Diseases » Urethritis » Diagnosis

Diagnosis of Urethritis

Urethritis Diagnosis: Book Excerpts

• Ask the Following Questions - VAGINAL DISCHARGE
• Ask the Following Questions - RECTAL DISCHARGE
• Differential Diagnosis - Vaginal Discharge
• Differential Diagnosis - Vaginal Discharge
• Approach to the Diagnosis - URETHRAL DISCHARGE
• Approach to the Diagnosis - VAGINAL DISCHARGE
• Approach to the Diagnosis - AURAL DISCHARGE (OTORRHEA)
• Approach to the Diagnosis - ORBITAL DISCHARGE
• Approach to the Diagnosis - RECTAL DISCHARGE
• History and physical examination - Urethral discharge
• History and physical examination - Vaginal discharge
• History and physical examination - Urethral discharge
• History and physical examination - Vaginal discharge
• History - Urethral Discharge
• History (2) - Vaginal Discharge
• Differential Overview - Vaginal Discharge
• History - Urethral discharge
• History - Vaginal discharge
• Clinical Features and Diagnosis - Vaginal Discharge
• History and physical examination - Urethral discharge
• History and physical examination - Vaginal discharge
• Approach to the Diagnosis - VAGINAL DISCHARGE
• Approach to the Diagnosis - AURAL DISCHARGE (OTORRHEA)
• Approach to the Diagnosis - ORBITAL DISCHARGE
• Approach to the Diagnosis - URETHRAL DISCHARGE
• Approach to the Diagnosis - RECTAL DISCHARGE

Diagnostic Tests for Urethritis: Online Medical Books

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VAGINAL DISCHARGE: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it purulent? A purulent vaginal discharge suggests nonspecific bacterial vaginitis and gonorrhea.
2. Is it frothy and yellow? This type of discharge is very often due to trichomoniasis vaginitis.
3. Is it cheesy and associated with itching? These findings suggest candidiasis vaginitis.
4. Is it watery and bloodstained? This type of discharge suggests carcinoma of the cervix or endometrium, polyps, hydatidiform mole, and chronic cervicitis. If a frankly bloody discharge is noted, consult the differential diagnosis discussed on page 309 .
5. Is it offensive smelling? An offensive smelling discharge would suggest foreign body in the vagina.
6. Is there inflammation of the cervix? The presence of cervical inflammation would suggest chronic cervicitis and gonorrhea.

DIAGNOSTIC WORKUP

The most important test is microscopic examination of a saline and potassium hydroxide preparation. This will diagnose most cases of trichomoniasis and candidiasis. Gardnerella vaginalis can be diagnosed if clue cells are found, and the pH of the discharge will be greater than 4.7. If this is unrevealing, a Gram stain for gonorrhea and cultures for trichomoniasis, candidiasis, chlamydia, Gardnerella vaginalis , and gonorrhea may be done. A Pap smear should be done to rule out malignancy. Polyps or inflamed areas of the cervix should be biopsied. Colposcopy may help further differentiate a cervical lesion. A dilation and curettage may be necessary to diagnose endometrial carcinoma and hydatidiform mole. Occasionally, pelvic ultrasound and CT scans are necessary. However, before ordering these expensive diagnostic tests, a gynecologist should be consulted. Patients with documented evidence of gonorrhea should have a VDRL test and HIV testing.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

RECTAL DISCHARGE: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it mucopurulent or feculent? A mucopurulent discharge suggests an anal fistula, perirectal abscess, proctitis, anal ulcer, or rectal prolapse. A feculent discharge suggests anal incontinence, internal hemorrhoids, chronic anal fissure, or ulcer.
2. Is it painful? Painful discharge suggests a perirectal abscess, proctitis, anal ulcer, or rectal prolapse.
3. Is there an abnormal neurologic examination? An abnormal neurologic examination suggests that there is anal incontinence from an upper or lower motor neuron lesion. This may be due to spinal cord trauma, multiple sclerosis, spinal cord tumor, transverse myelitis, and many other disorders.

DIAGNOSTIC WORKUP

Routine laboratory tests include a CBC, sedimentation rate, urinalysis, chemistry panel, and smear and culture of the discharge. A Frei test may be necessary to rule out lymphogranuloma venereum. Sigmoidoscopy, colonoscopy, and a barium enema may be needed in selected cases. A proctologist or gastroenterologist should be consulted in difficult diagnostic problems. If there are abnormalities on the neurologic examination, a neurologist should be consulted.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Vaginal Discharge: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Physiologic
  –Many women will have a consistent, slightly clear, non-odor-producing discharge, either midcycle or premenstrually, particularly if they are on oral contraceptives
  –A change in odor, consistency, or color of discharge may signify that evaluation is necessary
  –Increased discharge is associated with pregnancy
• Sexually transmitted disease
  –Trichomonas vaginalis: “Strawberry cervix” with punctate erythema, flagellated oval organisms on wet mount
  –Gonorrhea/Chlamydia may be associated with pelvic pain/dysmenorrhea and dyspareunia
• Bacterial vaginosis
  –Various organisms and changes in normal flora with a characteristic fishy odor
  –Not considered an STD
  –Increases the risk of preterm delivery in pregnant women

• Alteration of normal vaginal flora and/or inflammatory response
  –Candida albicans overgrowth is more common with recent antibiotic use, poorly controlled diabetes, and/or pregnancy; presents with intensely pruritic, inflamed, and erythematous introitus
  –Doderlein's cytolysis (caused by an overgrowth of lactobacilli)

• Atrophic vaginitis
  –Common in postmenopausal women, especially those not on HRT
  –Poor coital lubrication, dyspareunia
  –Dysuria due to atrophic urethral tissue
• Foreign body vaginitis (e.g., retained tampon)
• Noninfectious irritant/allergic contact vaginitis (e.g., soaps, feminine pads, perfumes)
• Cervicitis (usually due to gonorrhea or Chlamydia)
• Cervical dysplasia, cancer, or polyps
• Vaginal or vulvar trauma or cancer

Workup and Diagnosis

• A focused history and physical examination are crucial, including a complete sexual and exposure history, and full abdominal and pelvic examination
  –A wet mount and KOH of the discharge are imperative
  –pH of the discharge may aid in diagnosis
  –A whiff test is done by smelling the discharge after KOH is added; a positive test reveals a fishy odor characteristic of bacterial vaginosis
• Initial labs may include CBC, urinalysis, urine culture, β-hCG, and gonorrhea and Chlamydia cultures
• Test and treat for other STDs when one STD is found (HIV, hepatitis B and C, syphilis)

pH	Discharge	Odor	Wet Mount
Trich >4.5	yellow-green, copious	present	motile, flagellated
BV >4.5	white-grey	fishy	clue cells
Candida <4.5	white, curd-like	none	pseudo-hyphae
GC/chlamydia	mucopurulent	varies	PMNs
Atrophic vaginitis	thin, gray, watery	none	few epithelial cells

>

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Source: In a Page: Signs and Symptoms, 2004

Vaginal Discharge: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Physiologic leukorrhea
  –In newborns for 2–3 weeks, due to maternal estrogen effect, and in pubertal girls
  –Discharge typically clear to white, sticky, and nonirritating
  –Newborns may have withdrawal bleeding

• Infections
  –Bacterial vaginosis: Previously known as nonspecific vaginitis; polymicrobial in etiology (coliforms, streptococci, Gardnerella); discharge may be gray and malodorous (fishy smell) but generally nonirritating
  –Candida: Discharge may be cheesy and white with erythematous, pruritic, irritated vulva; typical discharge is rarely seen in prepubertal children; discharge typically has no odor
  –Trichomonas: Discharge may be frothy, malodorous, creamy, green, bloody, or pruritic (or asymptomatic)
  –Chlamydia: Commonly asymptomatic or a nonspecific discharge
  –Gonorrhea: Infection is commonly asymptomatic or has a gray-white, thick, purulent discharge
  –Group A β-hemolytic streptococci: Discharge may be bloody
  –Shigella: Discharge may be bloody

• Irritation/hygiene
  –Due to bubble baths and other chemical irritants, tight clothing, obesity, poor wiping
• Foreign body
  –Commonly includes toilet paper, forgotten tampon
  –Discharge is often bloody and malodorous
• Anatomic
  –Ectopic urethra
  –Rectovaginal fistula
  –Urethral prolapse
• Urinary tract infection
• Masturbation
• Sarcoma botyroides
• Oral contraceptives (estrogen effect)

Workup and Diagnosis

• History
  –Age of girl (pubertal vs prepubertal)
  –Sexual activity and number of partners
  –Possibility of sexual abuse
  –Medications (e.g., steroid, oral contraceptive, antibiotic)
  –PMH of diabetes mellitus or immunocompromised
  –Type of discharge and duration of symptoms
  –Hygiene practices including feminine hygiene products, soaps, wiping techniques
  –Therapy tried at home

• Physical exam
  –Frog-leg or lithotomy position; examine external genitalia for abnormalities; speculum exam in sexually active adolescents
  –Amount, odor, color, consistency of discharge

• Labs
  –pH: Normal in the pubertal female is 3.8–4.4; if >5, consider bacterial vaginosis or Trichomonas
  –Vaginal gram stain and culture
  –Cultures for gonorrhea and Chlamydia (DNA amplification may not hold up in court for abuse cases)
  –Wet prep: Trichomonas has motile trichomonads; bacterial vaginosis has clue cells (vaginal epithelial cells coated with bacteria)
  –KOH for Candida
  –Whiff test (KOH added to discharge yields a fishy smell in Trichomonas)

• Urine culture and pregnancy test as indicated by history

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Source: In A Page: Pediatric Signs and Symptoms, 2007

URETHRAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The association of other symptoms and signs is helpful in narrowing the list of possibilities. The discharge of acute urethritis is usually associated with severe pain on micturation whereas the discharge of prostatitis is often not. The discharge of chronic prostatitis is usually painless and occurs most frequently on arising. Urethral caruncles, papillomas, and carcinomas frequently have a bloody discharge, at least intermittently. On examination, the physician can detect induration of a urethral chancre and the erythema of a balanitis is obvious when the prepuce is retracted. The presence of arthritis or conjunctivitis makes Reiter syndrome a distinct possibility, although gonorrhea may do the same. The boggy prostate of prostatitis and the increase of the discharge on massage will assist greatly in this diagnosis.

In the laboratory, a smear and culture are axiomatic in diagnosis, and one must massage the prostate and milk the urethra if little discharge is found on simple inspection. After massaging the prostate, the first portion of a voided specimen should be examined, smeared, and cultured if no discharge is apparent. Culture for Chlamydia if routine cultures are negative. Cystoscopy and cystograms may be necessary, but the indications for these will be at the discretion of the urologist, who should be consulted if routine treatment is ineffective.

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Source: Differential Diagnosis in Primary Care, 2007

VAGINAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

To workup a vaginal discharge, simply examining a fresh wet saline and KOH (10%) preparation will expose the most common offenders, namely Trichomonas and Candida. Some physicians treat all patients with negative findings on these examinations as a nonspecific bacterial vaginitis, but this is not a particularly scientific procedure. It is best to do a smear and culture (especially for gonococci). Cultures are also available for Trichomonas and Candida. If gonorrhea is suspected, material from the endocervix should be cultured. Chlamydia cultures are routinely done in some clinics.

Obviously, if the cervix is eroded and the discharge seems to be coming from there, biopsy and conization may be indicated. Referral to a gynecologist is preferred if this procedure is deemed necessary; however, the primary physician may prefer to cauterize the superficial lesions. Patients with discharges thought to be due to lesions beyond the cervix should probably be referred.

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Source: Differential Diagnosis in Primary Care, 2007

AURAL DISCHARGE (OTORRHEA): Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis of an aural discharge is similar to the approach for discharges from any body orifice. After careful examination for a foreign body or obstruction, the discharge is cultured and appropriate therapy begun. A gram stain of the material often aids in the determination of the most appropriate antibiotic. If the discharge is chronic, x-rays of the mastoids and petrous bones may be necessary, as well as tomography. Obviously, referral to an otolaryngologist is wise at this point.

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Source: Differential Diagnosis in Primary Care, 2007

ORBITAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Anatomy has served us well in developing a differential, although the cause of a discharge from the eye is often easy to establish. Foreign bodies, trauma, toxins, and conjunctivitis are the conditions most commonly responsible. This is why in the approach to the diagnosis one will first examine the eye carefully under magnification and use fluorescein to rule out a foreign body or laceration. Then, a careful history of exposure to toxins (e.g., industrial) is in order. Finally, if the discharge is unilateral, a smear and culture of specific bacteria are valuable before treatment. If it is bilateral, allergy should be considered, as well as refractive errors. Tonometry should be performed. Referral to. an ophthalmologist may be appropriate at any one of these stages (when in doubt, refer it out).

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Source: Differential Diagnosis in Primary Care, 2007

RECTAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Smear and culture of the discharge are axiomatic. Visualization of the lesion with the anoscope or sigmoidoscope is usually necessary. A Frei test should be done if lymphogranuloma venereum is suspected.

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Source: Differential Diagnosis in Primary Care, 2007

Urethral discharge: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner.

Inspect the patient’s urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen.) Then obtain a urine sample for urinalysis, culture, and possibly a three-glass urine sample. (See Performing the three-glass urine test, page 608.) In the male patient, the prostate gland may have to be palpated.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Vaginal discharge: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Also, ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Next, ask if she has had vaginal discharge before or has ever been treated for a vaginal infection. What treatment did she receive? Did she complete the course of medication? Ask about her current use of medications, especially antibiotics, oral estrogens, and hormonal contraceptives.

Examine the external genitalia and note the character of the discharge. (See Identifying causes of vaginal discharge.) Observe vulvar and vaginal tissues for redness, edema, and excoriation. Palpate the inguinal lymph nodes to detect tenderness or enlargement, and palpate the abdomen for tenderness. A pelvic examination may be required. Obtain vaginal discharge specimens for testing.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Urethral discharge: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner.

Inspect the patient’s urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen, page 778.) Then obtain a urine specimen for urinalysis, culture and, possibly,, a three-glass urine test. (See How to perform the three-glass urine test.) Palpation of the male patient’s prostate gland may be necessary.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Vaginal discharge: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Also, ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Next, ask if she has had a vaginal discharge before or has ever been treated for a vaginal infection. What treatment did she receive? Did she complete the course of medication? Ask about her current use of medications, especially antibiotics, oral estrogens, and hormonal contraceptives.

Examine the external genitalia and note the character of the discharge. (See Identifying causes of vaginal discharge, page 792.)  Observe vulvar and vaginal tissues for redness, edema, and excoriation. Palpate the inguinal lymph nodes to detect tenderness or enlargement, and palpate the abdomen for tenderness. A pelvic examination may be required. Obtain vaginal discharge specimens for testing.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Urethral Discharge: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A detailed medical history is essential for the evaluation of UD. The essential symptoms addressed at the time of interview are (a) dysuria, (b) urethral discharge, (c) itching at the urethra, (d) hematuria, (e) rectal symptoms, (f) contact with infectious agents, and (g) sexual history. The characteristics of UD are noted in relation to color, quantity, odor, consistency, frequency, and relationship to urination. Profuse, yellowish UD occurring 3 to 7 days after sexual exposure is characteristic of GC. GC infection is more common in men than in women. In 1997, 324,901 cases of gonorrhea were reported to the Centers for Disease Control, with a case rate of 122/100,000 (1). Clear to white, scanty, or mucopurulent UD (23% to 55%) that develops gradually at least a week after exposure, with waxing and waning in intensity, suggests chlamydial infection. This is the most common sexually transmitted disease (STD) in the United States, with 3 million new cases occurring annually (2). As many as 85% of women with chlamydial infections and 40% of infected men are asymptomatic (3). Sexual history should include sexual behaviors, condom usage, number of sexual partners, recent sexual contacts, and the orifices used for sexual contacts. Consistent usage of condoms prevents sexually transmitted urethritis. Oral sex increases UD from oral flora infections.

Physical examination

 A. Focused physical examination (PE) should include vital signs, and urologic and rectal examination. In men, this should include examination of the penis, perimeatal region (for evidence of erythema), urethral meatus, scrotum, testicles, epididymis, prostate, and perianal and inguinal region. Stains present on the patient’s underwear may indicate the characteristics of the discharge, which is particularly useful in a patient who has urinated shortly before examination. Recent micturition can eliminate much inflammatory discharge. Sometimes it is necessary to examine the patient in the morning before voiding to enhance the diagnosis. Perform a complete gynecologic and urologic examination in women.

 B. Abdomen. Completely examine the abdomen to rule out intraabdominal pathology, including masses and inflammation, obstruction, or distention of organs.

C. Additional physical examination should include the skin and other systems, as needed. If a patient is suspected of gonococcal infection, it may be essential to check the patient’s joints, skin, throat, eye and other organs.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Vaginal Discharge: History (2)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. What is the specific vaginal complaint? Is it soreness, discharge, odor, itching, or dyspareunia? Vaginal soreness correlates with vulvovaginal candidiasis, allergy, contact dermatitis, or atrophy. Yeast, BV, atrophy, and trauma produce significant dyspareunia.

 B. What is the characteristic of the discharge? Is the discharge heavy or light, thick or thin? Does it have an odor? Most women have some physiologic discharge that changes during the menstrual cycle with hormonal flux. BV and T. vaginitis produce malodorous discharge of variable amount. Yeast produces a thick discharge that usually has no odor.

C. What is the sexual history (3)? Is there a new sexual partner in the last year? How does the patient protect herself from sexually transmitted disease? In taking this part of the history, it is key to convey necessary information concerning sexually transmitted disease transmission, both to allay anxiety and to modify behavior, when appropriate.

 D. What is the menstrual history? Ask when was the last period? Are you pregnant? What is your method of contraception? Yeast often overgrows in the vagina premenstrually. Trichomoniasis and BV during pregnancy are associated with premature labor, premature delivery, and septic abortion. Yeast vaginitis is more common during pregnancy and when taking oral contraceptives.

 E. Are you taking any medications? Have you tried any medications for your vaginal problem?

Antibiotics, contraceptive preparations, hormones, vaginal medications, and other OCT preparations often alter the vaginal ecosystem and allow infection to be introduced or normal vaginal flora to become unbalanced. Foreign bodies (e.g., tampons, diaphragms, or condoms) can create vaginal irritations, inflammation, and infections.

 F. If the problem is vaginal irritation, have any substances been used that cause allergic reaction or chemical irritation? Do you douche?

These might include deodorant soaps, feminine hygiene sprays, scented douches, laundry detergent, bath oils, dyed toilet tissue, synthetic clothing, or hot tub or swimming pool chemicals.

At times, only elimination of all possible offending agents, skin testing, or both permit identification of the allergies or irritants.

G. If no obvious infectious, traumatic, or chemical agent is identified, could the vaginal complaint be related to a systemic illness [e.g., diabetes mellitus or human immunodeficiency virus (HIV) infection] or with a life change?

Idiopathic vulvovaginal ulceration can be associated with HIV disease.

Atrophic vaginitis secondary to hormone depletion can cause significant dyspareunia, swelling, and discharge. Collagen-vascular disease, pemphigus, and Bechêt’s syndrome can manifest in vaginal symptoms.

Physical examination (4)

A general physical examination should be performed if systemic illness is suspected. Record vital signs, including temperature, blood pressure, and pulse.

In most cases, a genital examination with the patient in the lithotomy position is adequate.

The external genitalia is carefully inspected for evidence of trauma, blisters, lymph nodes excoriations, swelling, erythema, ulcerations, tenderness or pain.

The amount, color, texture, odor, and location of the discharge should be noted. A complete pelvic examination should be performed with particular attention given to the cervix for evidence of friability or inflammation and a cervical motion test which may indicate pelvic inflammatory disease.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Vaginal Discharge: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ 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.

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Source: Field Guide to Bedside Diagnosis, 2007

Urethral discharge: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Vaginal discharge: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Also, ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Next, ask if she has had vaginal discharge before or has ever been treated for a vaginal infection. What treatment did she receive? Did she complete the course of medication? Ask about her current use of medications, especially antibiotics, oral estrogens, and contraceptives.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Vaginal Discharge: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Prepubertal Onset

Physiologic Leukorrhea

Maternalestrogen passes across placenta and stimulates hypertrophy of glycogen-containingvaginal squamous epithelial cells in the fetus.

Decrease in serum estrogen after birthleads to shedding of these cells and production of whitish vaginaldischarge that may persist for a few weeks.

Some neonates also may have associatedwithdrawal bleeding secondary to decreased estrogen stimulationof the endometrium.

Vulvovaginitis

Nonspecific Causes

Most commoncause of vaginal discharge in prepubertal girls is nonspecific vaginitis, whichis usually due to poor perineal hygiene and contamination with mixedbowel flora.

Chemical irritants (e.g., bubble bathpreparations, shampoos, and harsh soaps) also may cause vaginitis.

Dysuria is sometimes associated finding.

Specific Infections

Some neonatesacquire T. vaginalis during passage through birth canal, and whitish oryellowish vaginal discharge may persist beyond neonatal period.Seeing motile flagellated organism on wet mount (saline) confirmsdiagnosis.

Infection with Candida species mayproduce whitish or yellowish discharge and vulvar inflammation.Risk factors include diabetes mellitus, use of broad-spectrum antibiotics,and immunodeficiency disorders. KOH preparation or culture of dischargeis diagnostic.

Group A Streptococcus, S. aureus, H.influenzae, S. pneumoniae, and Shigella species may produce foul-smellingvaginal discharge. Diarrhea usually occurs with Shigella vaginitis,and in some cases vaginal discharge contains blood. Positive vaginalculture is diagnostic.

E. vermicularis (pinworm) producesintense anal itching, particularly at night when worms move ontoperianal skin. Persistent scratching may produce secondary vulvovaginitis.Seeing white, threadlike worms, which are about 1 cm in length,or identifying eggs under microscope from cellophane tape preparationis diagnostic.

In prepubertal females, infection withT. vaginalis, herpes simplex virus, N. gonorrhoeae, or C. trachomatisimplies sexual abuse until proven otherwise. Infections with thesepathogens are discussed in sections Pubertal and Postpubertal Onset: Vulvovaginitis,and Cervicitis.

Foreign Body

Foreignbody in vagina causes foul-smelling discharge, which is often associated withpain or bleeding.

Toilet paper, pins, beads, and pencilerasers are some of the objects that may be found.

History and physical exam are usuallydiagnostic.

Radiography of pelvis is useful, especiallyif foreign body is radiopaque. Exam under anesthesia may be necessaryin some cases.

Pubertal and Postpubertal Onset

Physiologic Leukorrhea

Most commoncause of vaginal discharge in pubescent girls.

Cyclic ovarian activity with increasedestrogen secretion produces glycogen-containing vaginal epithelium.Desquamated vaginal cells and mucus produce whitish discharge thatusually starts before menarche and may continue for several years.

Wet preparation shows epithelial cellswith no evidence of inflammation.

Vulvovaginitis

Nonspecific Causes

Contributing factors to nonspecific vulvovaginitisinclude poor hygiene, obesity, chemical irritants, and tight-fittingnylon underpants.

Specific Infections

Primary causes of vaginitis in adolescentsare bacterial vaginosis, Candida species, T. vaginalis, and herpessimplex virus. Because of changes in vaginal epithelium and colonizingflora in puberty, vagina is more resistant to infections causedby N. gonorrhoeae and C. trachomatis. In adolescents these 2 pathogenscause cervicitis rather than vaginitis.

Bacterial Vaginosis

Presenceof vaginal Gardnerella and Mobiluncus species does not necessarilysignify a sexually transmitted disease because these bacteria alsocan occur in sexually inactive girls.

Presence of thin, white, homogenousdischarge; characteristic fishy odor when 1–2 drops of 10% KOHare added to specimen of vaginal discharge; neutral or alkalinevaginal pH; and appearance of small refractile bacteria coatingvaginal epithelial cells (clue cells) on saline wet mount or Gramstain confirm diagnosis.

Candida Species

Infectionwith Candida species produces thick, cheesy pruritic discharge.

Positive KOH preparation demonstratingyeast cells and mycelia or positive vaginal culture is diagnostic.

Trichomonas vaginalis

Infectionwith T. vaginalis usually produces frothy, pale yellow to gray-greendischarge with musty odor.

Although pathogen can survive on fomitevectors (damp clothes, towels), usual source of infection is throughdirect sexual contact.

Presence of motile flagellated organismson wet mount is diagnostic. If wet mount is negative, positive cultureor polymerase chain reaction test confirms diagnosis.

Herpes Simplex Virus

Infectionwith herpes simplex virus 1 (HSV-1) or HSV-2 may produce small painful vesiclesand ulcers on vulva, vagina, or cervix. Vaginal discharge, fever,and inguinal adenopathy also may occur.

Herpetic infections can present asprimary genital infections or as recurrent episodes, especiallywith HSV-2.

Fluorescent antibody staining of vesiclescrapings or positive culture from lesion confirms diagnosis.

Cervicitis

Is an inflammationof the ectocervix, endocervix, or both. T. vaginalis, Candida species,and herpes simplex virus can cause ectocervicitis, whereas C. trachomatisand N. gonorrhoeae are most common pathogens causing endocervicitis.

Typical clinical findings of cervicitisare mucopurulent discharge and inflamed cervix.

Chlamydia trachomatis

Infectionis almost always acquired through sexual contact. It is most prevalentbacterial sexually transmitted disease in U.S. and frequently accompaniesgonococcal genital infections.

Can be asymptomatic or produce mildcervical discharge. Associated findings include dysuria and urinaryfrequency.

Positive endocervical culture or identificationby nucleic acid amplification tests is diagnostic.

Neisseria gonorrhoeae

Transmissionoccurs by direct sexual contact.

Cervix is inflamed and tender and vaginaldischarge is thick creamy yellow.

Positive endocervical culture or identificationby nucleic acid amplification tests is diagnostic.

Pelvic Inflammatory Disease

Is an infectionwith spread of organisms from vagina or cervix to endometrium (endometritis),fallopian tubes (salpingitis, tubal abscess), pelvic peritoneum(pelvic peritonitis), or contiguous structures (oophoritis, tuboovarianabscess).

N. gonorrhoeae, C. trachomatis, andendogenous flora of lower genital tract including anaerobic bacteria(Bacteroides, Peptostreptococcus, Clostridium, and Actinomyces species)and facultative bacteria (E. coli, H. influenzae, Streptococcusspecies) are frequent pathogens.

Cervical and vaginal discharge, lowerabdominal pain, cervical motion tenderness, adnexal tenderness,vomiting, and fever are common findings.

Cervical culture for C. trachomatis,N. gonorrhoeae, and other aerobic and anaerobic bacteria shouldbe performed. Laparoscopy may be required to provide definitivediagnosis in equivocal cases.

Foreign Body

In adolescents,most common foreign body is retained tampon.

Discharge is foul smelling and oftenblood streaked.

Foreign body can usually be visualizedby speculum exam.

Diagnostic Approach

Nonspecificvulvovaginitis is most common cause of vaginal discharge in prepubertal girls.If discharge fails to improve with good perineal hygiene or if itis purulent, specific bacterial infection, sexually transmittedinfection, or foreign body should be suspected. Wet mounts (salineand KOH), Gram stain, and vaginal cultures should be performed.Exam under anesthesia may be necessary for suspected foreign body.

In pubertal girls who are not sexuallyactive, most common causes of vaginal discharge are physiologicleukorrhea, bacterial vaginosis, and C. albicans. Wet preparations(saline and KOH) and Gram stain should be performed. Bacterial andfungal cultures also should be considered.

In girls who are sexually active, thesame diagnoses described for pubertal nonsexually active femalesare possible, but sexually transmitted infections also are likely.In addition to wet preparations and Gram stain, cultures for C.trachomatis, N. gonorrhoeae, and other aerobic and anaerobic bacteria shouldbe performed. In some centers nucleic acid amplification technologyis available for detection of C. trachomatis and N. gonorrhoeaefrom endocervical and urine specimens. Laparoscopy may provide definitivediagnosis in suspected pelvic inflammatory disease with negativecervical cultures.

If sexual abuse is suspected at anyage, vaginal, rectal, and throat cultures for N. gonorrhoeae andvaginal and rectal cultures for C. trachomatis should be performed,even in an asymptomatic child. HIV testing should be considered.So should pregnancy prophylaxis, which depends on whether menarche hasbeen reached and on nature of abuse.

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Urethral discharge: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner. Obtain a complete drug history.

Inspect the patient's urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen.) Then obtain a urine specimen for urinalysis, culture, and possibly a three-glass urine specimen. (See Performing the three-glass urine test, page 613.) In the male patient, the prostate gland may have to be palpated.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Vaginal discharge: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Ask if she has had vaginal discharge before or has ever been treated for a vaginal infection or sexually transmitted disease. What treatment did she receive? Did she complete the course of medication and were all sexual contacts treated? Ask about her current use of medications, especially antibiotics, oral estrogens, and hormonal contraceptives.

Examine the external genitalia and note the character of the discharge. (See Identifying causes of vaginal discharge.) Observe vulvar and vaginal tissues for redness, edema, and excoriation. Palpate the inguinal lymph nodes to detect tenderness or enlargement, and palpate the abdomen for tenderness. A pelvic examination may be required. Obtain vaginal discharge specimens for testing.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

VAGINAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

To workup a vaginal discharge, simply examining a fresh wet saline and KOH (10%) preparation will expose the most common offenders, namely Trichomonas and Candida. Some physicians treat all patients with negative findings on these examinations as a nonspecific bacterial vaginitis, but this is not a particularly scientific procedure. It is best to do a smear and culture (especially for gonococci). Cultures are also available for Trichomonas and Candida. If gonorrhea is suspected, material from the endocervix should be cultured. Chlamydia cultures are routinely done in some clinics. Obviously, if the cervix is eroded and the discharge seems to be coming from there, biopsy and conization may be indicated. Referral to a gynecologist is preferred if this procedure is deemed necessary; however, the primary physician may prefer to cauterize the superficial lesions. Patients with discharges thought to be due to lesions beyond the cervix should probably be referred.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

AURAL DISCHARGE (OTORRHEA): Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis of an aural discharge is similar to the approach for discharges from any body orifice. After careful examination for a foreign body or obstruction, the discharge is cultured and appropriate therapy begun. A gram stain of the material often aids in the determination of the most appropriate antibiotic. If the discharge is chronic, x-rays of the mastoids and petrous bones may be necessary, as well as tomography. Obviously, referral to an otolaryngologist is wise at this point.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

ORBITAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Anatomy has served us well in developing a differential, although the cause of a discharge from the eye is often easy to establish. Foreign bodies, trauma, toxins, and conjunctivitis are the conditions most commonly responsible. This is why in the approach to the diagnosis one will first examine the eye carefully under magnification and use fluorescein to rule out a foreign body or laceration. Then, a careful history of exposure to toxins (e.g., industrial) is in order. Finally, if the discharge is unilateral, a smear and culture of specific bacteria are valuable before treatment. If it is bilateral, allergy should be considered, as well as refractive errors. Tonometry should be performed. Referral to an ophthalmologist may be appropriate at any one of these stages (when in doubt, refer it out).

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

URETHRAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The association of other symptoms and signs is helpful in narrowing the list of possibilities. The discharge of acute urethritis is usually associated with severe pain on micturation, whereas the discharge of prostatitis is often not. The discharge of chronic prostatitis is usually painless and occurs most frequently on arising. Urethral caruncles, papillomas, and carcinomas frequently have a bloody discharge, at least intermittently. On examination, the physician can detect induration of a urethral chancre, and the erythema of a balanitis is obvious when the prepuce is retracted. The presence of arthritis or conjunctivitis makes Reiter syndrome a distinct possibility, although gonorrhea may do the same. The boggy prostate of prostatitis and the increase of the discharge on massage will assist greatly in this diagnosis. In the laboratory, a smear and culture are axiomatic in diagnosis, and one must massage the prostate and milk the urethra if little discharge is found on simple inspection. After massaging the prostate, the first portion of a voided specimen should be examined, smeared, and cultured if no discharge is apparent. Culture for Chlamydia if routine cultures are negative. Cystoscopy and cystograms may be necessary, but the indications for these will be at the discretion of the urologist, who should be consulted if routine treatment is ineffective.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

RECTAL DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Smear and culture of the discharge are axiomatic. Visualization of the lesion with the anoscope or sigmoidoscope is usually necessary. A Frei test should be done if lymphogranuloma venereum is suspected.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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