A 39-year-old woman presented to her physician with a malodorous vaginal discharge. On exam, a thin white discharge was seen covering the introitus (Figure 82-1). A speculum exam revealed a thin whitish gray discharge and a distinct fishy odor. The pH of the discharge was 4.6, and 40% of the epithelial cells on her wet prep were clue cells (Figure 82-2). She was diagnosed with bacterial vaginosis and treated with oral metronidazole.
Thin white discharge from bacterial vaginosis seen covering the introitus prior to speculum exam. (Reproduced with permission from Seattle STD/HIV Prevention Training Center, University of Washington.)
A wet mount of vaginal discharge in saline under high-power light microscopy. Note the presence of vaginal epithelial cells, smaller white blood cells (polymorphonucleocytes), and bacteria. The bacteria are the coccobacilli of Gardnerella vaginalis covering the cell membranes of the two vaginal epithelial cells near the lower end of the field. These are clue cells seen in patients with bacterial vaginosis. (Reproduced with permission from Richard P. Usatine, MD.)
Vaginal discharge is a frequent presenting complaint in primary care. The three most common causes are bacterial vaginosis, candidiasis, and trichomoniasis. However, a significant number of patients with vaginal discharge will have some other condition, such as atrophic vaginitis. Providers must refrain from "diagnosing" a vaginitis based solely on the color and consistency of the discharge, as this may lead to misdiagnosis and may miss concomitant infections.1
The reported rates of chlamydia and gonorrhea are highest among females ages 15 to 19 years. Adolescents are at greater risk for sexually transmitted diseases (STDs) because they frequently have unprotected intercourse, are biologically more susceptible to infection, are often engaged in partnerships of limited duration, and face multiple obstacles to utilization of health care.1 Bacterial vaginosis, Candida vulvovaginitis, and trichomoniasis account for over 90% of vaginal infections.2
ETIOLOGY AND PATHOPHYSIOLOGY
The quantity and quality of normal vaginal discharge in healthy women vary. Physiologic leukorrhea refers to generally nonmalodorous, mucous, white or yellowish vaginal discharge in the absence of a pathologic cause. It is not accompanied by signs and symptoms, such as pain, pruritus, burning, erythema, or tissue friability. However, slight malodor and irritative symptoms can be normal for some women at certain times.3 Physiologic leukorrhea is usually a result of estrogen-induced changes in cervicovaginal secretions.
Noninfectious causes of vaginitis include irritants (e.g., scented panty liners, spermicides, povidone-iodine, soaps and perfumes, and some topical drugs) and allergens (e.g., latex condoms, topical antifungal agents, chemical preservatives) that produce hypersensitivity reactions.
Before starting an examination, determine whether the patient ...