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Chapter 36 • Vaginal Bleeding
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429
followed by abnormal bleeding. They may have some
symptoms of pregnancy (e.g., breast tenderness, nausea, and vomiting), have passed some tissue (decidual
cast), or have experienced fainting or dizziness.
Ninety percent of ectopic pregnancies are implanted
in the fallopian tube. About half of these women
will have an adnexal mass. Diagnosis is made through
serial quantitative hCG testing and transvaginal
ultrasound.
Leiomyomas (Myomas or Fibroids)
Fibroids are found in about 25% women over age 35.
They are more frequently found in African American
women than in white women, and they usually decrease in size after menopause. Depending on location, they are associated with infertility in 2% to
10% of patients. These benign tumors are estrogendependent and may grow during hormone therapy.
The most frequent symptom of leiomyomas is bleeding, which ranges from slightly heavier menstrual
ow to continuous bleeding. Fibroids may occur as
single or multiple tumors within the uterine layers or
they can be pedunculated. Pain is not a common
complaint of women with broids unless there has
been strangulation of a pedunculated broid, degeneration of a large broid, or compression of other
organ systems.
Adenomyosis
Adenomyosis is a condition in which there are endometrial glands and stroma within the myometrium of
the uterus. It is more common in multiparous women
and occurs in the later reproductive years. The uterus is
2 to 3 times its normal size, and there is often dysmenorrhea and infertility. Adenomyosis often coexists
with uterine broids. Ultrasound may not identify this
diffuse intramural lesion. Adenomyosis is found in
20% of hysterectomy specimens.
Uterine/Endometrial Cancer
Endometrial cancer is now the most common female
genital cancer in the United States. The average age
at diagnosis is 61 years, but it can occur at any time
during the reproductive and postmenopausal years.
Uterine cancer risk factors are anovulatory states
(e.g., obesity), endometrial hyperplasia (e.g., unopposed estrogen), and family history (see Box 36-2).
Classic symptoms include painless vaginal bleeding
and a rapidly enlarging uterus. Late symptoms, such
as weight loss and weakness, are those of systemic
disease.
Systemic Causes of Vaginal Bleeding
Anovulatory Cycles
Perimenopause. The perimenopausal years occur
from ages 40 to 50 and last about 7 to 10 years. The
perimenopausal woman experiences irregularities in
her menstrual ow. Often she has spotting, followed
by 1 or 2 days of heavy bleeding, or she has her regular
menstrual ow and a few days of spotting at the end of
the cycle. These types of irregular patterns are characteristic of a degenerating corpus luteum function.
EVIDENCE-BASED PRACTICE
This systematic review and meta-analysis evaluated prospective studies of pregnant women with abdominal pain or vaginal bleeding. Patient history, physical examination, laboratory
values, and sonography were compared to a reference standard of either direct surgical confirmation of ectopic pregnancy or clinical follow-up. Fourteen studies with 12,101
patients were included. The patient history and symptoms
were not helpful in diagnosing ectopic pregnancy. Cervical
motion tenderness, adnexal mass on bimanual examination,
abdominal pain with cough, or tenderness during light palpation suggested ectopic pregnancy. The absence of cervical
motion tenderness, peritoneal findings, adnexal mass, or adnexal tenderness did not decrease the likelihood of an ectopic
Reference: Crochet JR, Bastian LA, Chireau MV: Does this woman have an ectopic pregnancy? The rational clinical examination systematic review,
JAMA 309:1722, 2013.
Does This Patient Have an Ectopic Pregnancy?
pregnancy. No single quantitative serum human chorionic
gonadotropin (hCG) value determined ectopic pregnancy.
Transvaginal sonography was most useful in diagnosing ectopic pregnancy. The presence of an adnexal mass along with
the absence of an intrauterine pregnancy indicated a high
likelihood of an ectopic pregnancy. The sensitivity of transvaginal sonography to detect ectopic pregnancy was 88%
with specificity at 99%.
The authors concluded that patient history and clinical
examination alone are insufficient to determine the presence
of an ectopic pregnancy. When the patient is hemodynamically stable, the appropriate evaluation includes transvaginal
sonography and serial quantitative serum hCG testing.
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Chapter 36 • Vaginal Bleeding
A woman who has had 1 year of irregular periods and
who has missed the past three cycles can be clinically
diagnosed as being in perimenopause (a synonymous
term is climacteric). The perimenopause progresses to
menopause when the FSH level is greater than 40 mIU/
mL or there are no periods for a full year. An FSH level
of 30 mIU/mL is typical of perimenopause.
Perimenarche. With perimenarche, the patient has
a history of beginning her menstrual cycles and then
experiencing months of amenorrhea, followed by resumption of regular cycles, caused by an immature
hypothalamic-pituitary-ovarian axis. The menstrual
ow may be heavier, more frequent, or longer than
normal. The young adolescent has appropriate secondary sexual characteristics and sexual maturity ratings.
These symptoms are characteristic of anovulatory
cycles.
Newborn. A bloody vaginal discharge may occur
normally in the female newborn because of maternal
estrogen hormone withdrawal during the rst few
weeks of life.
Endocrinopathies
Polycystic ovary syndrome. In PCOS, the patient typ-
ically is obese, hirsute, and has oligomenorrhea and
large cystic ovaries. However, women with chronic anovulatory cycles and hyperandrogenemia meet the
criteria for PCOS even if they are slim and without
hirsutism. The LH/FSH ratio is greater than 3:1.
Dehydroepiandrosterone-sulfate levels are elevated.
Thyroid dysfunction. Both hypothyroidism and
hyperthyroidism are associated with abnormal menstrual bleeding. Menorrhagia can occur with hypothyroidism, whereas oligomenorrhea or scant menses may
occur with hyperthyroidism.
With hypothyroidism, the patient may also experience delayed growth, weight gain, fatigue, constipation,
and cold intolerance. On physical examination, you may
note dry skin, coarse hair, and galactorrhea. The TSH
level will be high.
With hyperthyroidism, the patient may experience
weight loss, nervousness, heat intolerance, and palpitations. On physical examination, the skin may be moist
and sweaty, the hair thin, and the pulse rate rapid. The
thyroid gland may be enlarged or nodular. The TSH
level will be low, with high triiodothyronine (T3) and
thyroxine (T4) levels.
Hyperprolactinemia. Prolactin inhibits gonadotro-
pin release and causes anovulatory cycles that may be
associated with irregular and sometimes heavy bleeding or with amenorrhea (see Chapter 5). Galactorrhea
often accompanies hyperprolactinemia. Nipple discharge will be negative for red blood cells. Prolactin
levels will be elevated. Thyroid function tests can rule
out hypothyroidism. Magnetic resonance imaging or
computed tomography scans along with a cone view
of the sella turcica assists in the diagnosis of pituitary
tumor.
Vaginal Infection
Atrophic vaginitis. In atrophic vaginitis, there is a dry
(shiny), pale, thin vaginal wall caused by an insufcient
amount of endogenous estrogen. During menopause,
the vaginal mucosa and vulva, which lack glycogen,
become fragile and are susceptible to injury and infection. The patient may experience burning, dryness, irritation, dyspareunia, or atrophic vaginitis. This also
occurs in the postpartum woman, the woman who is
breastfeeding, or the prepubertal girl. The pH is alkaline
and ranges from 6.5 to 7.0. Wet mount reveals a few
WBCs and is negative for pathogens.
Endometritis. Endometritis is an infection of the
endometrium, in which chlamydia is the cause about
25% of the time. Group A or B streptococci produces
puerperal sepsis and may lead to peritonitis, abscess,
thrombophlebitis, disseminated intravascular coagulation, septic shock, and infertility. The woman has a
slight vaginal discharge (lochia) that is bloody
or purulent. The bleeding is accompanied by fever
(temperature 39° C to 39.8° C [102° F to 103° F]) and
uterine tenderness often within the rst 24 hours after
delivery. Endometritis should be suspected in a woman
with these symptoms, especially if she has undergone
an emergency cesarean section or an intrauterine manipulative procedure. Other contributing factors for
endometritis are premature rupture of membranes and
prolonged labor.
Pelvic inammatory disease. PID is most com-
monly caused by Chlamydia trachomatis or Neisseria
gonorrhoeae (see Chapter 3) and can produce bleed-
ing, 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, there is abdominal, cervical
motion, and adnexal tenderness. As with peritonitis,
Chapter 36 • Vaginal Bleeding
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431
patients may also have guarding and rebound tender-
ness. WBCs and erythrocyte sedimentation rate are
usually elevated. Cultures, DNA testing, and Gram
staining can assist with the diagnosis (see Chapter 37).
Genital warts. Genital warts (condylomata acu-
minata) are caused by the human papillomavirus and
may be precursors to genital cancer. 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 leukor-
rhea. A wet mount should be performed to rule out
any coexisting vaginal infections. An acetic acid test
is helpful in identifying at warts. Refer to a derma-
tologist or gynecologist for treatment of warts of the
urethra or anus.
Foreign body. In foreign body retention, the
presenting symptom is a very malodorous, whitish
discharge. In children, the foreign body is as variable
as those objects found in the ears and nose. Children
younger than 12 months do not have the coordination
to insert anything into their vagina; suspect child abuse
in those cases and inspect for bruising or excoriations.
Wet mount reveals many WBCs.
Blood Dyscrasias
von Willebrand disease. von Willebrand disease is a
congenital autosomal dominant bleeding disorder characterized by altered factor VIII activity and decient
platelet function. The patient has a prolonged bleeding
time. Hypermenorrhea may occur at menarche or may
begin in women 20 to 30 years of age.
Leukemia. Hypermenorrhea may be one of the
chief concerns of the woman presenting with leukemia.
Other symptoms may include fatigue, bruising, and
lymph node enlargement. The CBC and bleeding times
will direct the workup for this diagnosis.
Other
Medications. Drugs such as rifampin, phenytoin, car-
bamazepine, and phenobarbital reduce the efcacy of
oral OCs. If the woman is on a low-estrogen-dose OC,
this is likely to be the cause of irregular vaginal bleeding. Changing the OC to a higher estrogenic potency
will alleviate the bleeding. Tamoxifen, which acts as an
antiestrogen on breast tissue, has estrogenic effects on
the endometrium and can cause endometrial hyperplasia and/or endometrial cancer. The symptom is vaginal
bleeding.
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
ORGANIC CAUSES OF VAGINAL BLEEDING
Pregnancy
Spontaneous abortion Vaginal bleeding following time
Threatened abortion Vaginal bleeding following
Placenta previa Late pregnancy: bright red,
Placenta abruptio Dark red, painful bleeding; any
Ectopic pregnancy Painless vaginal bleeding;
Leiomyomas Heavier menstrual bleeding;
Common Causes of Vaginal Bleeding
Implantation bleeding; breast
tenderness, nausea and
vomiting
of amenorrhea; cramping,
passage of tissue; history of
miscarriages
time of amenorrhea; mild
cramping
painless bleeding
time after 20 wk of gestation
multiparity, older gravida,
multiple gestation; history
of PID, infertility, STIs
menorrhagia
Internal cervical os closed; minimal
spotting; globular, enlarged
uterus; soft, bluish color cervix
Internal cervical os open; blood
from cervical os
Fetal activity present; internal
cervical os may be open
Fetal activity present; uterus is
nontender, normal resting tone
Vaginal bleeding; uterus tender
with tone; signs of fetal distress
Internal cervical os closed; bloody
discharge present
Enlarged uterine size; firm,
spherical masses; nontender
Pregnancy test; b-hCG
positive
Serial declining b-hCG
levels; ultrasound
negative
b-hCG positive;
ultrasound positive
Ultrasound
Rule out placenta pre-
via with ultrasound
b-hCG positive; ultra-
sound; laparoscopy
Pelvic examination;
ultrasound
Continued
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Chapter 36 • Vaginal Bleeding
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Vaginal Bleeding—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
ORGANIC CAUSES OF VAGINAL BLEEDING—cont’d
Adenomyosis Worsening menorrhagia;
dysmenorrhea
Uterine/endometrial
cancer
SYSTEMIC CAUSES OF VAGINAL BLEEDING
Anovulatory Cycles
Perimenopause
Perimenarche History of beginning menses
Newborn
Endocrinopathies
Polycystic ovary
syndrome
Thyroid dysfunction Hypothyroid: menorrhagia,
Hyperprolactinemia Menometrorrhagia,
Rapidly enlarging uterus;
painless menorrhagia;
pelvic pressure; weight
loss, weakness
Irregular menses, amenorrhea
coupled with heavier and
longer menstrual cycles;
hot flashes, night sweats,
insomnia, mood changes
within last 1-2 yr; amenorrhea followed by irregular
menstrual cycles that are
heavy, frequent, or of long
duration
Less than 2 mo old
Infertility; irregular menstrual
cycles
delayed growth, weight gain,
fatigue, constipation, cold
intolerance
oligomenorrhea
Pelvic enlargement (2-3 times normal
size)
Enlargement of uterus, often
symmetrical; fixed with advanced
disease
Pale, dry vaginal mucosa, few rugae FSH and LH high;
Physical examination normal;
secondary sexual characteristics
present
Small amount of vaginal spotting History and
Hirsute; obese; enlarged ovaries Pelvic examination;
Hypothyroid: dry skin, fine hair,
galactorrhea
Bilateral, multiduct, clear-to-white
nipple discharge
Pelvic examination;
ultrasound not
always helpful
Endometrial biopsy;
D&C; ultrasound;
CT or MRI
estradiol low
History and
examination
examination
ultrasound; enlarged ovaries with
multiple fluid-filled
cysts
TSH high
Serum prolactin level;
MRI if indicated
Vaginal Infection
Atrophic vaginitis Dyspareunia; vaginal dryness Pale, thin vaginal mucosa; brown or
Endometritis History of emergency cesarean
Pelvic inflammatory
disease
Genital warts Mild-to-moderate itching; foul
section, PROM, prolonged
labor, intrauterine manipulative procedures
History of PID; chronic
vaginitis; STIs
vaginal discharge; child:
history of sexual abuse;
adult: new or multiple
partners; history of warts
bloody discharge; pH .4.5
Tenderness of uterus on bimanual
examination; temperature 102°103° F; discharge or lochia may
be purulent
Bilateral abdominal pain following
menses; pelvic mass; cervical
motion tenderness; vaginal discharge; temperature .100.4° F
Moist, pale pink, verrucous projec-
tions on base; located on vulva,
vagina, cervix, or perianal area;
bleeding with trauma
Folded, clumped
epithelial cells
WBC .10,000/mm
WBC, ESR; Gram
staining, cultures,
DNA testing
Acetic acid test: white
3
Chapter 36 • Vaginal Bleeding
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433
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Vaginal Bleeding—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Foreign body Red and swollen vulva; vaginal
discharge; history of use
of tampon, condom, or
diaphragm
Blood Dyscrasias
von Willebrand
disease
Leukemia Menorrhagia; fatigue usually
Other
Medications
CT, Computed tomography; D&C, dilation and curettage; ESR, erythrocyte sedimentation rate; FSH, follicle-stimulating hormone; hCG, human cho-
rionic gonadotropin; LH, luteinizing hormone; MRI, magnetic resonance imaging; OC, oral contraceptive; PID, pelvic inflammatory disease; PROM,
premature rupture of membranes; STI, sexually transmitted infection; TSH, thyroid-stimulating hormone; WBC, white blood cell count.
Menorrhagia, adolescent Bruising; petechiae; gingival
,3 mo duration
Taking rifampin, phenytoin, car-
bamazepine, or phenobarbital
while on low-estrogen-dose
OC; tamoxifen
Foreign body present (tampon,
condom); bloody, foul-smelling
discharge
bleeding
Fever, bruising, pallor; lymph node
enlargement; hepatic or splenic
enlargement
Normal gynecological examination Bleeding stops with
Wet mount: many
WBCs, no pathogens; history and
examination
Bleeding time, factor
VIII deficiency,
decreased platelets
WBCs: 1000-
400,000/mm3,
leukocytosis with
immature blasts
or cells; anemia,
thrombocytopenia,
decreased factor
V or VIII
higher estrogen
dose OC; endometrial biopsy
References and Readings
Albers JR, Hull SK, Wesley RM: Abnormal uterine bleeding, Am
Fam Physician 69:1915, 2004.
Benjamins LJ: Practice guideline: Evaluation and management of
abnormal vaginal bleeding in adolescents, J Pediatr Health Care
23:189, 2009.
Brown DL: Congenital bleeding disorders, Curr Probl Pediatr
Adolesc Health Care 35:38, 2005.
Casablanca Y: Management of dysfunctional uterine bleeding,
Obstet Gynecol Clin North Am 35:219, 2008.
Cirilli AR, Cipot SJ: Emergency evaluation and management of
vaginal bleeding in the nonpregnant patient, Emerg Med Clin
North Am 30:991, 2012.
Davidson BR, Dipiero CM, Govoni KD, et al: Abnormal uterine
bleeding during the reproductive years, J Midwifery Womens
Health 57:248, 2012.
Deligeoroglou E, Karountzos V, Creatsas G: Abnormal uterine
bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology, Gynecol Endocrinol 29:74, 2013.
Ely JW, Kennedy CM, Clark EC, et al: Abnormal uterine bleeding:
A management algorithm, J Am Board Fam Med 19:590, 2006.
Gray SH: Menstrual disorders, Pediatr Rev 34:6, 2013.
Huancahuari N: Emergencies in early pregnancy, Emerg Med Clin
North Am 30:837, 2012.
Mahoney S, Parker C, Potlog-Nahari C, et al: Abnormal uterine
bleeding: A primary care primer, Consultant 46:225, 2006.
Sokkary N, Dietrich J: Management of heavy menstrual bleeding in
adolescents, Curr Opin Obstet Gynecol 24:275, 2013.
Strickland J, Gibson EJ, Levine SB: Dysfunctional uterine bleeding
in adolescents, J Pediatr Adolesc Gynecol 19:49, 2006.
CHAPTER
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Vaginal Discharge
37
aginitis is an inammation of the vagina that can
V
cause vaginal discharge. Vaginal infections are
common in postpubertal women. Trichomonas vagina-
lis, Candida, and bacterial vaginosis (BV) account for
95% of all vaginal infections in women in the United
States. Often patients have more than one infection at
a given time.
Some studies suggest that pregnant women with
BV have premature rupture of membranes and early
delivery. The most common cervical infections are
Chlamydia trachomatis, Neisseria gonorrhoeae, and
herpes simplex. Postmenopausal women often have
discharge related to atrophic vaginitis, caused by the
deciency of estrogen in the vaginal tissues.
Vulvar itching, burning, and a foul odor often
accompany vaginal discharge. Pubic lice, scabies,
pinworms, and genital warts (condylomata acuminata) can all cause itching. Common foreign bodies
found in the vagina of adult women are lost or forgotten tampons, which can produce a foul-smelling
discharge.
Vulvovaginitis is one of the most common gynecological disorders in young females as a result of
their hypoestrogenic state and their perineal hygiene,
which is often poor. Also, the vaginal mucosa is
thin and less resistant to infectious organisms. The
postmenopausal woman may experience these same
symptoms with estrogen deciency. Chemical vaginitis in a young girl is usually 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.
In childhood and adolescence, reports of vulvar
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 activities, environment, and baths) lead to this
complaint.
and Itching
DIAGNOSTIC REASONING: FOCUSED
HISTORY
What kind of vaginitis might this be?
Key Questions
l
What is the amount, color, and consistency of your
discharge?
l
Do you have itching, swelling, or redness?
l
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, curdlike 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 37-1).
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 an 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
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435
A
FIGURE 37-1 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
by the addition of potassium hydroxide (KOH) to the
wet mount slide and is considered a positive “whiff”
test. Odor commonly accompanies trichomonal infec-
tions. Retained tampons or other foreign bodies can
also cause a foul odor.
Is this likely a sexually transmitted infection?
Key Questions
l
Are you sexually active? Do you have multiple
partners? Do you have a new partner?
l
Have you had sex against your will? If a child, you
might ask, “Has anyone touched your private parts?”
l
What form of protection do you use? How often do
you use protection?
l
Have you or your partner(s) ever been tested or
treated for a sexually transmitted infection (STI)?
l
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, increase the risk of vaginal infection. STIs
are common in women of childbearing age (12 to
50 years) who have acquired a new partner, but the
highest prevalence is in sexually active females
younger than 24 years old. The patient who frequently
changes sexual partners or participates in risky sexual
practices (e.g., anal 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
C
active. Also, 50% of all children with an STI have been
found to be 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 the inner thighs. Typically,
condylomata acuminata (genital warts) are rough, verrucous lesions that are usually located inferiorly from
the fossa navicularis to the fourchette and 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
l
Have you ever been told that you have diabetes,
Cushing syndrome, or human immunodeciency
virus (HIV) infection?
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Chapter 37 • Vaginal Discharge and Itching
l
Have you been ill recently?
l
Are you taking antibiotics, hormones, or oral contra-
ceptive pills?
l
Have you received chemotherapy?
l
Does the itching seem to be worse at night?
l
Can you describe some of your recent activities?
l
If an adolescent: Have you had a menstrual period?
Immunocompromised States
Refractory fungal vulvovaginitis may indicate undiagnosed 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 vulvovaginitis. Oral contraceptives can alter the vaginal pH, and
antibiotics can alter the normal vaginal ora; both
predispose to fungal infection. Corticosteroids and
chemotherapy 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 37-2).
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
l
How long have you had these symptoms?
l
Are they getting better or worse?
l
Have you ever had these symptoms before?
l
How many episodes have you had in the past year?
l
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 an
STI. Symptoms associated with use of condoms or
spermicidal jelly suggest sensitivity to the product. If
the discharge occurs monthly with worsening after
menses, suspect a chronic condition, such as vulvovaginitis candidiasis. Recurrent episodes related to
bathing activities point to chemical irritation.
FIGURE 37-2 Pinworms (Enterobius vermicularis). A, On this wet mount, a mature worm is shown sur-
rounded by eggs. B, Eggs are shown more clearly at higher power. (From Zitelli BJ, Davis HW: Atlas of
pediatric physical diagnosis, ed. 3, St Louis, 1997, Mosby-Wolfe.)
BA
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If this is acute, could it be related to a previous infection?
Key Questions
l
Have you been tested and treated for this condition
recently? What medication was prescribed?
l
Did you take all of the medication?
l
What other prescriptions were you taking at that
time?
l
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 con-
comitant 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
Medication regimens that are not single dose present a
challenge to treatment completion. Women may stop us-
ing vaginal medications when menses begins and resume
after it ends. They may also discontinue the medication
early, as soon as symptom relief occurs, or if they have a
drug side effect (e.g., the metallic taste of metronida-
zole). Drug interactions may account for inadequate
therapy, or the intake of certain foods or substances, such
as alcoholic beverages, may need to be restricted.
If this is chronic, what should I suspect?
Key Questions
l
Have any family members or sexual partners re-
ported itching, rashes, sores, lumps, or bumps with
any vaginal or urinary tract infections? Do you have
a new or untreated partner?
l
What are your sexual practices (e.g., vaginal, oral,
anal sex)?
l
Have you had recurrent yeast infections in the past
year?
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. Oral contraceptives, hormone replacement therapy, antibiotics (e.g.,
tetracycline for acne), steroids, diets high in carbohydrates or articial sweeteners, and clothing that holds
moisture against the vulva (e.g., pantyhose, tight jeans)
are risk factors associated with vulvovaginitis.
What are other possible causes for this vaginitis?
Key Questions
l
What are your personal hygiene practices?
l
Do you douche?
l
Have you changed brands of contraceptive products?
l
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.
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.
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.
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.
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Chapter 37 • Vaginal Discharge and Itching
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?
Key Questions
l
Do you have burning or pain with urination? Do you
have urinary frequency or hesitation or nighttime
urination?
l
Is intercourse painful?
l
Do you have abdominal or pelvic pain?
l
If an infant: Does the infant have an eye infection?
l
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
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 dyspareunia. A more likely reason for deep
vaginal dyspareunia is endometriosis, pelvic inammatory disease (PID), or broids. STIs like gonorrhea
and chlamydia can cause cervicitis, which, if left
untreated, can progress to PID and produce abdominal
and/or pelvic pain (see Chapter 3).
Eye Infection
Eye infections in the newborn may be associated with
gonorrhea and chlamydia (see Chapter 30).
Cough
Pneumonia in the newborn may be an indication of
chlamydia (see Chapter 11).
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.
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
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 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—painful
vesicles on an erythematous base—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
perineal area.
In the overweight patient, vulvovaginitis candidiasis
is frequently accompanied by intertriginous candidiasis
(e.g., under the breasts and the abdominal apron).
In a young child it is important to tell her in simple
terms what you are about to do. A common position for
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