Diseases » Vaginitis » Diagnosis

Diagnosis of Vaginitis

Diagnostic Test list for Vaginitis:

The list of medical tests mentioned in various sources as used in the diagnosis of Vaginitis includes:

• Vaginal fluid tests
• Vaginal swab

Vaginitis Diagnosis: Book Excerpts

• Ask the Following Questions - METRORRHAGIA
• Ask the Following Questions - PRURITUS, VULVAE
• Ask the Following Questions - VAGINAL DISCHARGE
• Ask the Following Questions - VULVAL OR VAGINAL MASS
• Ask the Following Question - VULVAL OR VAGINAL ULCERATIONS
• Differential Diagnosis - Vaginal Discharge
• Differential Diagnosis - Vaginal Discharge
• Differential Diagnosis - Abnormal Vaginal Bleeding
• Approach to the Diagnosis - VAGINAL DISCHARGE
• Approach to the Diagnosis - VAGINAL BLEEDING
• History and physical examination - Metrorrhagia
• History and physical examination - Vaginal discharge
• History and physical examination - Vulvar lesions
• History and physical examination - Vaginal bleeding, postmenopausal
• Diagnosis - Vulvovaginitis
• Diagnosis - Vaginal cancer
• History and physical examination - Metrorrhagia
• History and physical examination - Vaginal discharge
• History and physical examination - Vulvar lesions
• History and physical examination - Vaginal bleeding, postmenopausal
• History (2) - Vaginal Discharge
• Differential Overview - Vaginal Discharge
• Differential Overview - Vaginal Bleeding
• Diagnosis - Vulvovaginitis
• History - Vaginal discharge
• History - Vulvar lesions
• History - Vaginal bleeding, postmenopausal
• Clinical Features and Diagnosis - Vaginal Discharge
• Clinical Features and Diagnosis - Vaginal Bleeding
• History and physical examination - Metrorrhagia
• History and physical examination - Vaginal discharge
• History and physical examination - Vulvar lesions
• History and physical examination - Vaginal bleeding, postmenopausal
• Approach to the Diagnosis - VAGINAL DISCHARGE
• Approach to the Diagnosis - VAGINAL BLEEDING

Tests and diagnosis discussion for Vaginitis:

The cause of vaginitis cannot be adequately determined solely on the basis of symptoms or a physical examination. Laboratory tests allowing microscopic evaluation of vaginal fluid are required for a correct diagnosis. (Source: excerpt from Vaginal Infections & Vaginitis: NWHIC)

Diagnostic Tests for Vaginitis: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Vaginitis.

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

1. 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.
2. Is there a history of hormone therapy? If the patient has been taking estrogen or progesterone, withdrawal or breakthrough bleeding should be considered.
3. Is there pallor or other signs of anemia? Most types of anemia, but particularly iron deficiency anemia, are associated with metrorrhagia.
4. Is there a history of tremor, tachycardia, or edema? Both hyperthyroidism and hypothyroidism may be associated with metrorrhagia.
5. 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.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PRURITUS, VULVAE: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there a vaginal discharge? The presence of a vaginal discharge should suggest candidiasis, trichomoniasis vaginitis, and bacterial vaginitis.
2. Is there a rash? The presence of a rash would suggest eczema, herpes simplex, folliculitis, scabies, and tinea infections.
3. Are there vulval or vaginal lesions? The presence of a lesion in the vulva or vagina would suggest kraurosis vulvae, leukoplakia or vulval carcinoma, condylomata lata, and condylomata acuminata.

DIAGNOSTIC WORKUP

If there is a discharge, microscopic examination of a potassium hydroxide preparation and saline preparation is necessary. A smear and culture of the discharge should be done for bacteria and fungi. Scrapings of the burrows for scabies may be useful. Skin biopsy may help diagnose the cause of a rash. Lesions should be biopsied also. If senile vaginitis is suspected, serum FSH and estradiol and a Pap smear may help determine if there is estrogen deficiency. A gynecologist should be consulted in all difficult diagnostic problems.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

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

DIAGNOSTIC WORKUP

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

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

VULVAL OR VAGINAL MASS: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it tender? A tender vulval or vaginal mass would suggest vulvitis, hematoma, acute bartholinitis, or urethral caruncle.
2. Is it reducible? A reducible vulval or vaginal mass would suggest pudendal hernia, varicocele, cystocele, rectocele, and uterine prolapse.
3. 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.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

VULVAL OR VAGINAL ULCERATIONS: Ask the Following Question:
(Algorithmic Diagnosis of Symptoms and Signs)

1. 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.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

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

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

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

Workup and Diagnosis

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

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

>

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Source: In a Page: Signs and Symptoms, 2004

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

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

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

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

Workup and Diagnosis

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

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

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

• Urine culture and pregnancy test as indicated by history

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

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

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

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

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

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

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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.

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Source: Differential Diagnosis in Primary Care, 2007

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.

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

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

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

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

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

Vulvar lesions: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when she first noticed a vulvar lesion, and find out about associated features, such as swelling, pain, tenderness, itching, or discharge. Does she have lesions elsewhere on her body? Ask about signs and symptoms of systemic illness, such as malaise, fever, or rash on other body areas. Is the patient sexually active? Could she have been exposed to sexually transmitted disease?

Also, examine the lesion, do a pelvic examination, and obtain cultures. (See Recognizing common vulvar lesions.)

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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.

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

Vulvovaginitis: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnosis of vulvovaginitis requires identification of the infectious organism during microscopic examination of vaginal exudate on a wet slide preparation (a drop of vaginal exudate placed in normal saline solution). In some cases, a culture of the vaginal discharge may identify the organism causing the infection.

Diagnosis of vulvitis or suspected venereal disease may require complete blood count, urinalysis, cytology screening, biopsy of chronic lesions to rule out malignancy, culture of exudate from acute lesions, and possible human immunodeficiency virus testing.

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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.)

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Source: Professional Guide to Diseases (Eighth Edition), 2005

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.

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

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

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

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

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

Vulvar lesions: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when she first noticed a vulvar lesion, and find out about associated features, such as swelling, pain, tenderness, itching, or discharge. Does she have lesions elsewhere on her body? Ask about signs and symptoms of systemic illness, such as malaise, fever, or a rash on other body areas. Is the patient sexually active? Could she have been exposed to a sexually transmitted disease?

Also, examine the lesion, do a pelvic examination, and obtain cultures. (See Recognizing common vulvar lesions, page 814.)

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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.

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

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

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

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

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

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

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

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

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

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

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

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

Idiopathic vulvovaginal ulceration can be associated with HIV disease.

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

Physical examination (4)

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

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

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

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

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

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

❑ Physiologic discharge

❑ Candida vulvovaginitis

❑ Bacterial vaginosis

❑ Trichomonas vaginitis

❑ Atrophic vaginitis

❑ Irritant dermatitis

❑ Gonorrheal cervicitis

❑ Chlamydial cervicitis

❑ Herpes simplex

❑ Cervical cancer

Diagnostic Approach

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

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

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Source: Field Guide to Bedside Diagnosis, 2007

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.

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Source: Field Guide to Bedside Diagnosis, 2007

Vulvovaginitis: Diagnosis
(Handbook of Diseases)

Vaginitis is diagnosed by identification of the infectious organism during microscopic examination of vaginal exudate on a wet slide preparation (a drop of vaginal exudate placed in normal saline solution).

❑ In trichomonal infections, the presence of motile, flagellated trichomonads confirms the diagnosis.

❑ In monilia vaginitis, 10% potassium hydroxide is added to the slide, and microscopic examination seeks “clue cells” (granular epithelial cells); however, diagnosis requires identification of C. albicans fungi.

❑ Gonorrhea necessitates culture of vaginal exudate on Thayer-Martin or Transgrow medium to confirm diagnosis.

Diagnosis of vulvitis or suspected venereal disease may require complete blood count, urinalysis, cytology screening, biopsy of chronic lesions to rule out malignancy, and culture of exudate from acute lesions.

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Source: Handbook of Diseases, 2003

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

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

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

Vulvar lesions: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient when she first noticed a vulvar lesion, and find out about associated features, such as swelling, pain, tenderness, itching, or discharge. Does she have lesions elsewhere on her body? Ask about signs and symptoms of systemic illness, such as malaise, fever, or rash on other body areas. Is the patient sexually active? Could she have been exposed to a sexually transmitted disease (STD)?

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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.

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

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

Prepubertal Onset

Physiologic Leukorrhea

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

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

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

Vulvovaginitis

Nonspecific Causes

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

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

Dysuria is sometimes associated finding.

Specific Infections

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

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

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

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

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

Foreign Body

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

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

History and physical exam are usuallydiagnostic.

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

Pubertal and Postpubertal Onset

Physiologic Leukorrhea

Most commoncause of vaginal discharge in pubescent girls.

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

Wet preparation shows epithelial cellswith no evidence of inflammation.

Vulvovaginitis

Nonspecific Causes

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

Specific Infections

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

Bacterial Vaginosis

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

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

Candida Species

Infectionwith Candida species produces thick, cheesy pruritic discharge.

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

Trichomonas vaginalis

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

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

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

Herpes Simplex Virus

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

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

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

Cervicitis

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

Typical clinical findings of cervicitisare mucopurulent discharge and inflamed cervix.

Chlamydia trachomatis

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

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

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

Neisseria gonorrhoeae

Transmissionoccurs by direct sexual contact.

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

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

Pelvic Inflammatory Disease

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

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

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

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

Foreign Body

In adolescents,most common foreign body is retained tampon.

Discharge is foul smelling and oftenblood streaked.

Foreign body can usually be visualizedby speculum exam.

Diagnostic Approach

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

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

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

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

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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.

>>

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

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.

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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.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Vulvar lesions: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient when she first noticed a vulvar lesion and find out about associated features, such as swelling, pain, tenderness, itching, or discharge. Does she have lesions elsewhere on her body? Ask about signs and symptoms of systemic illness, such as malaise, fever, or rash on other body areas. Is the patient sexually active? Ask whether she could have been exposed to sexually transmitted disease.

Examine the lesion, do a pelvic examination, and obtain cultures. (See Recognizing common vulvar lesions, page 640.)

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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.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

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

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

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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.

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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

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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.

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Source: Differential Diagnosis in Primary Care, 2007

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