gynecology and obstetrics
Vaginal Itching and Discharge
Evaluation of Vaginal Itching and Discharge
History of present illnessincludes nature of symptoms (eg, pruritus, burning, pain, discharge), duration, and intensity. If vaginal discharge is present, patients should be asked about the color and odor of the discharge and any exacerbating and remitting factors (particularly those related to menses and intercourse). They should also be asked about use of hygiene sprays or perfumes, spermicides, vaginal creams or lubricants, latex condoms, vaginal contraceptive rings, diaphragms, and pessaries. Review of systemsshould seek symptoms suggesting possible causes, including the following: Fever or chills and abdominal or suprapubic pain: Pelvic inflammatory disease (PID) or cystitis Polyuria and polydipsia: New-onset diabetes Past medical historyshould note risk factors for the following: Candidal infection (eg, recent antibiotic use, diabetes, HIV infection, other immunosuppressive disorders) Fistulas (eg, Crohn disease, genitourinary or gastrointestinal cancer, pelvic or rectal surgery, lacerations during delivery) Sexually transmitted infections (eg, unprotected intercourse, multiple partners) If sexual abuse of a child is suspected, a structured forensic interview based on theNational Institute of Child Health and Human Development (NICHD) Protocolcan be used. It helps the child report information about the experienced event and improves the quality of information obtained. Physical examination focuses on the pelvic examination. The external genitals are examined for erythema, excoriations, and swelling. A water-lubricated speculum is used to check the vaginal walls for erythema, discharge, and fistulas. The cervix is inspected for inflammation (eg, trichomoniasis) and discharge. Vaginal pH is measured, and samples of secretions are obtained for testing. A bimanual examination is done to identify cervical motion tenderness and adnexal or uterine tenderness (indicating PID). The following findings are of particular concern: Fever or pelvic pain Bloody discharge in postmenopausal women Fecal discharge (suggesting a fistula, even if not seen) Trichomonal vaginitis in children (suggesting sexual abuse) Often, the history and physical examination help suggest a diagnosis (see table Some Causes of Vaginal Pruritus and Discharge ), although there can be much overlap. a vaginal discharge suggests a foreign body in the vagina. If no foreign body is present and children have trichomonal vaginitis, sexual abuse is likely. If they have unexplained vaginal discharge, Cervicitis , which may be due to a sexually transmitted infection, should be considered, and cervical cultures should be done. Nonspecific vulvovaginitis is a diagnosis of exclusion. Inwomen of reproductive age,discharge due to vaginitis must be distinguished from normal discharge: Normal vaginal discharge is commonly white or clear, odorless, and nonirritating. Bacterial Vaginosis (BV) produces a thin, gray discharge with a fishy odor. A Trichomoniasis produces a frothy, yellow-green vaginal discharge, often with a fishy odor, and causes vulvovaginal soreness. Candidal Vaginitis produces a white discharge that may resemble cottage cheese. Contact irritant or allergic reactions cause significant irritation and inflammation with comparatively minimal discharge. Discharge due to Cervicitis (eg, due to PID) can resemble that of vaginitis. Abdominal pain, cervical motion tenderness, or cervical inflammation suggests PID. vaginal pruritus and discharge may result from skin disorders (eg, Psoriasis , Discharge that is watery, bloody, or both may result from Vulvar Cancer , In genitourinary syndrome of menopause, discharge is scant and may be watery and thin or thick and yellowish. Dyspareunia is common, and vaginal tissue appears thin and dry. All patients with vaginal itching or discharge require the following in-office testing: pH Wet mount Potassium hydroxide (KOH) preparation Testing for Diagnosis and Vaginal secretions are tested using pH paper with 0.2 intervals from pH 4.0 to 6.0. Then, a cotton swab is used to place secretions on 2 slides; secretions are diluted with 0.9%sodium chlorideon one slide (saline wet mount) and with 10% KOH on the other (KOH preparation). The KOH preparation is sniffed (whiff test) for a fishy odor, which results from amines produced in trichomonal vaginitis and bacterial vaginosis. The slide is examined using a microscope; KOH dissolves most cellular material except yeast hyphae, making identification easier. The saline wet mount is examined using a microscope as soon as possible to look for clue cells and motile trichomonads, which can become immotile and more difficult to recognize within minutes after slide preparation. If clinical criteria and in-office test results are inconclusive, the discharge may be cultured for fungi and trichomonads. 