Vaginal Discharge

Vaginal Discharge: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Physiologic discharge

❑ Candida vulvovaginitis

❑ Bacterial vaginosis

❑ Trichomonas vaginitis

❑ Atrophic vaginitis

❑ Irritant dermatitis

❑ Gonorrheal cervicitis

❑ Chlamydial cervicitis

❑ Herpes simplex

❑ Cervical cancer

Diagnostic Approach

Symptoms of vaginitis include vaginal discharge, pruritis, irritation, soreness, odor, and less commonly bleeding, dysuria, or pain with intercourse. It is important to distinguish burning on urination due to cystitis, which is internal and accompanied by irritative signs (urinary frequency), from dysuria due to vaginitis, which feels external as the urine passes over an inflamed vulva. Similarly, it is important to distinguish vaginitis, characterized by discharge and pruritus, from cervicitis, with discharge and pelvic pain.

On examination, the vulva appears normal in bacterial vaginosis, while erythema, edema or fissures suggest candidiasis, trichomonas or dermatitis. An erythematous, friable cervix with a mucopurulent discharge is consistent with cervicitis rather than vaginitis. This must be distinguished from ectropion (normal endocervical glandular tissue visible on the exocervix), which is not friable.

Clinical Findings

Physiologic discharge  Maximal mucous production occurs in midcycle.

Candida vulvovaginitis  Infection often occurs in the setting of recent antibiotic or steroid use, or diabetes. The onset is just before the menses, when pH decreases. Intense pruritus causes vulvar erythema, edema, fissures, and excoriation. The discharge is thick, white, and adherent, resembling cottage cheese. On KOH prep, budding yeast and branching hyphae are usually abundant, but the sensitivity is only 80%. Vaginal pH is typically 4 to 4.5, which distinguishes it from bacterial vaginosis or trichomoniasis, which have a pH above 4.5.

Bacterial vaginosis  Symptoms tend to be mild and inflammation is absent. The discharge is turbid, thin, pasty, gray to creamy yellow, and musty smelling, with a positive whiff-amine test (fishy smell when KOH added). “Clue cells,” which are epithelial cells that appear stippled due to the surface adhesion of coccobacilli, may be seen on saline wet mount microscopic examination in 45%. The background contains numerous short motile rods.

Trichomonas vaginitis  This infection is sexually transmitted. The discharge is copious, thin, frothy-white, gray, or greenish-yellow and also fishy smelling, especially after application of KOH. Petechial hemorrhages on the cervix occasionally produce a strawberry-like appearance. Mobile, flagellated organisms are seen on a saline mount or Pap smear in 50% to 70% of cases.

Atrophic vaginitis  Occurring in postmenopausal women, symptoms include vaginal and vulvar itching, post-coital burning, or soreness. The mucosa is thinned and diffusely erythematous, and there is a scant watery discharge.

Irritant dermatitis  It is most often caused by douching, using contraceptive products, or using scented tissue paper. A forgotten diaphragm or tampon may cause a malodorous discharge.

Gonorrheal cervicitis  This produces a thick, creamy, purulent, profuse, irritating discharge and involves the cervix, vagina, and urethra. Wet prep reveals many leukocytes. Gram-negative intracellular diplococci may be found in 50%.

Chlamydial cervicitis  A yellow-white mucopurulent discharge issues from the cervical os (will appear yellowish on a white swab). Erythema, easy bleeding with swabbing, and cervical ectropion are common concomitants. Cervical motion tenderness (chandelier sign) will usually be present.

Herpes simplex  Cervical infection produces ulceration, with a grayish exudate and a profuse watery discharge. Inguinal adenopathy may be present. The initial episode is often accompanied by a flu-like systemic illness. Multinucleated giant cells may be seen in scrapings from the lesions.

Cervical cancer  Cervical bleeding—a copious, watery, bloodstained, foul-smelling discharge—is the principal sign.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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