Evaluation of Vaginitis
Baylor College of Medicine
Anoop Agrawal, M.D.
Vaginitis is among the most common
conditions for women to seek medical care.
Vaginal discharge accounts for
approximately 6 million to 10 million office
visits per year.
Vaginitis can be infectious or non-infectious
Infectious is limited to three principle
diseases: bacterial vaginosis, candidiasis
Non-infectious: atrophic vaginitis,
chemical irritation, lichen planus, allergic
Review of normal
Lactobacilli are the predominant bacteria
and regulate the vaginal environment.
The bacteria make lactic acid which
maintains a vaginal pH of 3.8 to 4.5.
This inhibits adherence of bacteria to
Some lactobacilli (60%) also produce
hydrogen peroxide which has shown to
destroy HIV in vitro.
Examine external genitalia, vaginal sidewalls,
and cervix, quality of discharge.
Fissures/excoriations are signs of candidal
‘strawberry’ cervix assoc. with trich seen
in only 2-5% of cases
The microscopic evaluation of vaginal
discharge is the mainstay in diagnosis of
Samples for pH testing should be taken by
touching swab to the sidewall of vagina
Case One exam on a
You perform an annual pap/pelvic
sexually acitve 23 yo female. The results of
the pap and GC/Chlam are negative. However,
the pap smear report cites the presence of
clue cells. According to the chart, the patient
denied any symptoms and scant vaginal
discharge was noted on your exam.
Do you treat this woman for bacterial
If she is asymptomatic, then no treatment is
required. Other bacteria such as
Gardnerella vaginalis, strep species,
anaerobes are also present as part of the
Wet Mount Preparation
Place small amount of
discharge on two slides.
Add one drop of NaCl on
one, and KOH on the
First, view the saline
Let KOH slide sit for 1 to
2 minutes to allow the
solution to dissolve the
Start at low power (10x);
optimal viewing usually
at 40x, may try 100x
Normal Wet Mount
Epithelial cell borders
will be clear, with
and sharp distinct cell
On saline mount you
lactobacilli - which can
vary in size but typically
are large gram positive
May also see WBCs, but adherent to epithelial
should be less in number cell
B.V. accounts for 10 to 50% of infectious
vaginitis cases in women of childbearing
What is the change in the vaginal flora?
A shift from lactobacilli-dominant to a
mixed flora that can include Gardnerella
vaginalis, Mycoplasma hominis,
The characteristic discharge is thin, milky,
homogeneous, and fishy-smelling.
Diagnosis cannot be reliably made on patient’s
history alone. Studies have demonstrated
poor correlation between symptoms and final
Options for diagnosis:
Wet mount evaluation
culture of the vagina
What are the criteria for diagnosis?
The Amsel criteria is the standard used in
making a clinical diagnosis of B.V. Three
of the four criteria must be met:
vaginal pH greater than 4.5
thin, watery discharge
wet mount showing more than 20% clue
positive ‘whiff’ test (amine odor)
Bacterial Vaginosis -
Search for “clue cells” -
which are vaginal epithelial
cells with indistinct borders
because of large numbers of
Need more than 20% of cells to
be “clue cells” for diagnosis of
Lactobacilli can also adhere to
cell border, so take note of
morphology of organisms
30 yo female presents for her routine pap/pelvic
exam. Her LMP was 8 weeks ago and her UPT is
positive. She is asymptomatic and her exam is
normal. Her wet mount reveals clue cells. Does she
Though B.V. has been shown to be a risk factor for
premature labor and perinatal infection, evidence
supports treatment of high-risk women (prior h/o
preterm birth). The benefits of treating
asymptomatic, low risk pregnant women is less
If treatment is planned, then oral therapy is
recommended. Topicals should be avoided as it may
increase risk of prematurity. (CDC)
USPSTF Guidelines gave a ‘D’
recommendation for screening of bacterial
vaginosis in pregnancy - i.e., do not screen
asymptomatic, low-risk women, supported by
BV is associated with increased risk of PID,
endometritis following delivery, post-
hysterectomy infections, acquisition of HIV
and other STDs.
Hence, treatment is recommended for
asymptomatic women scheduled to undergo
certain gyn procedures to prevent
Oral: Metronidazole 500mg bid for 7 days
alternative: clindamycin 300mg bid for 7 days
Topical: Metrogel (0.75%) one 5 g application
intravaginally for 5 days.
alternative: clindamycin cream 2%
Oral vs. Topical - equal efficacy; topical with
fewer systemic side effects; patient preference
Recurrent BV infections: is common and requires
longer treatment course with above agents,
typically 10 to 14 days.
A 40 yo female with diabetes (Hgb A1c 6.3) is
complaining of vaginal itching and whitish
discharge. She reports having had frequent
yeast infections over the past year. She began
having symptoms last week and has tried OTC
therapies, but her symptoms have not
How reliable are a patient’s self-diagnosis of
Should the patient have tried OTC therapy
before coming to see you?
What are the options in managing this patient?
Most commonly caused by C. albicans 80 to
90% of the time, though other species such
as C. glabrata and C. tropicalis can be seen.
10 to 20% of women have asymptomatic
colonization with C. albicans
Symptoms include pruritis, dysuria, and
thick curdy discharge.
Studies have shown candidiasis to have
been confirmed in only 33% of women who
self-diagnosed yeast infection.
Candidiasis: Diagnosis and
KOH wet mountTherapy
is best means of diagnosis,
specificity of 97%.
Oral and topical therapies have equal efficacy
rates. Again patient preference guides
Severe infections: two or three sequential
doses of 150mg fluconazole each 72 hours
apart or intravaginal therapy for 7 to 14 days.
Vaginal cultures: can be performed in patients
with persistent or recurrent symptoms
Recurrent infection defined as four or
more infections in one year.
If patient is not responding to therapy,
then infection with candida species other
than albicans - glabrata or tropicalis.
Non-albicans species are often
resistant to azole therapy.
Therapies in such cases include
intravaginal teraconazole or boric acid.
Typical symptoms include pruritis, frothy,
Wet mount has low sensitivity, but high
specificity - i.e. 50% of wet mounts can be
negative in culture proven trichomoniasis
Treatment is single dose of 2 grams oral
metronidazole. Topical therapy is less
Unlike asymptomatic BV and candidiasis,
asymptomatic trichomoniasis should be
An 18 yo female reports pruritis and yellow
discharge for past 3 days. She also states
her LMP was 2 months ago. On examination
of the wet mount you see trichomonads.
Is metronidazole safe to use in this scenario?
Yes, the CDC no longer discourages use
during the first trimester.
What if the patient was asymptomatic and
trichomonads were found on a pap smear? or
wet mount? How would this change your
Case Four, cont.
Trichomoniasis in pregnancy: Studies have shown
that treating asymptomatic infections in pregnancy
can increase risk of preterm delivery.
Treat sexual partners. Reinfection of treated
partners of untreated women can only be avoided
by abstinence or use of condoms.
Trichomonas seen on pap smear:
Conventional cytology is not reliable (low
Liquid-based preps have low sensitivity (61%),
but high specificity (99%), so it is reasonable to
treat patient if trichomonas seen on pap.
Eckert, L.O. Acute Vulvovaginitis. New
England Journal of Medicine,
Owen, M.K. Clenney, T.L. Management
of Vaginitis. American Family Physician;
70:11; Dec 1, 2004.
Sobel, J.D. Bacterial Vaginosis.
UpToDate ® 2007.