eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Vaginitis: Differential Diagnoses & Workup

Author: Hetal B Gor, MD, FACOG, Consulting Staff, Private Practice, Bergen County, New Jersey
Contributor Information and Disclosures

Updated: Dec 8, 2008

Differential Diagnoses

Cervicitis
Ureaplasma Infection
Cystitis, Nonbacterial
Varicella-Zoster Virus
Cytomegalovirus
Herpes Simplex
Paget Disease

Other Problems to Be Considered

Atrophic vaginitis
Cervical polyp
Contact dermatitis
Entamoeba histolytica
Excessive desquamation of normal vaginal epithelium
Foreign objects
Large cervical ectropion
Lichen sclerosis
Lichen simplex chronicus
Vaginal adenosis
Vaginal cancer
Vaginal intraepithelial neoplasia
Vaginal ulcers
Vaginal emphysematosa (multiple gas-filled cysts on the vaginal and cervical mucosa)

Workup

Laboratory Studies

  • Saline wet mount: Vaginal discharge is placed on a slide with 1-2 drops of 0.9% isotonic sodium chloride solution and examined under high power (x 400).
    • Bacterial vaginosis: Saline wet mount is 60% sensitive and 98% specific. Clue cells are vaginal epithelial cells covered with many vaginal rods and cocci bacteria, creating a stippled or granular appearance. A decreased number of lactobacilli is observed, and WBCs are absent.
    • Vaginal candidiasis: Hyphae and budding yeast forms are noted.
    • T vaginalis infection: Saline wet mount is 80-90% sensitive in symptomatic women. T vaginalis is an oval- or fusiform-shaped protozoan that is 15 mm long (size of a leukocyte), with erratic, twitching motility. A large number of WBCs and epithelial cells are observed.
  • Potassium hydroxide preparation: Vaginal discharge is placed on a slide with 10% KOH solution. Known as the whiff test, a positive finding is the release of a fishy odor after addition of 10% KOH to discharge. The odor is due to the release of amines such as putrescine, cadaverine, histamine, and trimethylamine.
    • Bacterial vaginosis: Whiff test is one of the most specific tests for BV and the least sensitive.
    • Vaginal candidiasis: Negative whiff test is 65%-85% sensitive for candidal infection.
    • Trichomonas vaginitis: Whiff test may be positive.
  • pH: Vaginal pH can be determined with litmus paper. A pH greater than 4.5 often is found in patients with Trichomonas infection or BV (84-97% sensitive, 57-78% specific). Recent intercourse, douching, cervical mucus, and blood can lead to false-positive results.
    • Bacterial vaginosis: pH is 5.0-6.0.
    • Vaginal candidiasis: pH is less than 4.5.
    • T vaginalis infection: pH is 5.0-7.0.
  • Cultures
    • Cultures have little utility for diagnosing BV. Gram stain is 89-97% sensitive and 79-85% specific for detecting BV.
    • Cultures with Nickerson or Sabouraud mediums should be performed in refractory or recurrent cases of vaginal candidiasis.
    • Culture using Diamond medium is the criterion standard for detection of trichomonads and should be used when infection is suspected but cannot be confirmed by other means.
  • Other second-line tests
    • Staining methods (Giemsa, Papanicolaou, Schiff): Sensitivity is 55% and specificity is 97% for detecting BV. Papanicolaou test is not accurate in the diagnosis of Trichomonas infections due to high false-positive and false-negative rates.
    • Latex agglutination test: This test employs polyclonal antibodies reactive against multiple species of Candida.
    • Gas-liquid chromatography: This can be used to detect the succinate-to-lactate ratio in vaginal fluid to assist in diagnosis of BV. Succinate and lactate are metabolites produced by anaerobic gram-negative rods and lactobacilli, respectively.
    • Oligonucleotide probes: These detect high (>107/mL) concentrations of Gardnerella vaginalis. This test also can detect Candida.
    • Antigen-detecting immunoassays, the OSOM Trichomonas Rapid Test, DNA probes, and polymerase chain reaction (PCR): These are useful for detecting trichomonads.

Procedures

All women presenting with abnormal vaginal discharge should have a careful pelvic examination. Have patients take condition-specific tests, ie, colposcopy and cervical biopsies, for suspected cervical cancer.

Histologic Findings

T vaginalis infection can be confused with koilocytotic atypia, caused by the human papilloma virus, and may mimic findings of mild dysplasia. BV may produce inflammation and atypical squamous cells of undetermined significance (ASCUS) on Papanicolaou tests. Also, BV may be linked with cervical intraepithelial neoplasia (CIN).

More on Vaginitis

Overview: Vaginitis
Differential Diagnoses & Workup: Vaginitis
Treatment & Medication: Vaginitis
Follow-up: Vaginitis
References
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References

  1. ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis. Obstet Gynecol. May 2006;107(5):1195-1206. [Medline].

  2. American Academy of Family Practice. Vaginitis. ACOG Technical Bulletin. 2000;[Full Text].

  3. Association of Professors of Gynecology and Obstetrics. Diagnosis of vaginitis. In: APGO Educational Series in Women's Health Issues. 1996;1-9.

  4. CDC. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR Morb Mortal Wkly Rep. 1998;47(RR-1):70-79. [Medline].

  5. Davis JD, Connor EE, Clark P, et al. Correlation between cervical cytologic results and Gram stain as diagnostic tests for bacterial vaginosis. Am J Obstet Gynecol. Sep 1997;177(3):532-5. [Medline].

  6. DeCherney AH, Pernoll ML, eds. Obstetric and Gynecologic Diagnosis and Treatment. 8th ed. Stamford, Conn: Appleton & Lange; 1996:689-712.

  7. Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician. Sep 1 2000;62(5):1095-104. [Medline].

  8. Eschenbach DA, Hillier S, Critchlow C, et al. Diagnosis and clinical manifestations of bacterial vaginosis. Am J Obstet Gynecol. Apr 1988;158(4):819-28. [Medline].

  9. Force R. Management of Vulvovaginal Candidiasis: safe, effective and appropriate therapy -- A Pharmacology Perspective. Vulvovaginal Candidiasis: A contemporary approach to recognition and management. 1997:10-4.

  10. Gjerdingen D, Fontaine P, Bixby M, et al. The impact of regular vaginal pH screening on the diagnosis of bacterial vaginosis in pregnancy. J Fam Pract. Jan 2000;49(1):39-43. [Medline].

  11. Holmes KK, Sparling PF, Mardh P. Sexually Transmitted Diseases. 3rd ed. New York, NY: McGraw Hill Text; 1999:563-639.

  12. Katzung BG, ed. Basic and Clinical Pharmacology. 6th ed. New York, NY: McGraw-Hill Professional Publishing; 1995:723-9, 741-2, 799-803.

  13. Mishell DR, Stenchever MA, Droegemueller W. Comprehensive Gynecology. 3rd ed. St Louis, Mo: Mosby-Year Book; 1997:625-635.

  14. Siberry GK, Iannone R. The Harriet Lane Handbook. 15th ed. St Louis, Mo: Mosby-Year Book; 2000:615-892.

  15. Sobel JD. Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis. Am J Obstet Gynecol. Aug 1 1985;152(7 Pt 2):924-35. [Medline].

  16. Summers PR. Diagnosis of Vulvovaginal Candidiasis: considering conditions that mimic or mask. Vulvovaginal Candidiasis: A contemporary approach to recognition and management. 1997:6-9.

  17. Sweet RL. Importance of differential diagnosis in acute vaginitis. Am J Obstet Gynecol. Aug 1 1985;152(7 Pt 2):921-3. [Medline].

  18. Bornstein J, Zarfati D. A universal combination treatment for vaginitis. Gynecol Obstet Invest. 2008;65(3):195-200. [Medline].

  19. CDC. Tracking the Hidden Epidemics 2000: Trends in STDs in the United States. Centers for Disease Control and Prevention, Sexually Transmitted Diseases. Available at www.cdc.gov/std/Trends2000/trichomoniasis.htm. Accessed 12/8/2008.

  20. Vaginitis. NHIOnDemand. Available at http://content.nhiondemand.com/psv/HC2.asp?objID=100638&cType=hc. Accessed 12/8/08.

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Further Reading

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Keywords

vaginitis, vaginal infection, Trichomonas vaginalis, vaginal candidiasis, Candida infection, bacterial vaginosis, BV, pelvic inflammatory disease, PID, yeast infection, vaginal pH

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Contributor Information and Disclosures

Author

Hetal B Gor, MD, FACOG, Consulting Staff, Private Practice, Bergen County, New Jersey
Hetal B Gor, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Bruce A Meyer, MD, MBA, Vice President for Medical Affairs, Associate Dean for Health System Affairs and Director of the Faculty Practice Plan, Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School
Bruce A Meyer, MD, MBA is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Physician Executives, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Medical Group Management Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Antonio V Sison, MD, Medical Director, Ob/Gyn Group, Robert Wood Johnson University Hospital at Hamilton
Antonio V Sison, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Association of Professors of Gynecology and Obstetrics
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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