thick specimen interferes
with readability of the slide.
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Add one drop of NaCL to one
area of the discharge and one
drop of KOH to the other side
and mix with end of wooden
stick/swab
Observe for a fishy odor with the
addition of KOH (whiff test)
which is an indicator of
bacterial vaginosis (positive
whiff test)Two
Apply a coverslip to each side
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A negative whiff test;
Bacterial Vaginosis
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A positive whiff test;
Candida
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A positive whiff test;
Bacterial Vaginosis
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A positive whiff test;
Bacterial Vaginosis
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Begin on low power.
Scan the entire slideobserving for yeast and
Trichomonads on the
saline side and clue cells
on the KOH side.
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A diagnosis of Candida vaginitis is suggested clinically by the
presence of external dysuria and vulvar pruritis, pain,
swelling, and redness. Signs include vulvar edema, fissures,
excoriations, or thick curdy vaginal discharge.
The vaginal ph is <4.5
Wet mount examination may reveal budding yeast and/or
pseudohyphae.
Use of 10% KOH in wet preparations improves the
visualization of yeast and mycelia by disrupting cellular
material that might obscure the yeast or pseudohyphae.
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Budding yeasts and
Pseudohyphae
The morphology is typical
of actively growing
Candida sp. This slide is
also typical of one that
has been allowed to
‘incubate’ at room
temperature for
about 3 hours so that the
yeast cells tend to swell.
Fresh specimens do not
typically exhibit such
luxurious growth
and vacuolated yeast
cells.
Budding
yeast
Pseudohyphae
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Budding yeasts and Pseudohyphae
Low Power
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Pseudohyphae
These are fragile tube-like structures that arise
through elongation of the yeast form of Candida.
Pseudohyphe may demonstrate a terminal
swollen remnant of the original yeast cell.
They are called pseudohyphae because they
lack true branching as seen with mold like fungi.
The side walls are parallel to each other which
is an important characteristic that helps separate
pseudohyphae from artifact whose side walls
vary in width.
Small oval structures called bastoconidia are
often seen attached along the length of the
pseudohyphae.
The blastoconidia are smaller in size when
compared to the yeast form of Candida.
While pseudohyphae are usually seen along
with yeast cells or budding yeast, it is also
possible to see pseudohyphae in the absence of
yeast cells.
Pseudohyphae
with budding
yeast cells
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Budding yeast
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Trichomonads
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Clue Cells
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Pseudohyphae
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Pseudohyphae
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Artifact vs. Pseudohyphae
One of the more troublesome
artifacts is fibers that are sometimes
confused with pseudohyphae.
There are a few tips that may help in
the differentiation.
1. Fibers are generally larger in size that
pseudohyphae
2. Pseudohyphae have parallel sides
with a consistent dimension between
the sides while fibers show variable
widths along the fiber.
3. Fibers tend to be birefringent. That is
they change color when focusing up
and down on the object. Colors are
often gold or blue and result from the
microscope light being refracted by the
fiber.
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Trichomoniasis is caused by the protozoan T.
vaginalis.
Many infected women have symptoms characterized
by a diffuse, malodorous, yellow-green vaginal
discharge with vulvar irritation. However, some
women have minimal or no symptoms.
Diagnosis of vaginal trichomoniasis is usually
performed by microscopy of vaginal secretions, but
this method has a sensitivity of only approximately
60%–70% and requires immediate evaluation of wet
preparation slide for optimal results.
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Trichomonas are
parasitic protozoa.
 They can be very
motile
 When they begin to die
(within 10 minutes of
specimen collection),
they become
sedentary and begin to
round up.
 Trichomonas should
only be reported when
motility is observed

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True
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False
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False…….Trichomonas begin to die about
10 minutes
after specimen collection. Therefore, it is
imperative that the specimen be processed
quickly following collection.
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
Trichomonas have a very
complex structure.

They have four flagella
facing ‘forward’ and a
fifth facing ‘backward’
which is attached to an
undulating membrane.

The cells are oval in
shape, 10-23 µm in
length
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
Appearance of a
“strawberry cervix”
may be seen with
Trichomonas infection
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Must have 3 of the 4 signs for a diagnosis
of BV (AMSEL’S CRITERIA)
Discharge, white & homogeneous
Elevated pH, >4.5
Amine odor present
20% clue cells present on wet mount
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Gardnerella vaginosis (small, gram negative [red]
rounded rods - coccobacilli)
 Mobiluncus sp. (small, slender gram negative
[red] curved rods).
 Both are normally found in the vagina (i.e.,
normal flora)
 In bacterial vaginosis, these bacteria increase in
number and degrade proteins in the vagina to
form the amines that cause the characteristic
unpleasant odor associated with BV.

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True
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False
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True…….The vaginal pH of greater than 4.5 is
characteristic of BV. This is an alkaline state.
Additional criteria (other than an elevated
pH) are needed to make a diagnosis of BV.
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CLUE CELLS
Clue cells are squamous
epithelial cells that are covered
with a thick matte of bacterial
cells and are associated with
bacterial vaginosis.
The traditional definition of a
clue cell is that the bacterial
overgrowth is so thick that all
cellular detail (such as the cell
nucleus and the cellular edge) is
totally obscured.
It is sometimes possible to
detect the nucleus in a clue cell
by using the fine focus knob to
focus throughout the cell.
SQUAMOUS EPITHELIAL CELLS
The cell nucleus and the
cell boundary are clearly observed.
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CLUE CELL
SQUAMOUS EPITHELIAL CELLS
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Low Power
Squamous Epithelial cell – not a clue cell
Clue cell
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
The bacteria shown in this
slide are characteristic of
lactobacilli, which is normal
flora in women following
the onset on menses and
will persist as normal flora
until menopause.
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Once you are confident that you are comfortable with all the
materials presented, proceed to the Vaginal pH and Wet
Mount Testing post test at
http://www.classmarker.com/professional/
Your username is the first initial of your first name followed by
your full last name. Your password is= nwhealth
Click here to link to
CDC free CME/CNE
on vaginitis and STDs
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