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Key Features

Essentials of Diagnosis

  • Vaginal irritation

  • Pruritus

  • Abnormal or malodorous discharge

General Considerations

  • Inflammation and infection of the vagina are common

  • Vaginitis results from a variety of pathogens, allergic reactions to vaginal contraceptives or other products, vaginal atrophy, or the friction of coitus

  • The normal vaginal pH is 4.5 or less, and Lactobacillus is the predominant organism

  • Normal secretions can be confused with vaginitis by concerned women

Candida albicans

  • Pregnancy, diabetes, and use of broad-spectrum antibiotics or corticosteroids predispose to Candida vaginitis

  • Heat, moisture, and occlusive clothing also contribute to its risk

Trichomonas vaginalis

  • This protozoal flagellate infects the vagina, Skene ducts, and lower urinary tract in women and the lower genitourinary tract in men

  • It is sexually transmitted

Bacterial vaginosis

  • This condition is a polymicrobial overgrowth of Gardnerella vaginalis and other anaerobes and is not sexually transmitted

Condylomata acuminata (genital warts)

  • Caused by various types of the human papillomavirus

  • Sexually transmitted

  • Pregnancy and immunosuppression favor growth

Clinical Findings

Symptoms and Signs

  • Careful history regarding

    • Onset of the last menstrual period

    • Recent sexual activity

    • Use of contraceptives, tampons, or douches

    • Recent changes in medications or use of antibiotics

    • Vaginal burning, pain, pruritus

    • Profuse or malodorous discharge

  • Physical examination: careful inspection of the vulva and speculum examination of the vagina and cervix

Candida albicans

  • Pruritus

  • Vulvovaginal erythema

  • White curd-like discharge that is not malodorous

Trichomonas vaginalis

  • Pruritus and a malodorous frothy, yellow-green discharge

  • Diffuse vaginal erythema and red macular lesions on the cervix in severe cases ("strawberry cervix")

Bacterial vaginosis

  • Copious grayish, frothy, malodorous discharge

  • No obvious vulvitis or vaginitis

Condylomata acuminata

  • Warty growths on the vulva, perianal area, vaginal walls, or cervix

  • There may be fissures at the fourchette

  • Vaginal lesions may show diffuse hypertrophy or a cobblestone appearance

Differential Diagnosis

  • Normal vaginal discharge

  • Gonococcal infection

  • Chlamydial infection

  • Atrophic vaginitis

  • Friction from intercourse

  • Reaction to douches, tampons, condoms, soap

Diagnosis

Laboratory Tests

  • A vaginal, cervical, or urine sample can be obtained for detection of gonococcus and Chlamydia, if clinically indicated

  • The vaginal pH is frequently > 4.5 in infections due to trichomonads (pH of 5.0–5.5) and bacterial vaginosis

  • Examine a specimen of vaginal discharge microscopically:

    • In a drop of 0.9% saline solution (wet mount), search for motile organisms with flagella (trichomonads) and for epithelial cells covered with bacteria to such an extent that cell borders are obscured (clue cells)

    • In a drop of ...

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