Internal Medicine

0521779407-22 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:23

Vaginitis 1507

Signs & Symptoms

■BV: frequently asymptomatic, symptoms include malodorous vagi-

nal discharge, increased after coitus; signs: thin, gray/yellow dis-

charge, vaginal pH > 4.5, amine “fishy” odor with KOH (+whiff test)

■VVC: symptoms: vaginal discharge, intense pruritus, dysuria; signs:

thick, white discharge; vulvovaginal erythema, edema, erosions;

vaginal pH 3.5–4.5; no odor with KOH

■Trichomoniasis: symptoms: frothy malodorous vaginal discharge,

vulvovaginal pruritus, dysuria; signs: profuse purulent discharge,

vaginal inflammation, “strawberry cervix”, vaginal pH > 4.5,+/−

whiff test

tests

Basic Tests

■Vaginal pH: normal 3.8–4.2, BV > 4.5, VVC≤4.5, trichomoniasis > 4.5

■“Whiff” test: apply KOH to vaginal secretions (can place a few drops

onto speculum after removing from vagina) to inspect for amine

“fishy” odor

Specific Diagnostic Tests

■Vaginal wet mount: take sample from posterior vaginal sidewalls or

pooled secretions and add to glass slide with 1 or 2 drops of sterile

saline; clue cells (squamous epithelial cells coated in bacteria, partic-

ularly along cell edge creating a fuzzy appearance)=BV (sensitivity

> 90%); budding yeast and pseudohyphae=VVC; motile trichomon-

ads and WBCs=trichomoniasis (sensitivity averages 45–60%)

■Vaginal KOH preparation: add sample of vaginal secretions to glass

slide with 1 or 2 drops of 10% KOH; improves visualization of yeast;

budding yeast and pseudohyphae=VVC

■Culture: yeast=Sabourand’s medium; trichomoniasis=Diamonds

TYM medium; no culture for BV

differential diagnosis

■Atrophic vaginitis due to estrogen deficiency

■Chemical vulvitis/vaginitis

■Fixed drug eruption: multiple medications implicated

■Foreign body: visible on exam

■GC or CT cervicitis

management

What to Do First

■Examine patient; avoid empiric treatment