Vaginitis--%20trichomoniasis,%20candidiasis,%20bacterial%20vaginosis Diagnosis

• Clinical and sexual history, and physical examination are important parts of investigation
• Screening may be considered in asymptomatic women with risk factors (eg HIV infection) and/or those living in areas with high prevalence

• Inquire about characteristics of discharge (ie odor, onset eg association with menstrual cycle, duration, color, consistency), any associated symptoms (eg itch, dysuria, dyspareunia, abdominal pain, abnormal vaginal bleeding) and vulvovaginal hygiene practices (eg douching, shaving) 
• Assess possible risk for sexually transmitted infections (STIs) (ie <25 years old, new or multiple sexual partners, sexual practices, prior STIs, history of incarceration)
• Determine other comorbid conditions (eg diabetes mellitus, immunocompromised states, inflammatory bowel disease), contraception use, and history or current medication use

• Perform general assessment and look for signs of STI
• Examine mucocutaneous regions including the pharynx
• External genitalia should be inspected for anatomical irregularities, cutaneous lesions, inflammation and urethral discharge
• Perianal inspection
  • Digital rectal exam and anoscopy should be considered if patient has practiced receptive anal intercourse or has rectal symptoms
• Inguinal lymph nodes should be palpated

Illuminated Speculum Exam

• Visualize cervix and vaginal walls
• Evaluate vagina and endocervical vaginal discharges (consistency, amount, color, odor, pH)
• Observe for cervical mucopus, erosions, friability, foreign bodies, growth
• If resources are available, obtain specimens
  • Cervical swab for Chlamydia test, gonorrhea culture
  • Vaginal swab for Gram stain and Trichomonas slide

Bimanual Pelvic Exam

• Perform if upper genital tract infection is suspected
• Detect uterine or adnexal masses, tenderness or cervical motion tenderness
  •  A finding of lower abdominal tenderness or cervical motion tenderness should prompt the attending physician to evaluate the patient for salpingitis and/or endometritis which are part of pelvic inflammatory disease (PID)
    • Treat patient accordingly (please see Pelvic Inflammatory Disease disease management chart for further information)
    • Differential diagnoses may also include other surgical or gynecological conditions

Settings Where Diagnostic Lab Tests are Not Available

• Consider syndromic management for patients presenting with vaginal discharge
• A spontaneous complaint of abnormal vaginal discharge is most commonly a result of a vaginal infection T vaginalis, C albicans, and BV are the commonest causes of altered vaginal discharge
• In settings where Gram stain can be carried out in an efficient manner, identification of T vaginalis can be attempted
• In settings where diagnostic tests for the etiologic agent of vaginal infection cannot be done, it is recommended that patients be offered treatment for BV and T vaginalis
• Pap smear is not a reliable test for diagnosing vaginitis and confirmatory diagnostic tests are recommended when incidental findings of trichomoniasis, BV or VVC are noted on a Pap smear

Specimen Collection in Settings Where Diagnostic Lab Tests are Available

Collect vaginal specimens for the following:

• pH test: Specimen should be obtained from the mid-portion of the vaginal side wall to avoid false elevations in pH secondary to cervical mucus, semen, blood, lubricants or other substances
• Amine odor/whiff test: Considered positive if release of fishy odor occurs when swab from vaginal discharge is placed in 10% KOH
• Wet mount microscopy with saline or 10% KOH
• Gram stain: Dry Gram stain is the definitive diagnostic test for BV
• High vaginal swabs: Helps in diagnosing T vaginalis, BV, VVC or other genital tract infections particularly in pregnant, postpartum, or post-instrumentation patients with recurrent or inconsistent signs and symptoms, or in treatment failure
• Culture: Used to identify Candida when microscopy is inconclusive or in recurrent infection where identification of specific causative agent is useful

Lab Tests for Trichomoniasis

• pH: >4.5
• Amine odor/whiff test: Not consistently positive
• Wet mount microscopy with saline: Specimen from the posterior vaginal fornix may reveal motile flagellated trichomonads with abundant polymorphonuclear cells
  • With low sensitivity (as low as 40-60%)
  • Should be performed as soon as possible after taking the sample as motility is decreased with time
• Gram stain: May reveal T vaginalis and/or polymorphonuclear cells
• Culture: Has higher sensitivity (88%) than microscopy
  • Considered in patients with negative wet mount test result, history of trichomoniasis with persistent symptoms even after treatment, or positive T vaginalis on Pap test
• Nucleic acid amplification test (NAAT): Has the highest sensitivity (88-97%) for T vaginalis detection
  • Should be the test of choice where diagnostic lab tests are available
• Rapid tests for trichomoniasis include immunochromatographic capillary flow dipstick technology-based tests (eg OSOM Trichomonas rapid test), nucleic acid probe test (eg Solana trichomonas assay, Amplivue trichomonas assay), and antigen-detection testing
  • Availability may be limited
• Cervical screening (Pap smear) alone is not diagnostic of trichomoniasis

Lab Tests for Bacterial Vaginosis

• Should fulfill 3 out of 4 of the Amsel’s criteria:
  • Abnormal thin, homogenous, gray/white vaginal discharge
  • pH: >4.5
  • Amine odor/whiff test: Positive
  • Wet mount with saline: Presence of >20% clue cells (epithelial cells with granular appearance and obscured borders caused by adherent bacteria)
• Gram stain: May reveal a shift in vaginal flora with a decrease in large Gram-positive rods (Lactobacilli), and a marked increase in smaller Gram-variable coccobacilli (Gardnerella) and curved Gram-negative rods (Mobiluncus) (Nugent’s criteria, Hay-Ison criteria)
  • Considered to be the gold standard in diagnosing patients who fail to fulfill the Amsel’s criteria
• New lab tests which detect Gardnerella vaginalis DNA or vaginal fluid sialidase activity (eg OSOM BV Blue test) or other commercial microbiome-based, nucleic acid amplification assays (eg BD MAX^TM vaginal panel) have similar specificity and sensitivity compared with office-based testing
• Culture is not recommended because of low specificity; Pap smear is also not diagnostic of BV due to its polymicrobial nature

Lab Tests for Vulvovaginal Candidiasis (VVC)

• pH: 3.5-4.5
• Amine odor/whiff test: Negative
• Wet mount with 10% KOH: Typically shows budding yeast, spores and/or branching pseudohyphae
• Gram stain: May reveal polymorphonuclear cells, budding yeast and/or branching pseudohyphae
• Culture: Positive for yeast species
  • Not routinely indicated; should be obtained in patients with recurrent or resistant VVC, possible non-albicans candidiasis, or symptomatic patients with negative microscopy
• DNA probe testing with polymerase chain reaction (PCR) is now also available for complicated VVC