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C H A P T E R
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34
Vaginal Discharge and Itching
aginitis is an inammation of the vagina that
can cause vaginal discharge. Vaginal infec-
V
Trichomonas vaginalis, Candida, and bacterial vagi-
nosis (BV) (the epithelium is not inamed with this
syndrome) account for 95% of all vaginal infections in
U.S. women. Often patients have more than one infec-
tion at a given time.
have premature rupture of membranes and early delivery.
The most common cervical infections are Chlamydia
trachomatis, Neisseria gonorrhoeae, and herpes sim-
plex. Postmenopausal women often have discharge
related to atrophic vaginitis, caused by the deciency of
estrogen in the vaginal tissues.
accompany vaginal discharge. Pubic lice, scabies,
pinworms, and genital warts (condylomata acumi-
nata) can all cause itching. Common foreign bodies
found in the vagina of adults are lost or forgotten
tampons, which can produce a foul-smelling
discharge.
caused by sensitivity to bubble bath, whereas in the
adolescent or woman it occurs because of the use
of scented douches, lubricants, or hygiene sprays.
Vulvovaginitis is one of the most common gyneco-
logical disorders in girls as a result of their hypoes-
trogenic state and their perineal hygiene, which is
often poor. The vaginal mucosa is thin and less resis-
tant to infectious organisms. The postmenopausal
woman can experience these same symptoms with
estrogen deciency.
itching, soreness, or vaginal discharge are common.
The lack of estrogen stimulation; neutral pH of the
vaginal secretions; lack of protective thick labia
and pubic hair; and daily living habits (e.g., wiping,
clothing, play equipment, environment, and baths),
lead to this complaint.
tions are common in postpubertal women.
Some studies suggest that pregnant women with BV
Vulvar itching, burning, and a foul odor often
Chemical vaginitis in a young girl is usually
In childhood and adolescence, reports of vulvar
DIAGNOSTIC REASONING:
FOCUSED HISTORY
What kind of vaginitis might this be?
Key Questions
n What are the amount, color, and consistency of your
discharge?
n Do you have itching, swelling, or redness?
n Is there an odor?
Characteristics of Discharge
Copious amounts of greenish, offensive-smelling discharge are most consistent with T. vaginalis. Mucopurulent or purulent discharges are associated with
gonorrhea and Chlamydia. A moderate amount of
white, curd-like discharge is consistent with Candida
vulvovaginitis. BV typically produces a discharge
that is thin and either white, green, gray, or brownish.
Although characteristic symptoms associated with
each type of vaginal discharge can be helpful in
arriving at a diagnosis, they are not diagnostic in and
of themselves. Microscopic examination of the vaginal discharge is more sensitive than the clinical
picture in conrming the diagnosis (Figure 34-1).
Itching, Swelling, and Redness
Vaginitis causes inammation of the tissues, resulting in
erythema and edema. Because of the inammatory process, the amount of discharge will produce a concomitant
amount of swelling and redness of the vulva and vagina.
Itching is consistently present with candidiasis. Scratching can lead to excoriations and satellite lesions. BV does
not involve the inammatory process and results in discharge with little vulvovaginal erythema and edema.
Odor
A shy odor caused by the release of amines from
organic acids is prominent with BV. It is accentuated
by the addition of potassium hydroxide (KOH) to the
411
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A
FIGURE 34-1 Microscopic differential diagnosis of vaginal infections. A, Clue cells (epithelial
cells with clumps of bacteria) are evident in bacterial vaginosis. B, Budding, branching hyphae
characterize candidiasis. C, Motile trichomonads are seen with trichomoniasis. (From Zitelli BJ,
Davis HW: Atlas of pediatric physical diagnosis, ed 3, St Louis, 1997, Mosby-Wolfe.)
B
wet mount slide and is considered a positive “whiff”
test. Odor commonly accompanies trichomonal infections. Retained tampons or other foreign bodies can
also cause a foul odor.
Is this likely a sexually transmitted infection?
Key Questions
n Are you sexually active? Do you have multiple
partners? Do you have a new partner?
n Have you had sex against your will? If a child: You
might ask, “Has anyone touched your private parts?”
n What form of protection do you use? How often do
you use protection?
n Have you or your partner(s) ever been tested or
treated for a sexually transmitted infection (STI)?
n Do you have any rashes, blisters, sores, lumps, or
bumps in the genital area?
Sexual History
Early-age onset of sexual activity, multiple partners,
and nonuse of barrier contraceptives, particularly condoms, increases the risk of vaginal infection. STIs
are common in women of childbearing age (12 to
50 years) who have acquired a new partner. The
patient who frequently changes sexual partners or
participates in risky sexual practices (e.g., rectal intercourse without a condom) is at high risk for STIs.
Do not ignore the possibility of an STI in older
women or children. An older woman may be sexually
active, for example, after a divorce or widowhood. Also,
50% of all children with an STI have been found to be
C
sexually abused. T. vaginalis is rare in children but can
be transmitted to the neonate from an infected mother.
Recent Treatment for a Sexually Transmitted
Infection
Recent treatment for an STI may indicate treatment
failure, a coinfection that was not covered by the
prescribed drug, or recent exposure.
Lesions
Vesicles usually indicate herpes infection. Patients typically notice them on the external labia and report that they
itch or burn. Condylomata lata, condylomata acuminata,
and molluscum contagiosum are all papular lesions found
on the labia, perineum, and anal regions. Molluscum contagiosum, when occurring in the genital area, may extend
to include the inner thighs. Typically, condylomata acuminata (genital warts) are rough, verrucous lesions that
are usually located inferiorly from fossa navicularis to the
fourchette and the perineal area. A painless ulcer suggests
syphilis and classically appears as a solitary lesion. However, there can be more than one chancre, especially if the
patient is immunocompromised.
Can this be vaginitis that is not related
to an STI?
Key Questions
n Have you ever been told that you have diabetes or
Cushing syndrome or that you are positive for HIV
infection?
n Have you been ill recently?
Chapter 34 • Vaginal Discharge and Itching 413
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n Are you taking antibiotics, hormones, or oral con-
traceptive pills?
n Have you received chemotherapy?
n Does the itching seem to be worse at night?
n Can you describe some of your recent activities?
n Is the patient premenarche?
Immunocompromised States
Refractory fungal vulvovaginitis may indicate undiag-
nosed diabetes or an immunocompromised state.
Recent Illness
Chickenpox, scarlet fever, and measles can cause
vaginitis.
Medications or Chemotherapy
Birth control pills, corticosteroids, antibiotics, and
chemotherapy are associated with candidal vulvovagi-
nitis. Oral contraceptives can alter the vaginal pH, and
antibiotics can alter the normal vaginal ora; both pre-
dispose to fungal infection. Corticosteroids and che-
motherapy can produce an immunocompromised state
and provide the opportunity for fungal infection.
Night Itching
Pinworms are intestinal parasites that inhabit the rectum
or colon and emerge to lay eggs in the skinfolds of the
anus. Perianal pruritus, especially at night, along with
pain or itching of genitals is common (Figure 34-2).
Activities
Riding a bicycle, using pools or hot tubs, or wearing
tight-tting pants or pantyhose can lead to heat and
moisture in the genital area, causing mechanical irritation and such infections as candidiasis or BV.
Premenarche
Girls who have not yet reached menarche are prone to
vulvovaginal infections because of a nonestrogenized
vagina and the lack of labial development and hair
growth.
Is this condition acute, recurring,
or chronic?
Key Questions
n How long have you had these symptoms?
n Are they getting better or worse?
n Have you ever had these symptoms before?
n How many episodes have you had in the past year?
n Are the episodes related to any particular activity
or time?
Chronology of Symptoms
The occurrence of vaginal discharge after having a
new sex partner suggests an acute condition, such as a
sexually transmitted infection. Symptoms associated
with use of condoms or spermicidal jelly suggest sensitivity to the product. If the discharge occurs monthly,
A B
FIGURE 34-2 Pinworms (Enterobius vermicularis). On this wet mount, a mature worm is shown
surrounded by eggs (A), which are shown more clearly at higher power (B). (From Zitelli BJ,
Davis HW: Atlas of pediatric physical diagnosis, ed 3, St Louis, 1997, Mosby-Wolfe.)
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becoming worse after menses, suspect a chronic condition, such as vulvovaginitis candidiasis. Recurrent
episodes related to bathing activities point to chemical
irritation.
If this is acute, could it be related
to a previous infection?
Key Questions
n Have you been tested and treated for this condition
recently?
n What medication was prescribed?
n Did you take all of the medication?
n What other prescriptions were you taking at that time?
n Have you taken any over-the-counter medications?
Adequate Diagnosis
Diagnoses made clinically on the basis of the color or
appearance of discharge may be incorrect, or a concomitant vaginal infection may have been missed.
However, self-diagnosis and treatment are common,
especially with the over-the-counter medicines for
“yeast infection.”
Adequate Treatment
Most medications that are prescribed are not taken
exactly as directed. Women may stop using their
vaginal medications when menses begins and resume
after it ends. This practice can lead to treatment failure. They may also discontinue the therapeutic agent
early, as soon as relief from symptoms takes place
or a drug side effect is experienced (e.g., the metallic
taste of metronidazole). Drug interactions may
account for inadequate therapy, or there may be
the need to alter dietary regimen (e.g., abstain from
alcoholic beverages).
If this is chronic, what should I suspect?
Key Questions
n Do any family members or sexual partners have
recurrent vaginal or urinary tract infections? Do
they have any itching, rashes, sores, lumps, or
bumps?
n Do you have a new or untreated partner?
n What are your sexual practices (e.g., vaginal, oral,
and/or anal sex)?
n How many yeast infections have you had in the
past year?
Transmission
Caregivers, parents, and siblings can spread infections, such as candidiasis, molluscum contagiosum,
herpes, lice, and pinworms to children through poor
hygiene practices. Autoinoculation is also possible,
especially for herpes, genital warts, and molluscum
contagiosum.
New or Untreated Partner
The most common cause of reinfection is intercourse
with a new or untreated partner.
Sexual Practices
Possible infection reservoirs are oral and anal cavities,
which may need to be cultured for herpes or gonorrhea.
Additionally, materials used during intercourse may
need to be disinfected (e.g., diaphragm). Less common
modes of transmission include shared intimate clothing.
Chronic Vulvovaginitis
If the patient has had more than three separate episodes
of candidal vulvovaginitis in 1 year, consider diabetes
or the immunocompromised state of HIV/AIDS as the
underlying cause. Yeast grows best in areas that are
dark, moist, warm, and high in glucose—areas where
the normal ora has been compromised. The use of
oral contraceptive pills or hormone replacement therapy, antibiotic (e.g., tetracycline for acne) or steroid
therapy, diets high in carbohydrates or articial sweeteners, and clothing that holds moisture against the
vulva (e.g., pantyhose, tight jeans) are excellent potentiators for infection.
What are other possible causes for this
vaginitis?
Key Questions
n What are your personal hygiene practices?
n Do you douche?
n Have you changed brands of contraceptive products?
n Could you have forgotten to remove your diaphragm
or tampon?
Hygiene Practices
Feminine hygiene practices can contribute to vaginitis
by causing a local allergic reaction, altered vaginal
ora, or contamination of the vagina from the rectum.
Perfumes in douches, sprays, lubricants, and bubble
baths are frequent offenders in allergic vaginitis.
Chapter 34 • Vaginal Discharge and Itching 415
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Once a child is out of diapers, toileting is less
closely assisted, and wiping techniques may be poor,
leading to contamination of the vagina with bowel
ora.
Douching
Frequent douching can change the balance of normal
vaginal ora by altering the pH. This allows recolonization of the vagina with enteric bacteria, leading to
pruritus and discharge. Douching can cause an allergic
reaction. Colored or perfumed toilet paper can irritate
the perineum, causing redness and itching. Wiping
with tissue after urination or defecation in the direction
from the anus toward the vagina can inoculate the
vagina with rectal microbes.
Contraceptive Products
Contraceptive products (e.g., spermicidal jellies, suppositories, foam, and condoms) can cause an allergic
inammation of the sensitive mucosa and produce
itching, erythema, tenderness, and an increase in usual
vaginal secretions.
Foreign Body
Foul-smelling vaginal discharge can be caused by
a lost tampon or condom or a forgotten diaphragm.
A child who puts a foreign object into her vagina
may have pruritus, burning, or foul, purulent vaginal
discharge. Foreign bodies in the vagina are associated with vaginal bleeding or spotting. If the object
is left for some time, it can imbed and perforate the
vaginal wall.
Are there any associated symptoms
that point to a cause?
produce symptoms that can be confused with a urinary
tract infection. Low estrogen levels may exacerbate
stress and urge incontinence. Trichomonas and
Chlamydia may produce a coexisting urethritis that
causes frequency and dysuria.
Dyspareunia and Pain
Vaginal atrophy, genital warts, or vaginal infections
can cause introital dyspareunia. A more likely reason
for deep vaginal dyspareunia is endometriosis, pelvic
inammatory disease (PID), or broids. Sexually
transmitted infections like gonorrhea and Chlamydia
can cause cervicitis, which, if left untreated, can progress to PID and produce abdominal and/or pelvic pain
(see Chapter 2).
Eye Infection
Eye infections in the newborn may be associated with
gonorrhea and Chlamydia (see Chapter 27).
Cough
Pneumonia in the newborn may be an indication of
chlamydiosis (see Chapter 10).
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Note Vital Signs
The presence of a fever may alert you to a serious
infection, such as PID. Fever is uncommon with
vaginitis.
Perform an Oral Examination
Oral thrush may accompany vulvar candidiasis, particularly in children. Look for white patches that bleed when
you try to scrape them off.
Key Questions
n Do you have burning or pain with urination?
Do you have urinary frequency or hesitation, or
nocturia?
n Is intercourse painful?
n Do you have abdominal or pelvic pain?
n If an infant: Does the infant have an eye infection?
n If an infant: Does the infant have a cough?
Urinary Tract Symptoms
Atrophic vaginitis is often accompanied by dysuria,
dyspareunia, and vaginal dryness. Estrogen deciency
affects the woman’s entire lower genital tract and may
Perform an External Genitalia
Examination
Palpate for inguinal lymphadenopathy and tenderness,
which can be present with vaginal infections. Inspect
the vulva and labia, looking for erythema, excoriations,
and induration. The skin is often bright red and swollen
with small ssures or excoriations from candidiasis.
Also, thick white curds of discharge are often noted in
the labial folds. BV often produces a profuse, thin,
whitish discharge that will leak out of the vagina onto
the perineum. Palpate Bartholin and Skene glands and
milk the urethra for discharge. Palpable Bartholin
glands often coexist with STIs. If purulent discharge
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is seen, consider the diagnoses of gonorrhea or
Chlamydia and obtain specimens for diagnostic tests.
Condylomata lata, condylomata acuminata, and
molluscum contagiosum are all papular lesions found
on the labia, perineum, and anal regions. Molluscum
contagiosum, when occurring in the genital area, may
extend to include the inner thighs. Herpes lesions are
usually ulcerative in nature when seen clinically and
need to be differentiated from other similar lesions
(e.g., syphilitic chancre can be more than one lesion
and tender if secondarily infected). Herpetic lesions are
found in clusters and can extend from the labia into the
vagina. Typically, condylomata acuminata (genital
warts) are rough, verrucous lesions that are located
inferiorly from the fossa navicularis to the fourchette
and the perineal area.
In the overweight patient, vulvovaginitis candidia-
sis is frequently accompanied by intertriginous candidiasis (e.g., under the breasts and the abdominal apron).
Perform an Internal Vaginal Examination
Note the condition of the vaginal walls. A plastic
speculum makes vaginal wall inspection easy and
helps in the identication of a foreign body for removal. In children, the knee-chest position is very useful for inspecting the vagina. In children, an otoscope
or a nasal speculum may be used; rarely is a hysteroscope (under anesthesia) needed. Pale or mottled red
splotches of the vaginal mucosa are associated with
atrophic vaginitis, and the sticky discharge is yellow or
brown. In severe cases of atrophic vaginitis, the pale,
thin mucosa may have adhered to the opposing vaginal
wall, and the speculum examination often causes an
oozing bloody discharge.
The appearance of the cervix should be noted. A
friable or “strawberry” appearance of cervical petechiae with a frothy, foul-smelling discharge is descriptive of a Trichomonas infection. A mucopurulent discharge from the cervical os is an indication to obtain an
endocervical sample for gonorrhea and Chlamydia
testing. This discharge is yellowish-green when collected on an endocervical swab. The character of the
discharge does not consistently identify common infectious causes of vaginitis. Treat vaginal infections
before the Papanicolaou test is obtained because
BV and trichomoniasis may cause inammatory atypia
results.
The wet mount is a valuable diagnostic tool, and a
sample of vaginal discharge is best obtained from the
lateral vaginal fornices. Three positive characteristics
for any one etiology can correctly identify the causative agent (e.g., increased pH; the presence of “clue
cells,” which are epithelial cells full of bacteria that
obscure the cell border; and a thin gray discharge seen
in BV) (see Differential Diagnosis).
DNA probes and nucleic acid amplication tests
(NAATs) are available to test for Chlamydia trachomatis
and N. gonorrhoeae. A combination organism DNA
probe is available for Trichomonas vaginalis, Gardner-
ella vaginalis, and Candida species. Cultures for BV,
fungal infections, and T. vaginalis are not routinely rec-
ommended and are usually reserved for determining
resistant organisms.
Perform a Bimanual Examination
Assess the condition of the uterus, fallopian tubes,
and ovaries by checking for uterine and cervical motion tenderness (CMT), ovarian size, and presence of
masses. CMT or pain on palpation of the uterus and
adnexa conrms the spread of vaginitis or cervicitis
to the upper genital tract and results in PID. This
warrants immediate evaluation and treatment, or
referral, to prevent tubal scarring, ectopic pregnancy, and infertility.
Perform a Vaginal-Rectal Examination
Vaginal-rectal examination is an important technique
in assessing the posterior uterus and condition of the
cul-de-sac as well as the rectum. Make sure that the
internal examination glove is changed before rectal
insertion to prevent contamination of the rectum with
vaginal discharge organisms. A rectal examination is
used to palpate a foreign body and to check for normal
pelvic anatomy in the child.
LABORATORY AND DIAGNOSTIC
STUDIES
Potassium Hydroxide and Wet Mount/
Preparation
Obtain a discharge sample from the lateral fornices of
the vagina, using a cotton-tipped applicator. There are
several acceptable techniques for preparing a potassium
hydroxide (KOH) and wet mount. One technique is to
prepare two slides with a smear of vaginal discharge. To
one slide, add a drop of 10% KOH and put a coverslip
in place. To the other slide, add a drop of normal saline
and put a coverslip in place. The whiff test is positive
when the addition of the 10% KOH produces a shy
Chapter 34 • Vaginal Discharge and Itching 417
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odor, which is caused by the release of amines. The
whiff test has a positive predictive value of 76% for BV.
Look under the microscope at the KOH slide for the
presence of branching and budding hyphae that are
characteristic of yeast infection. Examine the saline wet
mount microscopically for motile trichomonads that
signal the presence of Trichomonas. Clue cells are
characteristic of BV (see Figure 34-1).
Test for pH
Most litmus paper reads the pH range from 3.0 to
9.0. This is a simple inexpensive test to aid in determining the cause of the vaginal discharge. Normal
vaginal secretions are less than pH 4.5. A pH greater
than 4.5 is consistent with BV, trichomoniasis, or
atrophic vaginitis.
Fungal Culture or Sabouraud Agar
Culture
Fungal culture may be needed in the diagnosis
of non–Candida albicans (e.g., C. glabrata, C. tropi-
calis, C. krusei) that are refractory to medication
regimens.
Herpes Viral Culture
Viral culture is the most specic method of diagnosing
herpes. Results may take from 1 to 7 days, with maximum sensitivity achieved at 5 to 7 days. The herpes
culture will probably not be able to identify the causative agent if the specimen is taken from a lesion that
is 5 or more days old. It is important to document
positive genital herpes infections in the pregnant
woman and in skin lesions of the newborn. Collect
cells or uid from a fresh sore with a cotton swab and
place them in the culture container.
Herpesvirus Antigen Detection Test
This test detects antigens on the surface of cells infected with the herpes virus. Cells from a fresh sore
are scraped off and then smeared onto a microscope
slide. This test may be done in addition to or in place
of a viral culture.
Tzanck Smear
Tzanck smear characteristic ndings are multinucleated giant cells that are likely to be found if the specimen is from an intact herpes lesion. Prepare the Tzanck
smear by removing the roof of the vesicle and scraping
the skin with a scalpel blade. Make sure that the base
and the margins of the vesicle are scraped; do not use
the vesicular uid for this specimen. The cellular mate-
rial is spread onto a glass slide, xed with absolute
alcohol for 1 minute, and then stained with Wright’s
stain. Alternative staining methods are available, and
guidelines can be obtained from local laboratories.
Modified Diamond Culture
Diamond culture is used to identify Trichomonas.
However, it is seldom needed to make the diagnosis.
Thayer-Martin Culture
Thayer-Martin medium is a bacterial culture that
identies gonococcal infections. A culture is taken
from the endocervical canal of the uterine cervix.
First remove excess mucus from a portion of the cer-
vix, using a cotton ball held in ring forceps or a large
cotton-tipped procto-swab. Insert a sterile cotton-
tipped applicator (Q-tip) into the endocervical canal
and allow it to absorb the mucus for 10 to 30 seconds
before inoculating the medium. Inoculate the medium
bottle or plate in a zigzag manner while simultane-
ously rolling the small cotton-tipped applicator. When
opening the Thayer-Martin culture bottle, avoid hold-
ing the bottle totally upright, which will allow for
the loss of the carbon dioxide from the specimen
collection bottle.
DNA Testing for Infectious Organisms
DNA testing using a sample taken from the vagina
provides rapid, sensitive, and specic results. A num-
ber of products are available. Follow manufacturer
directions to collect and transport the sample.
DNA probes and nucleic acid amplication tests
(NAATs) are available to test for Chlamydia tracho-
matis and N. gonorrhoeae. Single or dual organism
tests are available. For gonorrhea testing, the sample
should be taken from the endocervical canal because
N. gonorrhoeae has a predilection for the columnar
and transitional cells.
A multiorganism DNA probe is available to test
for Trichomonas vaginalis, Gardnerella vaginalis, and
Candida species.
Serology for Syphilis
Serological tests are used for screening and diagnosing
syphilis and are recommended if other STIs are found or
suspected. The screening tests are nontreponemal and
include VDRL (Venereal Disease Research Laboratory),
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RPR (rapid plasma reagin), and enzyme immunoassay
(EIA) tests. Diagnostic tests are Treponema pallidum
specic and include FTA-ABS (uorescent treponemal
antibody absorption test) and TPPA (Treponema palli-
dum particle agglutination assay).
Urinalysis
Obtain a U/A if the patient has dysuria. However,
external pain on urination may originate from urine
on inamed vulvar tissue, eliminating the need for
urinalysis.
Microscopy and Skin Scraping
Viewing a skin scraping under the microscope is used
to assist with the differential diagnosis of scabies and
pubic lice (see Chapter 25).
Scotch Tape Test
Use this test when you suspect pinworms (Enterobius
vermicularis), which occur most commonly in children.
Instruct the adult to apply adhesive cellophane tape to
the child’s perianal region early in the morning when
the child awakens. The tape is then recovered and
brought in. Place it on a glass slide and examine under
a microscope for the presence of eggs. Parents may also
be able to see the worms by shining a ashlight on the
external anus of the child at night. The female worm is
about 10 mm long (see Figure 34-2).
Acetic Acid Test (Acetowhite)
The acetic acid test is best used to detect subclinical
lesions caused by human papillomavirus (HPV) when
a genital wart has been identied on the patient, when
there has been sexual contact, or when the Pap test
indicates dysplasia. The application of 5% acetic acid
(vinegar) to the cervix, labia, or perianal area causes
the lesion to turn white (acetowhite). Saturate a gauze
pad with vinegar and place on the lesion for 5 to
10 minutes. After this soaking, the white wart will
have a sharp circumscribed macular or papular border.
The surface will appear verrucous. False positive
results can occur with candidiasis, psoriasis, lichen
planus, and sebaceous glands.
Follicle-Stimulating Hormone
Follicle-stimulating hormone (FSH) levels that are
greater than 30 milliunits/mL are diagnostic of perimenopause, and levels of 40 milliunits/mL or higher
represent menopause. This test is particularly helpful
in establishing the hypoestrogenic status of a young
woman who is experiencing premature menopause and
atrophic vaginitis (see Evidence-Based Practice box).
EVIDENCE-BASED PRACTICE
Vaginal candidiasis, bacterial vaginosis, and trichomoniasis
are the three most common causes of vaginitis.
In a systematic review of the literature, Anderson et al
(2004) report that symptoms alone are not able to adequately
distinguish between the causes of vaginitis and that physical
findings are limited in their diagnostic power. Laboratory examination and microscopy of vaginal discharge are the most
useful ways of diagnosing the three conditions.
However, the following symptoms and signs can suggest
a particular diagnosis:
• Candidiasis is associated with itching, a cheesy dis-
charge, redness, and self-diagnosis. A watery discharge
makes candidiasis unlikely. Inflammatory signs are relatively specific for vaginal candidiasis but are not always
present. Odor on physical examination is absent.
• Bacterial vaginosis is associated with increased discharge
and a patient report of odor. An absent or mild discharge
makes bacterial vaginosis unlikely. Odor is noted on physical
examination.
Data from Anderson MR, Klink K, Cohrssen A: Evaluation of vaginal complaints, JAMA 291:1368, 2004.
Clinical Diagnosis of Vaginitis
Most diagnoses are made by microscopy and the
whiff test. Anderson et al (2004) also report the following
findings:
• Most studies (but not all) support that candidiasis is
associated with a normal pH.
• Although the microscopic identification of yeast or tricho-
monads is diagnostic, negative findings do not rule out
the condition.
• The presence of clue cells makes candidiasis less likely.
• A lack of lactobacilli and the presence of bacilli with
corkscrew motility are highly associated with bacterial
vaginosis.
The authors conclude that the likelihood ratios found in
the review were not particularly robust, that the current research on vaginitis has a number of weaknesses, and that
the existing diagnostic approach fails to diagnose approximately 30% of women with vaginal symptoms.
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DIFFERENTIAL DIAGNOSIS
Discharges
Physiological Discharge
Normal vaginal discharge is produced by the cervical
and vulvar glands. It is mucoid, clear, or white in color
and has no foul odor. The amount varies from scant to
profuse, depending on the amount of estrogen stimulation to the tissues. On occasion physiological discharge can lead to slight vulvar irritation and mild
itching secondary to wetness. The vaginal pH is less
than 4.5. Wet mount reveals up to 3 to 5 white blood
cells (WBCs)/high-power eld (HPF) and the presence of epithelial cells and lactobacilli.
Bacterial Vaginosis
BV is the most common cause of vaginal discharge
and is considered a disturbance in normal vaginal
ora. It is often found after intercourse with a new
partner or in conjunction with other STIs. Fifty percent of women are asymptomatic; hence, treatment
may not be necessary except for pregnant patients
(increased preterm labor) or patients undergoing vaginal surgical procedures (increased infection). Consistent symptomatology includes a thin homogeneous
white, gray, green, or brownish discharge that has a
foul odor; there can be pelvic tenderness or pain but
no CMT. The vaginal pH is greater than 4.5. Wet
mount shows clue cells and a few lactobacilli; the
“whiff” test is positive (see Figure 34-1).
Candida Vulvovaginitis
Ninety percent of women with Candida vulvovaginitis present with vulvar pruritus. In children, it may
be accompanied by oral thrush. The discharge is
often thick, white, and “curdy”; the labia are erythematous and edematous. Vaginal pH is 4.0 to 4.7.
A KOH wet mount shows pseudohyphae and spores
(see Figure 34-1).
Trichomoniasis
Trichomoniasis is asymptomatic in about half of the
women affected and 90% of the men. It is usually
transmitted via sexual contact but can also be spread
by fomites. Women with chronic infections will have
copious amounts of discharge and little or no inammation of the vaginal tissues. When there is an acute
infection, they will report vulvar itching, swelling,
and redness. The pH is greater than 5; the discharge
is white, grayish-green, or yellow and sometimes
frothy; infrequently there will be a “strawberry cer-
vix” (cervical petechiae). If the woman has douched
within the past 24 hours, the sensitivity of tests will
be greatly decreased. Wet mount shows “gyrating”
motile protozoa and often greater than 10 WBCs/
HPF (see Figure 34-1).
Atrophic Vaginitis
In atrophic vaginitis, there is a dry (shiny), pale, thin
vaginal wall caused by an insufcient amount of endog-
enous estrogen. During menopause, the vaginal mucosa
and vulva, which lack glycogen, become fragile and are
susceptible to injury and infection. Patients may experi-
ence burning, dryness, irritation, or dyspareunia. This
also occurs in postpartum women, those who are breast-
feeding, and prepubertal girls. The pH is alkaline and
ranges from 6.5 to 7.0. Wet mount shows a few WBCs
and is negative for pathogens.
Allergic Vaginitis
The causes of allergic vaginitis are different for the
child and the adult. In the child, the most common
offending agents are bubble baths and perfumed soaps.
Adult vulvovaginitis involves any harsh or caustic sub-
stance that has direct contact with the area. Often a new
brand of vaginal lubricant, douche, spermicide, or con-
dom will cause the inammation and edema. Vinegar
douches stronger than 1 to 2 tablespoons per quart of
water may also irritate tissues. The wet mount is posi-
tive for WBCs and negative for pseudohyphae.
Foreign Body
The presenting symptom in foreign body retention is
a very malodorous, whitish discharge. In children,
the foreign body is as variable as those objects found
in the ears and nose. However, children younger than
12 months do not have the coordination to insert
anything into their vagina, so suspect child abuse in
such cases and inspect for bruising or excoriations.
Wet mount reveals many WBCs.
Chlamydia
Chlamydia is the most prevalent STI in the
United States. About 30% of infected women are as-
ymptomatic. Gonorrhea and Chlamydia coexist in up
to 60% of patients. Women with Chlamydia have an
increasing amount of vaginal discharge and bleeding
after intercourse. Those patients at greatest risk for
420 Chapter 34 • Vaginal Discharge and Itching
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infection are younger than 25 years, sexually active
with three or more partners, and not using barrier
methods of contraception. Wet mount shows greater
than 10 WBCs/HPF and few microscopic bacteria.
Except for perinatal syndromes, nonsexual transmission has not been reported; therefore, suspect child
abuse in children with Chlamydia infection.
Gonorrhea
Gonorrhea is one of the most common reportable diseases. Women are asymptomatic 50% to 80% of the
time. However, the patient may have purulent discharge
that originates from the endocervical columnar and transitional cells. Patients often experience inammation of
Skene glands, Bartholin glands, or the urethra, which
causes pain and dysuria. Culture or DNA probe conrms
the diagnosis. A nding of gonorrhea in children is considered specic evidence of sexual abuse.
Pelvic Inflammatory Disease
PID is most commonly caused by Chlamydia trachomatis and N. gonorrhoeae (see Chapter 2) and can
produce bleeding, abdominal pain, fever, and vaginal
discharge. Women with PID have an increasing
amount of vaginal discharge and bleeding after intercourse. Infection begins intravaginally in most cases
and then spreads upward, causing salpingitis. In the
early stages, women may be asymptomatic. Patients
may have a purulent discharge that originates from the
endocervical columnar and transitional cells. With
gonorrhea, patients often experience inammation of
Skene glands, Bartholin glands, or the urethra, which
causes pain and dysuria. On examination, abdominal
tenderness, CMT, and adnexal tenderness is present.
As with peritonitis, patients may also have guarding
and rebound tenderness. WBCs and erythrocyte sedimentation rate are usually elevated. Cultures and
Gram staining can assist with diagnosis.
Itching and Lesions
Syphilis
The chancre of primary syphilis is an ulcerative lesion
that most often develops at the site of initial inoculation. The syphilitic chancre begins as a papule and
progresses to a painless to tender, hard, indurated ulcer.
The infection causes inguinal lymphadenopathy. Even
without treatment, the lesion will heal in 3 to 6 weeks.
Many chancres go unnoticed until the appearance of
condylomata lata, the warty papule of secondary syphilis, or a maculopapular rash on the palms of the hands
and soles of the feet. Diagnosis is conrmed with serological testing for syphilis.
Genital Warts
Genital warts (condylomata acuminata) are caused by
the human papillomavirus and may be precursors to
genital cancers. The warts may involve the vagina,
cervix, perineum, or perianal areas. Condylomata can
be at or raised verrucous lesions. The patient usually
notices a bump on the genital region, accompanied by
itching and leukorrhea. A wet mount should be performed to rule out any coexisting vaginal infections.
An acetic acid test is helpful in identifying at warts.
Referral to a dermatologist or gynecologist is indicated
for treatment of warts of the urethra or anus.
Herpes
Herpetic lesions can be difcult to distinguish from
ulcerative lesions. The most typical presentation is that
of grouped vesicles that rupture and leave an erosion.
A prodrome of tingling or itching occurs before the
outbreak of the vesicles. On the vulva, the erosions are
covered with a whitish, exudative layer. Herpetic outbreaks can involve the cervix, vagina, vulva, anus, or
extragenital organs, like the pharynx. Culture, antigen
test, or Tzanck smear conrms the diagnosis.
If the mother has an active primary herpes simplex
virus infection at the time of birth, the infant has a 50%
risk of becoming infected. Recurrent maternal infections
impart less than a 5% risk of transmission. Clinical signs
of the infant’s infection become apparent in the rst
week of life and pose the possibility of death.
Molluscum Contagiosum
Molluscum are small (2 to 5 mm in diameter), umbilicated, esh-tone papules. These characteristic lesions
are the hallmark of the diagnosis. Scratching can spread
them. Molluscum is an STI of adults and is a likely
nding in HIV-infected patients. When children are
found to have genital molluscum, suspect child abuse.
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