Approach to Vaginitis

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Clinical Features of Vaginitis

Variable Normal Vulvovaginal Bacterial Trichomoniasis candidiasis vaginosis

Sympotoms Normal or Pruritis, soreness Malodorous Malodorous, purulent mild transient change in dis- discharge, no discharge, dyspareunia charge, dyspa- dyspareunia reunia

Signs - Vulvar erythema, Adherent Purulent discharge edema, fissure discharge vulvovaginal erythema

pH 4.0-4.5 4.0-4.5 >4.5 5.0-6.0

Amine test Negative Negative Positive(about Often positive 70-80 percent)

Saline PMN:EC PMN:EC ratio PMN:EC <1; loss PMN++++; mixed microscopy ratio <1; <1; rods dominate; of rods; increased flora; motile rods dominate; squames +++; coccobacilli; clue trichomonads

(60 squames pseudohyphase cells (>90 per percent) +++ (about 40 percent) cent)

10 percent Negative Pseudohyphae Negative Negative potassium (about 70 percent) hydroxide examination

Miscellaneous - Culture if micro- Culture of no value Culture if micros scopy negative copy negative

Differential Physiologic Contact irritant Purulent vaginitis, diagnosis leukorrhea or allergic vulvitis desquamative chemical irritation, inflammatory focal vulvitis vaginitis, atrophic (vulvodynia) vaginitis plus secondary infection, erosive lichen planus

Characteristic of vaginal discharge

  • Trichomonas is classically associated with a purulent discharge.
  • Candidiasis with a thick, adherent, "cottage cheese-like" discharge.
  • Bacterial vaginosis presents with a thin, homogeneous, "fishy smelling" discharge.

The appearance of the discharge is unreliable and should never form the basis for diagnosis.

Cervical inflammation is suggestive of cervicitis rather than vaginitis. The cervix in women with cervicitis is usually erythematous and friable. Cervical erythema in this condition must be distinguished from ectropion, which represents the normal physiologic presence of endocervical glandular tissue on the exocervix. Ectropion is not friable and is more common in women taking oral contraceptives. Abdominal or cervical motion tenderness is suggestive of PID.

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