- • Patient complaints and sexual history.
- • Appearance of the discharge (character and color).
- • Vaginal pH higher than 4.5.
- • Presence of motile trichomonads, yeast or pseudohyphae,
or clue cells on light microscopy.
- • Positive “whiff” test.
Vaginal discharge is a common complaint that is often considered
trivial and thus incorrectly managed by the clinician. Empiric diagnosis
and treatment based on either history or appearance of the discharge
alone is inadequate and frequently results in inappropriate treatment
and repeated visits by the patient. When considering the etiology
of vaginitis it is important to take into account the patient’s
age and sexual history. Lactobacilli, the predominant bacteria in
the vagina of a healthy premenopausal woman, are typically absent
in women who are menopausal and not receiving estrogen replacement
therapy. The estrogen-deficient vaginal epithelium in postmenopausal
women is also thinner; thus, atrophic vaginitis is a consideration
in this age group. For sexually active women, sexually transmitted
diseases (STDs) such as trichomoniasis, genital herpes, gonorrhea,
and chlamydia should be considered.
The three major causes of vaginal discharge during the reproductive
years are candidiasis, bacterial vaginosis, and trichomoniasis.
The latter is the only one of the three that is known to be sexually
transmitted; however, bacterial vaginosis is clearly associated
with sexual activity. In addition, vaginal candidiasis is frequently
seen in the setting of increased sexual activity, likely due to
colonizing organisms that gain entry to the epithelium via microabrasions
from sexual intercourse. In older women, as previously mentioned,
atrophic vaginitis should be considered.
Other STDs, such as gonorrhea, chlamydia, and genital herpes,
may lead to vaginal complaints. However, the physical signs of gonorrhea
and chlamydia are cervical inflammation, not vaginal discharge.
Genital herpes may cause discharge along with ulceration.
Some other causes of vaginal discharge include retained foreign
body, cytolytic vaginosis, and desquamative inflammatory vaginitis.
It should be noted that some women perceive their vaginal discharge
to be abnormal when it is simply physiologic.
Use of condoms is protective against STDs and also appears to
protect against acquisition of bacterial vaginosis. If an STD is
diagnosed, the patient’s sex partners should be treated
to avoid reinfection. Episodes of recurrent bacterial vaginosis
may be prevented by use of twice weekly intravaginal metronidazole
gel. Similarly, recurrent vaginal candidiasis can be controlled
with use of once weekly fluconazole (150 mg). Estrogen replacement
therapy will prevent atrophic vaginitis.
Patients should be asked about the consistency and color of the
discharge and whether it is accompanied by pruritus (internal and
external), irritation, or a fishy odor. Another useful question
is whether a fishy odor is present after unprotected intercourse
(a characteristic finding in bacterial vaginosis). During the examination,
the clinician should note the presence or absence of vaginal ulcerations,
erythema, characteristics (color and consistency) of the discharge,
and the appearance of the cervix (mucopus at the os may suggest ...