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Home Books The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e

Chapter 49. Vaginitis

Carol K. Bates, MD

A 21-year-old woman is upset to report vaginal discharge. The discharge has been present for the past 10 days. She has never had this before and appears to be very anxious.

  • What additional questions would you ask to learn more about her discharge?
  • Why do you think that she is anxious, and how will you explore that with her?
  • What associated symptoms might she have?
  • What will you need to know about her sexual history?

Vulvovaginal symptoms are among the most common reasons that patients consult a primary care physician. It is difficult to assess the actual prevalence of vulvovaginitis because many patients treat their own symptoms with over-the-counter medications and never seek medical advice.

Although not usually life threatening, recurrent or chronic vulvovaginal complaints often involve significant discomfort, sexual dysfunction, and emotional distress. Most patients will ultimately prove to have a benign cause of vaginitis, but vaginal symptoms may indicate more serious upper genital tract disease requiring urgent evaluation and treatment. Clinicians should not rely on history alone and should confirm the suspected diagnosis with pelvic examination and microscopy.

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VaginitisInflammation of the vagina characterized by vaginal soreness and/or itching, usually but not always accompanied by vaginal discharge. A summative term used to describe a variety of vaginal complaints.
Vaginal dischargeVaginal fluid composed of cervical mucus, exfoliated epithelial cells, bacteria, and vaginal secretions. Normally, it is odorless and white or clear in appearance. The appearance and amount of vaginal discharge vary with estrogen and progesterone levels, irritation, and infection.
VulvitisSymptoms of irritation felt externally in the vulva. The irritation is not always accompanied by an increase or change in vaginal discharge.
VulvovaginitisIrritation felt externally in the vulva and internally in the vagina.
CervicitisIrritation or infection that primarily involves the cervix and can cause vaginal discharge. Usually the vulva is spared.
DyspareuniaDiscomfort during intercourse. The discomfort may be superficial (pain on initial penetration or with attempted penetration) or deep (related to deep penetration only).
DysuriaPain or burning with urination.
PruritusItching.
Upper genital tractThe upper genital tract includes the ovaries, fallopian tubes, and uterus.
Lower genital tractThe lower genital tract includes the vagina, vulva, and other external structures. The cervix is in the lower tract but is the portal to the upper tract and so may be involved in upper tract processes.
Sexually transmitted infection (STI)Infection anywhere in the genital tract transmitted via interpersonal genital contact. Includes infection with chlamydia, gonorrhea, syphilis, herpes simplex, and Trichomonas.
Pelvic inflammatory disease (PID)Infection involving the uterus, fallopian tubes, and ovaries, which can lead to peritonitis.
Toxic shock syndrome (TSS)Life-threatening syndrome of fever, hypotension, multiorgan failure, and rash caused by enterotoxins produced by Staphylococcus aureus or group A Streptococcus. Associated with the use of highly absorbent tampons or foreign bodies left in the vagina for prolonged periods.
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