eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Vulvovaginitis: Differential Diagnoses & Workup

Author: Mark J Leber, MD, MPH, Clinical Assistant Professor of Emergency Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, Brooklyn Hospital Medical Center
Coauthor(s): Anuritha Tirumani, MD, Research Coordinator, Department of Emergency Medicine, Brooklyn Hospital Center
Contributor Information and Disclosures

Updated: Aug 12, 2009

Differential Diagnoses

Candidiasis
Pediatrics, Child Sexual Abuse
Dermatitis, Atopic
Pediatrics, Foreign Body Ingestion
Dermatitis, Contact
Pediatrics, Urinary Tract Infections and Pyelonephritis
Dermatitis, Exfoliative
Pelvic Inflammatory Disease
Gonorrhea
Trichomoniasis
Herpes Simplex
Vaginitis
Pediatrics, Child Abuse

Workup

Laboratory Studies

  • Laboratory evaluation, if indicated, for a patient with vulvovaginitis consists of checking vaginal pH, performing microscopy, and obtaining a culture.10
  • Measurement of vaginal pH using nitrazine paper is the single most important finding that drives the diagnostic process and should always be determined. Vaginal pH can be tested using a narrow-range pH paper. A pH above 4.5 suggests infections such as bacterial vaginosis or trichomoniasis (pH 5-6) and helps to exclude candidal vulvovaginitis (pH 4-4.5).10,3,5 Remember, the specimen should be obtained in the mid vagina, usually the side walls and not the posterior fornix, since that area is contaminated by cervical mucous that is alkaline. pH testing performed by the patient is available on the market. Studies have shown good agreement between patient and doctor performed testing.16,17
  • A wet preparation and/or mount can be prepared by placing a drop of vaginal secretion on a slide with a drop of saline and viewing the slide under a microscope. This can be used to look for candidal buds or hyphae, motile Trichomonas, epithelial cells studded with adherent coccobacilli (clue cells), and polymorphonuclear cells.10,4


The photomicrograph reveals bacteria adhering to ...

The photomicrograph reveals bacteria adhering to vaginal epithelial cells known as clue cells. The presence of clue cells is a sign that the patient has bacterial vaginosis. Source CDC Phil/ M.Rein.

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The photomicrograph reveals bacteria adhering to ...

The photomicrograph reveals bacteria adhering to vaginal epithelial cells known as clue cells. The presence of clue cells is a sign that the patient has bacterial vaginosis. Source CDC Phil/ M.Rein.

    • For Trichomonas, the saline should be at room temperature and not cold to enhance Trichomonas movement, and microscopy should be performed within 10-20 minutes to reduce the possibility of loss of any trichomonas. It is best to use high power with the condenser dampened to produce the greatest contrast.3
  • A potassium hydroxide (KOH) preparation is prepared by placing a drop of vaginal secretion on a slide with a drop of 10-20% KOH and using a coverslip to protect the microscope lens. This is particularly useful in diagnosis of candidal vaginitis. Smelling ("whiffing") the slide immediately after applying KOH is useful for detecting the fishy (amine) odor of bacterial vaginosis. Sensitivity to detect candidiasis is 40-60%.7
  • These diagnostic point-of-care testing are available commercially, providing a rapid test in confirming the diagnosis of bacterial vaginosis.
    • Quickvue Advance ph+amines3
    • QuickVue Advance tests for proline iminopeptidase activity a marker for G vaginalis3
    • OSOM BV Blue tests for sialidase activity: These are especially useful for practitioners who are unable to perform microscopy. The test detects the presence of elevated vaginal pH level and increased amine, with a sensitivity of 87-92% and a specificity of 92%.3  
    • The tests are expensive with poor reimbursement, so they are not performed in routine or emergency settings.
  • Vaginal fungal culture is the criterion standard for fungal infection. However, it takes 7 days to run and is expensive. Rapid immunoassay testing is being developed that is as accurate as cultures.18
  • Cultures are not useful for bacterial vaginosis. Gardnerella species can be cultured as typical flora in many women who are asymptomatic; therefore, a culture that is reported as positive for Gardnerella species should not be assumed to indicate a vaginal infection that requires treatment unless the woman also has complaints of vaginitis.
  • Culture may be useful in trichomonad infection in case of diagnostic uncertainty after a negative wet mount.5
  • Two other point-of-care tests for Trichomonas are being used:6
    • The OSOM Trichomonad Rapid Test - Overall sensitivity of 83%3,5
    • The Affirm VP 11119,5
    • PCR techniques are also under development but are not cleared by the FDA.8,20,5
  • Routine workup in prepubertal girls is as follows:
    • For most patients, laboratory evaluation does not lead to an etiologic diagnosis; thus, lengthy evaluations are not indicated. A complete history and physical examination are all that are required.
    • Culture for GABHS and a urine culture may be appropriate in children.
    • For patients in whom abuse is suspected, perform cultures for gonorrhea and chlamydia.
    • If a vaginal foreign body is suspected, irrigating the vagina with saline may dislodge certain types of foreign bodies (eg, toilet paper). An examination sometimes requires conscious sedation or general anesthesia.
    • If pinworms are suspected, the infection may be diagnosed by direct visualization of the worm (typically at night). Another method is to use transparent tape applied to the perineum in the morning in hopes of collecting the eggs of Enterobius vermicularis (ie, pinworm), which then can be observed under low-power microscopy.
  • Routine workup in females of childbearing age is as follows: 
    • Remember, the physician diagnosis of vulvovaginitis is not very accurate, because of unfamiliarity with microscopy. Errors are made particularly with mixed infections and candidiasis.21 Trichomonas seen on pap smear makes a woman more prone to a mixed infection as bacterial vaginosis.22  Also, the patient's self-diagnosis of vaginitis is not reliable.23
    • The correct diagnosis is typically obtained by checking pH and performing microscopy. Vaginal pH of a physiologic discharge caused by Candida species is 4-4.5. Bacterial vaginosis is associated with a pH of 5-6. Trichomonas species infection has the highest pH, generally 6-7. Chlamydial infection does not change the vaginal pH.24
    • In bacterial vaginosis, the presence of clue cells is the single most reliable predictor of bacterial vaginosis. Clue cells are vaginal epithelial cells studded with adherent coccobacilli that are best appreciated at the edge of the cell. At least 20% of the epithelial cells on wet mount should be clue cells.4,3
    • In 80-90% of women with symptomatic trichomonal infections, a wet preparation or mount viewed under high power reveals many leucocytes and mobile trichomonas. The accuracy drops to 50% if the patient is asymptomatic or has few Trichomonas.
    • Consider screening for other STDs such as syphilis, gonorrhea, and chlamydiae. Urine or endocervical smears can be performed for gonorrhea and chlamydia.19
    • KOH preparation in candidal vaginitis may reveal budding filaments, mycelia, or pseudohyphae. A fungal culture may be used if the diagnosis is uncertain. For recurrent or severe vulvovaginitis, consider a screening test for diabetes, either serum glucose or urine dip for glucose.


<EM>Candida albicans</EM> photomicrograph. Source...

Candida albicans photomicrograph. Source CDC.

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<EM>Candida albicans</EM> photomicrograph. Source...

Candida albicans photomicrograph. Source CDC.

    • Perform a pregnancy test on all women of reproductive age.
  • Workup in postmenopausal women is as follows:
    • History and physical examination generally provide sufficient information to diagnose atrophic vaginitis.
    • Vaginal pH, if performed, generally is 6-7.
    • A wet mount or preparation may demonstrate inflammatory cells and an increased number of parabasal epithelial cells.
    • Culture and a KOH preparation usually are unrewarding.

More on Vulvovaginitis

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

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Further Reading

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Keywords

vulvovaginitis, vaginitis, vaginal yeast infection, vaginosis, bacterial vaginosis, lactobacillus, inflammation of vagina, inflammation of vulva, vaginal discharge, vaginal itching, vaginal irritation, vaginal fluid, vaginal pH, Gardnerella vaginalis, G vaginalis, Staphylococcus epidermis, S epidermis, Trichomonas vaginalis, T vaginalis, vulvovaginal candidiasis, VVC, candidal vulvovaginitis, desquamative inflammatory vaginitis, atrophic vaginitis, trichomoniasis

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Contributor Information and Disclosures

Author

Mark J Leber, MD, MPH, Clinical Assistant Professor of Emergency Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, Brooklyn Hospital Medical Center
Mark J Leber, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Anuritha Tirumani, MD, Research Coordinator, Department of Emergency Medicine, Brooklyn Hospital Center
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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