Diagnosis of Vagina conditions
Vagina conditions Diagnosis: Book Excerpts
Diagnostic Tests for Vagina conditions: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Vagina conditions.
DYSMENORRHEA:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Are there abnormalities on pelvic examination? A tubo-ovarian mass on pelvic examination should suggest salpingo-oophoritis, endometriosis with a chocolate cyst, or ectopic pregnancy. Perhaps the uterus is abnormal, in which case one should suspect fibroids, endometrial carcinoma, uterine pregnancy, retroverted uterus, endometrial cast, or cervical polyp. A normal examination should suggest ovarian dysfunction, endocrine imbalance, and psychogenic causes.
- What is the age of the patient? If the patient is young, she probably has a virginal uterus and may be considered to have primary dysmenorrhea. These cases are usually due to uterine hypoplasia, congenital malformations, ovarian dysfunction, or psychogenic causes.
DIAGNOSTIC WORKUP
Routine studies should include a CBC, sedimentation rate, chemistry panel, and thyroid profile. If there is vaginal discharge, a smear and culture should be done for gonorrhea and chlamydia. A cervical and rectal culture for these organisms may also be necessary. If there is a tubo-ovarian mass or enlarged uterus, abdominal ultrasound may help in differentiating the cause. A pregnancy test should be done. The pregnancy test of choice is
radioimmunoassay
for the beta subunit of human chorionic gonadotropin (HCG), which will be positive within a week of fertilization. If a ruptured ectopic pregnancy is expected, a peritoneal tap or culdocentesis may help if abdominal ultrasound is not conclusive. Laparoscopy may also be helpful in the diagnosis. A fern test and basal body temperature may help diagnose endometriosis. An exploratory laparotomy may be the only way to make a diagnosis in cases of a pelvic mass. If the pelvic examination is perfectly normal, sometimes a course of progesterone hormones is useful in alleviating the problem. A dilation and curettage may also be done to address the problem. Referral to a gynecologist is usually made before doing expensive diagnostic tests.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
MENORRHAGIA:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there persistent or recurring abdominal or pelvic pain? The presence of pain with menorrhagia should make one suspect PID, endometriosis, and ectopic pregnancy.
- Are there abnormalities on the pelvic examination? The pelvic examination will usually be positive in cases of uterine fibroid, pregnancy, cervical polyp, pelvic inflammatory disease, and ectopic pregnancy. Endometriosis may not always be detected on pelvic examination.
- Is there anemia or other systemic symptoms or signs? The clinician should remember that iron deficiency anemia, hypothyroidism, lupus erythematosus, and cirrhosis of the liver are just a few of the systemic conditions that may present with menorrhagia.
DIAGNOSTIC WORKUP
Routine studies include a CBC, sedimentation rate, urinalysis, pregnancy test, chemistry panel, ANA titer, VDRL test, coagulation profile, thyroid profile, and flat plate of the abdomen. A Pap smear and vaginal smear and culture should be done.
If these tests are negative, referral to a gynecologist should be made before undertaking expensive tests such as pelvic ultrasound or CT scan of the abdomen and pelvis. Some clinicians will probably ignore this advice. A gynecologist will often be able to resolve the diagnostic dilemma with a good pelvic examination. Laparoscopy, culdocentesis, endometrial biopsy, and dilation and curettage are just a few of the diagnostic tools at his disposal.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
METRORRHAGIA:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Are there abnormalities found on the vaginal examination? An enlarged uterus suggests pregnancy, fibroids, retained secundina, hydatiform mole, choriocarcinoma, endometrial carcinoma, or endometrial polyp. An adnexal mass suggests a granulosa cell tumor, salpingitis, or ectopic pregnancy. Cervical lesions that cause metrorrhagia are cervicitis, carcinoma of the cervix, and cervical polyp. Vaginal lesions include vaginal carcinoma and senile vaginitis.
- Is there a history of hormone therapy? If the patient has been taking estrogen or progesterone, withdrawal or breakthrough bleeding should be considered.
- Is there pallor or other signs of anemia? Most types of anemia, but particularly iron deficiency anemia, are associated with metrorrhagia.
- Is there a history of tremor, tachycardia, or edema? Both hyperthyroidism and hypothyroidism may be associated with metrorrhagia.
- Is there hirsutism or virilism? Look for an adrenal or ovarian neoplasm in these cases.
If all of these questions fail to turn up any positive answers, then dysfunctional uterine bleeding, collagen disease, or a coagulation disorder should be strongly considered.
DIAGNOSTIC WORKUP
Routine studies include a CBC, sedimentation rate, urinalysis, pregnancy test, chemistry panel, ANA test, coagulation profile, thyroid profile, and flat plate of the abdomen. A Pap smear and vaginal smear and culture should also be done.
If these are negative, referral to a gynecologist should be made before undertaking expensive diagnostic tests such as ultrasound or CT scans of the abdomen and pelvis. Alternatively, a trial of cyclical estrogen and progesterone hormones may be done if dysfunctional bleeding is suspected before referral is made. A gynecologist may be able to resolve the diagnostic dilemma with a good pelvic examination or, if that is unsuccessful, may perform laparoscopy or culdocentesis. A dilation and curettage or office endometrial biopsy are among the additional procedures at the gynecologist's disposal. An endocrinologist may be of help in deciding whether pituitary or ovarian dysfunction is responsible. An FSH of greater than 40 ml suggests ovarian failure. The endocrinologist may note hirsutism and order a free testosterone and 17-hydroxy progesterone to rule out adrenal or ovarian neoplasm.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
VAGINAL DISCHARGE:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it purulent? A purulent vaginal discharge suggests nonspecific bacterial vaginitis and gonorrhea.
- Is it frothy and yellow? This type of discharge is very often due to trichomoniasis vaginitis.
- Is it cheesy and associated with itching? These findings suggest candidiasis vaginitis.
- 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
.
- Is it offensive smelling? An offensive smelling discharge would suggest foreign body in the vagina.
- 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.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
VULVAL OR VAGINAL MASS:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it tender? A tender vulval or vaginal mass would suggest vulvitis, hematoma, acute bartholinitis, or urethral caruncle.
- Is it reducible? A reducible vulval or vaginal mass would suggest pudendal hernia, varicocele, cystocele, rectocele, and uterine prolapse.
- Is the rectal examination abnormal? The rectal examination will be abnormal when there is an impacted feces or rectal carcinoma.
DIAGNOSTIC WORKUP
Referral to a gynecologist or urologist can obviate an expensive diagnostic workup in most cases. The primary care physician may wish to treat acute bartholinitis or vulvitis, however. A culture and sensitivity is the only procedure required in those cases.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
VULVAL OR VAGINAL ULCERATIONS:
Ask the Following Question:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the lesion or are surrounding lymph nodes tender? The presence of tenderness of the lesion or the surrounding lymph nodes would suggest chancroid, lymphogranuloma venereum, herpes genitalis, and carcinoma. On the other hand, if the lesions or the surrounding lymph nodes are nontender, chancre, yaws, condyloma latum, and lupus should be suspected.
DIAGNOSTIC WORKUP
The workup includes a CBC, sedimentation rate, urinalysis, and VDRL test. A smear and culture of material from the ulceration should be done. A dark field examination may also be necessary. The Frei test may diagnose lymphogranuloma venereum, but a serologic test for this disorder may also be ordered. Biopsy may be ultimately necessary. It is wise to enlist the help of a urologist or gynecologist in difficult cases.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Dysmenorrhea:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Primary dysmenorrhea
–Symptoms develop before age 25
–Pain occurs with onset of bleeding, then gradually diminishes
- Secondary dysmenorrhea
–Endometriosis (uterosacral ligament nodules, severe dysmenorrhea)
–Adenomyosis (enlarged uterus, menorrhagia, age 40–50, parous)
–Acute PID (acute adnexal and cervical motion tenderness, fever, discharge, and/or new-onset dysmenorrhea)
–Chronic PID (due to scarring)
–Uterine leiomyoma/fibroids (enlarged, mobile uterus, menorrhagia)
–Ovarian cysts (new dysmenorrhea, unilateral fullness)
-
Mental health issues
–Somatization
–Substance abuse
–Depression
–Sexual abuse
-
Extrapelvic disorders
–Irritable bowel syndrome
–Appendicitis
–Urinary tract infection
–Inflammatory bowel disease
–Diverticulitis
–Cholecystitis
-
Fibromyalgia
-
Malformations of the müllerian ducts
-
Interstitial cystitis
-
Intestinal or uteropelvic junction obstruction
-
Malignancy (e.g., uterine, ovarian)
-
Ectopic pregnancy
Workup and Diagnosis
-
History, physical, pelvic, and rectal examination will often identify the diagnosis
-
Patients unresponsive to an initial trial of NSAIDs and oral contraceptives may have pelvic pathology (secondary dysmenorrhea)
-
- Initial labs include CBC, urinalysis, β-hCG, wet mount, KOH prep, and gonorrhea and Chlamydia cultures, which may uncover pathology associated with secondary dysmenorrhea
-
Abdominal and/or vaginal (with vaginal probe) ultrasound may be used to detect pelvic masses (e.g., ovarian cysts, uterine leiomyoma)
-
Hysterosonogram if intrauterine pathology is suspected
-
Hysteroscopy should follow abnormal hysterosonogram
-
Abdominal and/or pelvic CT scan will evaluate gynecologic and abdominal pathology
-
Laparoscopy may be both diagnostic and therapeutic
-
Culdocentesis may be indicated if ruptured ectopic pregnancy is suspected; however, rarely used today, because of the advent of ultrasound
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
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 |
>
» READ BOOK EXCERPT ONLINE »
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
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Abnormal Vaginal Bleeding:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Dysfunctional uterine bleeding (DUB)
–Physiologic anovulation is normal for up to 2
years after menarche
–Androgen excess
–Functional ovarian hyperandrogenism, or
polycystic ovary syndrome, is common in
adolescence
–Estrogen excess
–Hyperprolactinemia
–Hypothyroidism
–Early premature ovarian failure
-
Luteal phase defects
-
Pregnancy disorders
–Spontaneous abortion (threatened, missed,
incomplete)
–Molar pregnancy
–Ectopic pregnancy
-
True vaginal bleeding
–Trauma (including sexual abuse)
–Vaginal sarcoma (sarcoma botyroides)
–Foreign body (more common in the younger
child)
-
Menorrhagia
–Idiopathic: Most common cause of menorrhagia in adolescents
–Coagulopathy/bleeding disorder (e.g., thrombocytopenia, von Willebrand disease, factor IX deficiency)
–Uterine polyp or neoplasm
-
Hematuria mistaken for vaginal bleeding
–Urethral prolapse
–Urinary tract infection
-
Excoriations due to pruritus
-
Vulvovaginitis
–Trichomonas
–Chlamydia
–Gonorrhea
–Pinworms (rare)
-
Cervical lesions
–Cervical polyp
–Hemangioma
–Cervical friability
Workup and Diagnosis
- History
–Age at onset of bleeding
–Quantity, duration, and frequency of bleeding
–Associated pain or discomfort
–Age at onset of puberty
–First day of last menstrual period
–Other symptoms: Dysuria, symptoms of
hypothyroidism (fatigue, cold intolerance, constipation), symptoms of hyperprolactinemia (headaches, nipple discharge/galactorrhea)
–Sexual abuse; sexual activity
–Family history of irregular periods/infertility
- Physical exam
–Inspection of external genitalia (anatomy, evidence of trauma, source of bleeding)
–Evidence of puberty (breast development,
estrogenization of vaginal mucosa)
–Signs of virilization (hirsutism)
–Nipple discharge
–Signs of hypothyroidism (bradycardia, dry skin, coarse
hair, short stature, delayed reflexes)
-
Labs
–LH, FSH, estradiol (E2), hCG
–T4, TSH, prolactin
–Platelet count, PT, PTT, bleeding time, vWF
–Urine analysis
-
Pelvic US to detect ovarian and uterine abnormalities
-
MRI of pituitary to detect abnormalities of the gland
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
DYSMENORRHEA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical approach to dysmenorrhea is simply to rule out significant organic disease by a thorough pelvic and rectal examination. A smear and culture for gonococcus and Chlamydia should be done. A course of contraceptives or progesterone in adequate doses may then be tried. Diuretics may be indicated if examination suggests pelvic congestion. When the aforementioned measures fail, a dilatation and curettage (D & C) may be indicated. A gynecologist may decide to do a culdoscopy, a peritoneoscopy, or an exploratory laparotomy.
» 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
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
VAGINAL BLEEDING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The differential diagnosis of vaginal bleeding depends on the clinical picture. The most common cause of unexpected bleeding in all women is dysfunctional uterine bleeding due to imbalance of estrogen and progesterone during the menstrual cycle. Nevertheless, vaginal bleeding in a postmenopausal woman must be considered a malignancy until proven otherwise. Vaginal bleeding in the prepubertal female should prompt an investigation for child abuse or incest as well as neoplasm.
A careful vaginal examination with the patient fully relaxed is most important. A rectovaginal examination must be performed to palpate masses in the cul-de-sac. Any vaginal discharge must be cultured for gonococci and Chlamydia organisms to rule out PID. Any suspicious lesion of the vagina or cervix must be biopsied and a pap smear is performed. If the diagnosis is uncertain at this point, a gynecology consult is in order. A D & C or endometrial biopsy must be done if uterine carcinoma is suspected. In women of childbearing age, a routine pregnancy test should be done but if an ectopic pregnancy is suspected a serum β-hCG subunit pregnancy test will be more definitive. Ultrasonography will often determine if a pelvic mass is an ectopic pregnancy. Ultrasonography will also be helpful in diagnosing ovarian cysts and tumors, but a CT scan of the pelvis can be more definitive.
Dysfunctional uterine bleeding is most often physiologic. However, a granulosa cell tumor of the ovary can be the cause. Ultrasonography or a CT scan may be able to reveal such a tumor, but culdoscopy or laparoscopy may be required. If the dysfunctional bleeding is thought to be due to hypothyroidism or hyperthyroidism, a thyroid profile may be done. If it is believed to be due to a pituitary adenoma, an MRI of the brain and serum LH and FSH assays should be done. Anemia and systemic disease must be ruled out also (see below).
If pathologic causes of dysfunction uterine bleeding are excluded, normal cyclic bleeding may be reestablished by a course of cyclic estrogen and progesterone or progesterone alone (a “medical D & C”). If this unsuccessful, a surgical D & C is required.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Dysmenorrhea:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it's bilateral. When does the pain begin and end, and when is it severe? Does it radiate to the back? How long has she been experiencing the pain? If it's a recent complaint, obtain a human chorionic gonadotropin level to determine if the patient is or was pregnant, because miscarriage can cause painful bleeding. Explore associated signs and symptoms, such as nausea and vomiting, altered bowel or urinary habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.
Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk of sexually transmitted diseases.
Next, perform a focused physical examination. Take the patient's vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Menorrhagia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
When the patient’s condition permits, obtain a history. Determine her age at menarche, the duration of menstrual periods, and the interval between them. Establish the date of the patient’s last menses, and ask about recent changes in her normal menstrual pattern. Have the patient describe the character and amount of bleeding. For example, how many pads or tampons does the patient use? Has she noted clots or tissue in the blood? Also ask about the development of other signs and symptoms before and during her period.
Next, ask if the patient is sexually active. Does she use a method of birth control? If so, what kind? Could the patient be pregnant? Be sure to note the number of pregnancies, the outcome of each, and any pregnancy-related complications. Find out the dates of her most recent pelvic examination and Papanicolaou smear and the details of any previous gynecologic infections or neoplasms. Also, be sure to ask about previous episodes of abnormal bleeding and the outcome of treatment. If possible, obtain a pregnancy history of the patient’s mother, and determine if the patient was exposed in utero to diethylstilbestrol. (This drug has been linked to vaginal adenosis.)
Be sure to ask the patient about her general health and medical history. Note particularly if the patient or her family has a history of thyroid, adrenal, or hepatic disease; blood dyscrasias; or tuberculosis because these may predispose the patient to menorrhagia. Also, ask about the patient’s past surgical procedures and recent emotional stress. Find out if the patient has undergone X-ray or other radiation therapy, because this may indicate prior treatment for menorrhagia. Obtain a thorough drug and alcohol history, noting the use of anticoagulants or aspirin. Perform a pelvic examination, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Metrorrhagia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin your evaluation by obtaining a thorough menstrual history. Ask the patient when she began menstruating and about the duration of menstrual periods, the interval between them, and the average number of tampons or pads she uses. When does metrorrhagia usually occur in relation to her period? Does she experience other signs or symptoms? Find out the date of her last menses, and ask about other recent changes in her normal menstrual pattern. Get details of previous gynecologic problems. If applicable, obtain a contraceptive and obstetric history. Record the dates of her last Papanicolaou smear and pelvic examination. Ask the patient when she last had sex and whether or not it was protected. Next, ask about her general health and any recent changes. Is she under emotional stress? If possible, obtain a pregnancy history of the patient’s mother. Was the patient exposed in utero to diethylstilbestrol? (This drug has been linked to vaginal adenosis.)
Perform a pelvic examination if indicated, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Vaginal bleeding, postmenopausal:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her periods regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.
Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Dysmenorrhea:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Pelvic examination and a detailed patient history may help suggest the cause of dysmenorrhea.
Primary dysmenorrhea is diagnosed when secondary causes are ruled out. Appropriate tests (such as laparoscopy, dilatation and curettage, and pelvic ultrasound) are used to diagnose underlying disorders in secondary dysmenorrhea.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Vaginal cancer:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
The diagnosis of vaginal cancer is based on the presence of abnormal cells on a vaginal Papanicolaou smear. Careful examination and a biopsy rule out the cervix and vulva as the primary sites of the lesion. In many cases, however, the cervix contains the primary lesion that has metastasized to the vagina. Then, any visible lesion is biopsied and evaluated histologically. It's sometimes difficult to visualize the entire vagina because the speculum blades may hide a lesion, or the patient may be uncooperative because of discomfort. When lesions aren't visible, colposcopy is used to search out abnormalities. Painting the suspected vaginal area with Lugol's solution also helps identify malignant areas by staining glycogen-containing normal tissue, while leaving abnormal tissue unstained. (See Staging vaginal cancer.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Dysmenorrhea:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it’s bilateral. How long has she been experiencing it? When does the pain begin and end, and when is it severe? Does it radiate to the back? Explore associated signs and symptoms, such as nausea and vomiting, altered elimination habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.
Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe any vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have any signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk for sexually transmitted diseases.
Next, perform a focused physical examination. Take vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Menorrhagia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
When the patient’s condition permits, obtain a history. Determine her age at menarche, the average duration of menstrual periods, and the interval between them. Establish the date of the patient’s last menses, and ask about any recent changes in her normal menstrual pattern. Have the patient describe the character and amount of bleeding. For example, how many pads or tampons does the patient use? Has she noted clots or tissue in the blood? Also ask about the development of other signs and symptoms before and during the menstrual period.
Next, ask if the patient is sexually active. Does she use a method of birth control? If so, what kind? Could the patient be pregnant? Be sure to note the number of pregnancies, the outcome of each, and any pregnancy-related complications. Find out the dates of her most recent pelvic examination and Papanicolaou smear and the details of any previous gynecologic infections or neoplasms. Also, be sure to ask about any previous episodes of abnormal bleeding and the outcome of any treatment. If possible, obtain a pregnancy history of the patient’s mother, and determine if the patient was exposed in utero to diethylstilbestrol. (This drug has been linked to vaginal adenosis.)
Be sure to ask the patient about her general health and medical history. Note particularly if the patient or her family has a history of thyroid, adrenal, or hepatic disease; blood dyscrasias; or tuberculosis because these may predispose the patient to menorrhagia. Also, ask about the patient’s past surgical procedures and any recent emotional stress. Find out if the patient has undergone X-ray or other radiation therapy, because this may indicate prior treatment for menorrhagia. Obtain a thorough drug and alcohol history, noting the use of anticoagulants or aspirin. Perform a pelvic examination, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Metrorrhagia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin your evaluation by obtaining a thorough menstrual history. Ask the patient when she began menstruating and about the duration of menstrual periods, the interval between them, and the average number of tampons or pads she uses. When does metrorrhagia usually occur in relation to her period? Does she experience other signs or symptoms? Find out the date of her last menses, and ask about any other recent changes in her normal menstrual pattern. Get details of any previous gynecologic problems. If applicable, obtain a contraceptive and obstetric history. Record the dates of her last Papanicolaou smear and pelvic examination. Ask the patient when she last had sex and whether or not it was protected. Next, ask about her general health and any recent changes. Is she under emotional stress? If possible, obtain a pregnancy history of the patient’s mother. Was the patient exposed in utero to diethylstilbestrol? (This drug has been linked to vaginal adenosis.)
Perform a pelvic examination if indicated, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth 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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Vaginal bleeding, postmenopausal:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her periods regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.
Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Dysmenorrhea:
History (2)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. It is extremely important to distinguish primary from secondary dysmenorrhea.
B. Primary dysmenorrhea starts at the onset of menarche, and is thought to be the result of prostaglandin-2α, which produces uterine ischemia. It can be treated with antiprostaglandins and oral contraceptives.
C. Secondary dysmenorrhea starts later in a woman’s ovulatory life and may be caused by endometriosis or pelvic pathology.
D. If abnormal bleeding is associated with either type of dysmenorrhea, it is important to elicit symptoms of pregnancy, such as missed or late menses, breast tenderness, nausea, or urinary frequency (Chapter 11.5).
E. If severe pain develops during the first part of the menstrual cycle, ascertain the history of a new sexual partner, abnormal vaginal discharge, or dyspareunia. These symptoms could point toward pelvic inflammatory disease (PID) (Chapter 11.3).
F. Pain that develops during menses, but not related to pregnancy or infection, can also be caused by tumor. In younger women, secondary dysmenorrhea sufficiently severe to affect daily functioning or relationships suggests endometriosis. This condition can affect as many as 10% of women. Deep dyspareunia and sacral backache with menses are common symptoms. Premenstrual tenesmus or diarrhea correlates with endometriosis of the rectosigmoid area, whereas cyclic hematuria or dysuria may indicate bladder endometriosis.
G. Infertility is often a consequence of endometriosis.
Physical examination
As with all menstrual complaints, a thorough physical examination is an essential part of making a diagnosis.
A. The general condition of the patient needs to be assessed. Are the vital signs stable or is the patient showing signs of systemic illness such as fever, which can indicate pelvic infection. Hypotension and pallor can indicate a ruptured ectopic pregnancy.
B. A general physical assessment with attention to the back, sacrum, spine abdomen, and bladder is important.
C. A thorough pelvic examination is key. The external genitalia may show signs of cyanosis, as is seen with pregnancy, or abnormal discharge, as is seen with infection. Palpate the vaginal area for nodules which may present on the anterior cul-de-sac or on the posterior vaginal fornix on bimanual examination; they could indicate endometriosis. Cervical motion tenderness and cervical leukorrhea may be present in PID. Uterine tenderness is often present and uterine displacement and fixation may be noted. Ovarian enlargement or adnexa fixation, which correlates with endometriosis or adnexal mass from neoplastic or infectious cause, may be found. Nodules may also be palpated along the uterosacral ligaments on rectovaginal examination.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Menorrhagia:
History (2)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. A menstrual and reproductive history is necessary. First, assess the first day of the last menstrual period and the first day of the previous menstrual period; the regularity, duration, frequency, and intermenstrual flow; and the number of pads or tampons per period.
B. Pregnancy should always be considered and diagnosed, if present. Complications of pregnancy (e.g., spontaneous abortion, ectopic pregnancy, abruptio placentae, and placenta previa) need to be considered if pregnancy is diagnosed.
C. Weight loss or gain, excessive exercise, anxiety or stress disorders, as well as symptoms of systemic disease (e.g., coagulopathy; thyroid, renal, and hepatic disease), must be considered when taking the history.
D. A key question. Is the patient having ovulatory or anovulatory cycles? Do molimenal symptoms (e.g., edema, abdominal bloating, pelvic cramping, and breast fullness) precede menses that follow an ovulatory cycle. If these symptoms are not present and the patient has irregular, heavy periods, the patient is anovulatory and has dysfunctional uterine bleeding.
E. How old is the patient?
1. Menarche to 16 years. Without molimenal symptoms and with irregularity, the problem in the young woman is most probably anovulatory. Whereas some irregularity is normal, it is not normal to soak 25 to
30 tampons or pads per day. In this setting, pregnancy remains a consideration if the patient is sexually active. Fever and pelvic pain can indicate pelvic inflammatory disease (PID). Easy bruising suggests a coagulopathy and neurologic symptoms (e.g., blurred vision, visual field defects, and headache) point to a pituitary lesion.
2. Age 16 to 40 years. Anovulation is a less common cause of abnormal bleeding; up to 8% of problems are caused by pregnancy and contraception complications in this age group. Endometriosis, endometrial hyperplasia, and endometrial polyps increase in frequency as a woman ages. PID and endocrinopathies also occur in this age group.
3. Age 40 years and above. Abnormal bleeding in this age group should arouse suspicion of cancer, until proved otherwise. Of women in this age group, 90% who have abnormal bleeding are anovulatory. Menopausal symptoms, use of estrogens, and personal or family history of malignancy are important to elicit.
Physical examination
A. Assess vital signs and the patient’s general appearance. Signs of impending shock (e.g., hypotension and tachycardia) are likely related to pregnancy, particularly in the younger age group, but they can be related to trauma, sepsis, or cancer.
B. Pallor not associated with hypovolemia can be found with chronic blood loss associated with anovulatory cycles, leiomyoma, blood dyscrasia, or malignancy (Chapter 16.1).
C. Fever, leukocytosis, and pelvic tenderness are usually found in acute PID (Chapter 2.6).
D. Pelvic masses found on physical examination point toward abscess, ectopic pregnancy, or malignancy.
E. Signs of thyroid disease (e.g., rapid or slow pulse, reflex changes, hair changes, and thyromegaly) can be associated with menstrual abnormalities.
F. Excessive bruising can indicate nutritional deficiency, eating disorder, trauma, abuse, medication overuse, or coagulopathy (Chapter 15.3).
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Vaginal Bleeding:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Ovulatory bleeding
❑ Anovulatory bleeding
❑ Uterine leiomyoma
❑ Dysfunctional bleeding
❑ Threatened abortion
❑ Cervical erosion or polyp
❑ Perimenopause
❑ Retained products of gestation
❑ Ectopic pregnancy
❑ Oral contraceptives
❑ Hyperandrogenism
❑ Cervical cancer
❑ Endometrial cancer
❑ Anticoagulation therapy
❑ Thrombocytopenia
❑ Hypothalamic-pituitary-gonadal immaturity
Diagnostic Approach
Passage of clots or inability to control bleeding with tampons is consistent with heavy flow (menorrhagia). Bleeding between normal cyclic menses is metrorrhagia. Remember to establish that bleeding is uterine and not from the rectum or urethra.
In adolescents, anovulation is the cause in 90% of cases of metrorrhagia, although pregnancy should be considered. An underlying bleeding diathesis is found in about 20% of adolescents with menorrhagia. In adult premenopausal women, pregnancy and malignancy are the most important considerations, although leiomyomas (fibroids) are the most common. In perimenopausal women, anovulatory cycles and progesterone deficiency with long periods of unopposed estrogen lead to endometrial hyperplasia and polyps. Bleeding in postmenopausal women should be thoroughly evaluated for endometrial cancer, which will be found in 10% of cases.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vaginal bleeding, postmenopausal:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her menses regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.
» READ BOOK EXCERPT ONLINE »
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
Vaginal Bleeding:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Before Normal Menarche
In addition to conditions discussed in thissection, genital tract tumors can cause vaginal bleeding (see section Genital Tract Tumors below).
Trauma
Blunt traumafrom a fall or bicycle injury is common cause of vaginal bleedingduring childhood. Abrasions and lacerations of vulva, vagina, and,less commonly, cervix may occur.Sexual abuse or rape is another commoncause of genital tract injury and bleeding.Trauma also may injure urethra, bladder,rectum, and abdominal viscera. Exam of these areas should be performedin anyone with significant vaginal or vulvoperineal injury. Dependingon circumstances and age of child, vaginal exam under general anesthesiamay be necessary. Vulvovaginitis
Nonspecificvulvovaginitis usually presents with nonbloody discharge. Pathogens thatmay be associated with blood-tinged discharge are Shigella speciesand group A Streptococcus. Vaginal culture is diagnostic.Some children with pinworm infestationmay scratch so much that excoriation and bleeding occur. Seeingthreadlike white pinworms or viewing pinworm eggs under microscopeis diagnostic. Foreign Body
Highestincidence of vaginal foreign body is at 2–4 yrs of age.Some common items are pins, paper clips,beads, crayons, and toilet paper.Vaginal bleeding may occur with orwithout discharge, which is usually foul smelling.Sometimes foreign body can be palpableon rectal exam. Pelvic radiography may be diagnostic if foreignbody is radiopaque.Vaginoscopy is usually necessary fordiagnosis and removal, and sometimes it is necessary to performthis exam under anesthesia. Urethral Prolapse
Is the protrusion of mucosa through the urethralmeatus. Small urethral opening is seen in middle of inflamed, edematous,purplish tissue that is above and separate from vaginal introitus.Mild bleeding appears to come from the vagina, but its origin isthe prolapse.
Condyloma Acuminata
Human papillomavirus (HPV) is the cause of condyloma acuminata, which are skin-coloredwarts with cauliflower-like appearance that can involve labia, perinealarea, and vagina.Because incubation period may be manymonths, child with warts before age 2 yrs may have been infectedas infant. Whether longer intervals result in this infection isunknown.Nonsexual contact also may be possibleexplanation in infants and children. However, possibility of sexualabuse should be considered regardless of age, because this is asexually transmitted infection.Diagnosis of condyloma acuminata isusually clinical. Biopsy is definitive, and specific HPV type canbe established by molecular techniques. Exogenous Hormone Preparations
Exogenous hormone preparations that containestrogens may induce breast development and uterine bleeding. Historyand physical exam are usually diagnostic.
Precocious Puberty
Precocious puberty with premature onset ofmenses can produce vaginal bleeding (see Chap. 48, Precocious Puberty).
Premature Menarche
Isolatedmenses that occur earlier than normal menstruation and without otherevidence of sexual development characterize the rare condition ofpremature menarche.Intermittent spotting or bleeding maycontinue for several days at a time. These episodes may occur onceor in cycles for several months. Puberty occurs at normal time,and menstrual cycles are normal.This disorder is most likely due totransient production of estrogen by ovary.In some girls, abdominal U/Sreveals ovarian follicular cysts. Hypothyroidism
With primary severe hypothyroidism, cross-reactivityof high levels of TSH with ovarian follicle-stimulating hormonereceptors can cause increase in estrogen secretion and subsequentbreast development and vaginal bleeding. Regression occurs followingtreatment with thyroid hormone.
After Menarche
Trauma
Injuriesto vulva and vagina from falls or straddle injuries may cause vaginalbleeding. Sexual assault is another cause of vaginal trauma andbleeding.Erosions of cervix may occur in girlswho have had sexual intercourse or who have borne a child. Intermittentvaginal spotting is frequent occurrence.Diagnosis is confirmed by exam of thecervix. Vulvovaginitis, Foreign Body, and Pelvic Inflammatory Disease
See previous section. In adolescent girls,most common foreign body is retained tampon. Pelvic inflammatorydisease is discussed in Chap.71, Vaginal Discharge.
Cervicitis
Infection with C. trachomatis, N. gonorrhoeae,herpes simplex virus, or T. vaginalis may cause cervicitis. Cervixis inflamed and mucopurulent discharge may be visible. Diagnosisof these infections is discussed in Chap.71, Vaginal Discharge.
Cervical Polyps
May cause intermenstrual spotting in adolescentgirls, especially in those who have borne children or who have hadgonorrhea. Exam of cervix is diagnostic.
Anovulatory Cycles
In adolescence,uterus is most often source of abnormal vaginal bleeding. Most commoncause is anovulatory cycles, which lead to dysfunctional uterinebleeding.During first years after menarche,bleeding may be frequent, prolonged, irregular, and excessive.Prolonged anovulation increases riskfor dysfunctional uterine bleeding. Reason seems to be an impairednegative feedback system. Unopposed estrogen produces thickenedendometrium, and without adequate progesterone, sloughing occurswith potential for heavy bleeding.This is diagnosis of exclusion. Ovulation
Mild, self-limited, midcycle bleeding for1–2 days may be associated with transient decrease in serumestrogen that occurs at time of ovulation. Bleeding also may beaccompanied by mild pain (mittelschmerz).
Endometriosis
Irregular menses with anovulation has beenassociated with endometriosis, which is discussed in Chap. 2, Abdominal Pain.
Genital Tract Tumors
Benign andmalignant tumors of female genital tract are rare in pediatric population butcan present with abnormal vaginal bleeding.Cervical papilloma may present withvaginal bleeding, and soft, friable polypoid mass may be seen arisingfrom cervix.Adenocarcinoma of vagina or cervixand rhabdomyosarcoma (sarcoma botryoides) may present with vaginalbleeding or blood-tinged vaginal discharge. History of maternalingestion of diethylstilbestrol or other synthetic estrogen duringpregnancy may exist with adenocarcinoma. Mass may be seen on pelvicexam with vaginal or cervical tumor.Uterine tumors may present with vaginalbleeding, mass protruding from os, enlarged uterus, or pelvic mass. Although genital tract tumors are rare,they should be considered in any child or adolescent who has abnormalgenital tract bleeding, vaginal discharge, tissue protruding fromvagina, abdominal enlargement, or pelvic mass.Vaginoscopy, pelvic U/S, andlaparoscopy are useful in diagnosis. Histologic diagnosis is definitive. Bleeding Disorders
Presenceof excessive or gushing bleeding with cyclic menses from time ofmenarche should suggest coagulation disorder [e.g., thrombocytopenia(idiopathic thrombocytopenic purpura, leukemia, aplastic anemia),von Willebrand disease, or, rarely, a factor deficiency].CBC, blood smear, platelet count, prothrombintime, activated partial thromboplastin time, and bleeding time effectivelyscreen for most bleeding disorders. See Chap. 52, Purpura and Bleeding,for discussion of these disorders. Endocrine Disorders
Irregularmenses may be associated with hypothyroidism, hyperthyroidism, hyperprolactinemia,and adrenal disorders (Addison disease, Cushing syndrome, late-onsetcongenital adrenal hyperplasia).Ovarian disease (e.g., steroid-secretingovarian tumors, polycystic ovary syndrome, and premature ovarianfailure) also may cause abnormal bleeding. Polycystic ovary syndromeshould be considered in adolescent with hirsutism, acanthosis nigricans,acne, and obesity. Systemic Diseases
Menstrualfunction is usually normal with diabetes mellitus, but irregularcycles can occur, especially with poorly controlled disease.Females with chronic renal diseaseon dialysis have irregular menses that vary from occasional spottingto dysfunctional uterine bleeding. Drugs
Use of oralcontraceptives may produce intermittent vaginal spotting or bleeding,especially during initial 3 mos of use. Intermittent spotting orbreakthrough bleeding also may occur with injectable medroxyprogesteroneand long-acting progesterone implants.Medications (e.g., anticoagulants andplatelet inhibitors) may be associated with excessive bleeding.Irregular menses may be caused by tricyclicantidepressants and valproic acid. Anabolic steroids also may produceanovulatory cycles with irregular bleeding. Complications of Pregnancy
Before 20 Wks' Gestation
Pregnant female with uterine bleeding before20 wks' gestation has complicated intrauterine pregnancy,ectopic pregnancy, or molar pregnancy.
Intrauterine Pregnancy
Threatenedabortion is diagnosed if U/S shows intrauterine pregnancywith viable fetus.Spontaneous abortion is consideredinevitable when there is gross rupture of membranes in presenceof cervical dilatation.In incomplete abortion, tissue fragmentshave already been expelled from uterus. Bleeding is usually heavy,and painful uterine contractions may occur.Missed abortion is retention of deadproducts of conception in utero for several weeks. After fetal death,vaginal bleeding may or may not occur. Occasionally, serious coagulationdefects may occur with prolonged retention of dead fetus. Ectopic Pregnancy
Classically,ectopic pregnancy presents with pelvic pain, vaginal bleeding, andamenorrhea.Although most females have pelvic pain,the other 2 symptoms are less consistent.Results of urine or serum pregnancytest are positive. If question exists about possibility of ectopicpregnancy in nonemergent situation, serial quantitative serum humanchorionic gonadotropin pregnancy tests are useful.Pelvic U/S can help in demonstratingpresence of normal intrauterine pregnancy or mass.Laparoscopy should be considered ifdiagnosis remains uncertain.If vaginal bleeding occurs during firstor second trimester with signs of cardiovascular compromise, rupturedectopic pregnancy is possible. Immediate fluid resuscitation ismandatory, and emergency laparoscopy or laparotomy may be necessary.If patient is stable, pelvic U/S may help clarify diagnosis. Molar Pregnancy
Hydatidiform mole presents with uterine bleedingusually during first trimester. Bleeding may be intermittent orcontinuous. Uterus is often larger than expected for duration ofgestation. Pelvic U/S is diagnostic.
After 20 Wks' Gestation
Third-trimester bleeding may indicate anemergency due to placenta previa or abruptio placenta, and obstetricevaluation should be undertaken without delay.
Diagnostic Approach
Before Menarche
Trauma,vulvovaginitis, and foreign body are most common causes of abnormalvaginal bleeding before menarche.Complete history and physical examshould be performed, including exam of external genitalia and vaginalintroitus. Exam under anesthesia is necessary with significant trauma,foreign body that cannot be removed, or suspected genital tumor.Approach to precocious puberty andvulvovaginitis is described in Chap.48, Precocious Puberty, and Chap. 71,Vaginal Discharge,respectively. After Menarche
Girls withabnormal vaginal bleeding should have complete history and physicalexam, which includes speculum exam of vagina and cervix and bimanualvaginal exam. Source of bleeding must be determined, whether vulvar,vaginal, cervical, or uterine. If significant vaginal trauma hasoccurred from injury, exam of vagina and cervix may have to be performedunder anesthesia.Diagnostic approach to vulvovaginitisin this age group is discussed in Chap.71, Vaginal Discharge. If uncertainty about pregnancyexists, urine pregnancy test should be performed.If bleeding is from normal-sized uterus,most common cause is from anovulatory cycle, but this is diagnosisof exclusion. Other common causes include ovulation and oral contraceptiveuse. Abnormal vaginal discharge and abdominal pain suggest pelvicinflammatory disease. Heavy cyclic bleeding suggests coagulationdisorder, and certain tests should be performed: CBC with differential,analysis of blood smear, platelet count, prothrombin time, activatedpartial thromboplastin time, and bleeding time. Uterine tumors arerare in adolescent age group.If bleeding is from enlarged uterus,it is likely that there is complication of pregnancy (e.g., spontaneousabortion, ectopic pregnancy, placenta previa, or abruptio placenta).If individual is <20 wks pregnant and has normal BP, eitherectopic pregnancy or spontaneous abortion is likely. In either case, pregnancytest should be performed unless it is a known pregnancy, and obstetricconsultation should be obtained.In girl who is <20 wks pregnantand hypotensive with severe bleeding, ectopic pregnancy is mostlikely cause. If uterine bleeding occurs during third trimesterof pregnancy, placenta previa or abruptio placenta is likely. Externalgenitalia should be inspected and obstetric consultation shouldbe requested. An intravenous line should be placed, CBC drawn, andblood sent for type and cross-match. If patient is hypotensive,fluid resuscitation should be started immediately. >>
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Dysmenorrhea:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it's bilateral. When does the pain begin and end, and when is it severe? Does it radiate to the back? How long has she been experiencing the pain? If it's a recent complaint, obtain a human chorionic gonadotropin level to determine if the patient is or was pregnant, because miscarriage can cause painful bleeding. Explore associated signs and symptoms, such as nausea and vomiting, altered bowel or urinary habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.
Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk of sexually transmitted diseases.
Next, perform a focused physical examination. Take the patient's vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Menorrhagia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
When the patient's condition permits, obtain a history. Determine her age at menarche, the duration of menses, and the interval between them. Establish the date of the patient's last menses, and ask about recent changes in her normal menstrual pattern. Have the patient describe the character and amount of bleeding. For example, how many pads or tampons does the patient use per period? Has she noted clots or tissue in the blood? Also ask about the development of other signs and symptoms before and during her menses.
Next, ask if the patient is sexually active. Does she use a method of birth control? If so, what kind? Could the patient be pregnant? Be sure to note the number of pregnancies, the outcome of each, and any pregnancy-related complications. Find out the dates of her most recent pelvic examination and Papanicolaou smear and the details of any previous gynecologic infections or neoplasms. Also, be sure to ask about previous episodes of abnormal bleeding and the outcome of any treatment. If possible, obtain a pregnancy history of the patient's mother, and determine if the patient was exposed in utero to diethylstilbestrol. (This drug has been linked to vaginal adenosis.)
Be sure to ask the patient about her general health and medical history. Note particularly if the patient or her family has a history of thyroid, adrenal, or hepatic disease; blood dyscrasias; or tuberculosis because these may predispose the patient to menorrhagia. Also, ask about the patient's past surgical procedures and recent emotional stress. Find out if the patient has undergone X-ray or other radiation therapy, because this may indicate prior treatment for menorrhagia. Obtain a thorough drug and alcohol history, noting the use of anticoagulants or aspirin. Prepare the patient for a pelvic examination, and obtain blood samples and urine specimens for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Metrorrhagia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin your evaluation by obtaining a thorough menstrual history. Ask the patient when she began menstruating, the duration of menses, the interval between them, and the average number of tampons or pads she uses each month. Establish when metrorrhagia occurs in relation to her menses. Does she experience other signs or symptoms? Find out the date of her last menses, and ask about other changes in her normal menstrual pattern. Ask for details of previous gynecologic problems. If applicable, obtain a contraceptive and obstetric history. Record the dates of her last Papanicolaou (Pap) smear and pelvic examination. Ask the patient if she is sexually active. Next, ask about her general health and any recent changes. Is she under emotional stress? If possible, obtain a pregnancy history of the patient's mother. Was the patient exposed in utero to diethylstilbestrol? (This drug has been linked to vaginal adenosis.)
Prepare the patient for a pelvic examination if indicated, and obtain blood samples and a urine specimen for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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 bleeding, postmenopausal:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Determine the patient's age and her age at menopause. Ask when she first noticed the abnormal bleeding then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her menses regular? If not, ask her to describe menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient's mother and ask about a family history of gynecologic cancer. Determine whether the patient has associated symptoms and if she's taking estrogen.
Observe the external genitalia, noting the character of vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient's breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
DYSMENORRHEA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical approach to dysmenorrhea is simply to rule out significant
organic disease by a thorough pelvic and rectal examination. A smear and
culture for gonococcus and Chlamydia should be done. A course of contraceptives or
progesterone in adequate doses may then be tried. Diuretics may be indicated
if examination suggests pelvic congestion. When the aforementioned measures
fail, a dilatation and curettage (D & C) may be indicated. A gynecologist
may decide to do a culdoscopy, a peritoneoscopy, or an exploratory
laparotomy.
» 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
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
VAGINAL BLEEDING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The differential diagnosis of vaginal bleeding depends on the clinical
picture. The most common cause of unexpected bleeding in all women is
dysfunctional uterine bleeding due to imbalance of estrogen and progesterone
during the menstrual cycle. Nevertheless, vaginal bleeding in a
postmenopausal woman must be considered a malignancy until proven otherwise.
Vaginal bleeding in the prepubertal female should prompt an investigation
for child abuse or incest as well as neoplasm.
A careful vaginal examination with the patient fully relaxed is most
important. A rectovaginal examination must be performed to palpate masses in
the cul-de-sac. Any vaginal discharge must be cultured for gonococci and
Chlamydia organisms to rule out PID. A biopsy is done of any suspicious lesion of the
vagina or cervix, and a Pap smear is performed. If the diagnosis is
uncertain at this point, a gynecology consult is in order. A dilation and
curettage (D & C) or endometrial biopsy must be done if uterine carcinoma
is suspected. In women of childbearing age, a routine pregnancy test should
be done, but if an ectopic pregnancy is suspected a serum beta-human
chorionic gonadotropin (β -hCG) subunit pregnancy test will be more
definitive. Ultrasonography will often determine if a pelvic mass is an
ectopic pregnancy. Ultrasonography will also be helpful in diagnosing
ovarian cysts and tumors, but a computed tomography (CT) scan of the pelvis
can be more definitive.
HEMATURIA
|
| I
| C
| A
| T
| E |
|
| Intoxication
| Congenital
| Allergic or Autoimmune
| Trauma
| Endocrine |
|
| | Malformation |
| | Disorders |
|
|
|
| |
Intercourse Trauma to hymen |
|
| | | |
Foreign body |
| |
| |
|
|
|
Placenta previa |
|
Laceration |
| |
|
| Birth control pills Estrogens and other
hormones |
Anteversion of uterus Retroversion or flexion
of uterus | Idiopathic thrombocytopenic purpura |
Foreign body Abortion, induced |
Menopause Dysfunctional bleeding
Abruptio placenta |
| |
| |
|
| |
|
|
|
| | |
Hypopituitarism Hypothyroidism
Stein–Leventhal ovaries |
|
|
Toxic suppression of platelets Heparin Warfarin |
|
Lupus erythematosus |
Surgery |
|
|
Dysfunctional uterine bleeding is most often physiologic. However, a
granulosa cell tumor of the ovary can be the cause. Ultrasonography or a CT
scan may be able to reveal such a tumor, but culdoscopy or laparoscopy may
be required. If the dysfunctional bleeding is thought to be due to
hypothyroidism or hyperthyroidism, a thyroid profile may be done. If it is
believed to be due to a pituitary adenoma, a magnetic resonance imaging
(MRI) of the brain and serum LH and FSH assays should be done. Anemia and
systemic disease must be ruled out also (see tests listed below).
If pathologic causes of dysfunctional uterine bleeding are excluded, normal
cyclic bleeding may be reestablished by a course of cyclic estrogen and
progesterone or progesterone alone (a “medical D & C”). If this is
unsuccessful, a surgical D & C is required.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
The first step in effective treatment for vulvovaginal candidiasis is correct diagnosis to rule out bacterial vaginitis and establish species of...
Appropriate treatment for vulvovaginal candidiasis depends on a variety of factors including severity of symptoms, species of yeast and patient...
Stress takes its toll by making us anxious, depressed and not able to function as fully as we'd like. What many don't know is that stress can...
Sleep is necessary to feel refreshed, but now we know sleep actually impacts the way the body functions. Sleeping poorly can affect how often you get...
See full list of 4 related videos
» Next page: Signs of Vagina conditions
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
