eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Vaginitis: Differential Diagnoses & Workup

Author: Ann S Botash, MD, Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University
Contributor Information and Disclosures

Updated: Nov 3, 2009

Differential Diagnoses

Foreign Bodies, Rectum
Salmonella Infection
Pediatrics, Child Sexual Abuse
Sexual Assault
Pinworms
Urinary Tract Infection, Female
Pregnancy, Postpartum Infections
Vulvovaginitis

Workup

Laboratory Studies

  • The workup for patients with vaginitis depends on the risk factors for infection and the age of the patient.
  • Test for Candida albicans via a potassium hydroxide (KOH) preparation.
    • As many as 30% of symptomatic candidiasis cases have false-negative KOH results.
    • One drop of vaginal discharge is mixed with 1 drop of 10% KOH solution and covered with a coverslip.
    • Branching hyphae and buds of Candida are visible.
    • Gram stain or culture on Nickerson media and Sabouraud agar may enhance diagnosis.
    • Papanicolaou tests (Pap smears) may have frequent false-positive results for yeast.
  • Motile trichomonads may be revealed by wet preparation (1 gtt of isotonic sodium chloride solution with 1 gtt of discharge).
    • With trichomoniasis, more than 10 white blood cells (WBCs) per high power field (HPF) are seen on wet preparation. Diagnostic accuracy may be improved by culture on Diamond medium or Trichosel broth.
    • InPouch TV is 90-95% specific and 100% sensitive for culturing Trichomonas vaginalis. Compared with culture, the sensitivity of the wet prep is only 60%.
    • Trichomonas Rapid Test (an ELISA strip test) has 80% sensitivity.
    • Affirm DNA hybridization is 80% sensitive for Trichomonas, and 94% sensitive for bacterial vaginosis.
    • Pap smears may reveal trichomonads but have a high false-positive rate.
  • Bacterial vaginosis is associated with an intense amine odor with the KOH preparation (the whiff test). The "Whiff" test is not very sensitive or specific for diagnosis.
    • On wet preparation, clue cells are seen with a paucity of WBCs.
    • On Gram stain, clue cells are identified as epithelial cells covered by small gram-negative rods.
    • The Affirm DNA hybridization method is 94% sensitive for bacterial vaginosis.
    • Culture is not generally indicated or recommended.
  • Gonorrhea usually causes a cervicitis, not a vaginitis, and may be asymptomatic. Symptomatic Neisseria gonorrhoeae usually results in a purulent discharge.
    • Obtain cultures of the vagina (prepubertal), cervix (pubertal, adult), oral pharynx, and rectum if gonococcal vulvovaginitis is suspected.
    • Obtain cultures using a cotton-tipped swab and Thayer-Martin media on chocolate agar, incubated in a carbon dioxide–rich environment (see Pediatrics, Child Sexual Abuse).
    • DNA amplification assays of genital tract specimens are both sensitive and specific. First-void urine specimens for nucleic acid amplification tests (NAATs) have also been shown to be sensitive and specific in females. They are less invasive than swabs, and with confirmation such as repeat testing using a different form of NAAT, urine NAAT may be used for the evaluation of chlamydia and gonorrhea in cases of suspected sexual abuse.
  • Test for chlamydial vulvovaginitis via culture in prepubertal girls and in patients who show signs of abuse or sexual assault.
  • Nucleic acid amplification testing can be performed as a screen using cervical swabs of pubertal and adult women. Use of this form of testing in prepubertal children may be done for initial screening, but confirmation testing should be assured due to medical legal concerns.1
  • The use of nucleic acid amplification tests has been implemented by many office and emergency settings. Tests such as polymerase chain reaction (PCR) can be performed using swabs of the cervix or vagina or by collecting a urine sample. These tests are generally used to test for common sexually transmitted diseases such as chlamydia and gonorrhea, but utilization for the diagnosis of bacterial vaginosis has been studied and shown to be potentially more sensitive and specific than Gram stain and clinical diagnosis.2,1

More on Vaginitis

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

  1. [Best Evidence] Black CM, Driebe EM, Howard LA, Fajman NN, Sawyer MK, Girardet RG, et al. Multicenter Study of Nucleic Acid Amplification Tests for Detection of Chlamydia trachomatis and Neisseria gonorrhoeae in Children Being Evaluated for Sexual Abuse. Pediatr Infect Dis J. Jul 2009;28(7):608-613. [Medline].

  2. Fredricks DN, Fiedler TL, Thomas KK, et al. Targeted PCR for detection of vaginal bacteria associated with bacterial vaginosis. J Clin Microbiol. Oct 2007;45(10):3270-6. [Medline]. [Full Text].

  3. Angotti LB, Lambert LC, Soper DE. Vaginitis: Making Sense of Over-the-Counter Treatment Options. Infectious Diseases in Obstetrics and Gynecology [serial online]. Aug 7, 2007;Available at http://www.hindawi.com/GetPDF.aspx?doi=10.1155/2007/97424.

  4. Sobel JD, Chaim W, Nagappan V, Leaman D. Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine. Am J Obstet Gynecol. Nov 2003;189(5):1297-300. [Medline].

  5. Van Kessel K, Assefi N, Marrazzo J, Eckert L. Common complementary and alternative therapies for yeast vaginitis and bacterial vaginosis: a systematic review. Obstet Gynecol Surv. May 2003;58(5):351-8. [Medline].

  6. [Guideline] 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].

  7. American Academy of Pediatrics. 2009 Red Book Report of the Committee on Infectious Diseases. 28th ed. 2009.

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  9. Barousse MM, Van Der Pol BJ, Fortenberry D, et al. Vaginal yeast colonisation, prevalence of vaginitis, and associated local immunity in adolescents. Sex Transm Infect. Feb 2004;80(1):48-53. [Medline].

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  11. Daniels RV, McCuskey C. Abnormal vaginal bleeding in the nonpregnant patient. Emerg Med Clin North Am. Aug 2003;21(3):751-72. [Medline].

  12. Department of Health and Human Services, Centers for Disease Control and Prevention. Sexually Transmitted Diseases. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/std/default.htm.

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  16. Hardick J, Yang S, Lin S, et al. Use of the Roche LightCycler instrument in a real-time PCR for Trichomonas vaginalis in urine samples from females and males. J Clin Microbiol. Dec 2003;41(12):5619-22. [Medline].

  17. Hillier SL, Nugent RP, Eschenbach DA, et al. Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. The Vaginal Infections and Prematurity Study Group. N Engl J Med. Dec 28 1995;333(26):1737-42. [Medline].

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  20. Kellogg ND, Parra JM, Menard S. Children with anogenital symptoms and signs referred for sexual abuse evaluations. Arch Pediatr Adolesc Med. Jul 1998;152(7):634-41. [Medline].

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  25. Shapiro RA, Schubert CJ, Siegel RM. Neisseria gonorrhea infections in girls younger than 12 years of age evaluated for vaginitis. Pediatrics. Dec 1999;104(6):e72. [Medline].

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  27. Straumanis JP, Bocchini JA Jr. Group A beta-hemolytic streptococcal vulvovaginitis in prepubertal girls: a case report and review of the past twenty years. Pediatr Infect Dis J. Nov 1990;9(11):845-8. [Medline].

  28. Swygard H, Sena AC, Hobbs MM, Cohen MS. Trichomoniasis: clinical manifestations, diagnosis and management. Sex Transm Infect. Apr 2004;80(2):91-5. [Medline].

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  30. Wilson JF. In the clinic. Vaginitis and cervicitis. Ann Intern Med. Sep 1 2009;151(5):ITC3-1-ITC3-15; Quiz ITC3-16. [Medline].

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Keywords

vaginitis, vaginitis symptoms, bacterial vaginitis, vaginitis treatment, candida vaginitis, causes of vaginitis, vulvovaginitis, bacterial vaginosis, yeast infection, vaginal discharge, candidiasis, Candida albicans, trichomoniasis, Trichomonas vaginalis

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Contributor Information and Disclosures

Author

Ann S Botash, MD, Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University
Ann S Botash, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, Helfer Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Medicines Company Consulting fee Consulting; Pfizer Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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