Vaginal Discharge

Key Points

• Douching is not helpful for prevention or treatment of vaginitis.

• Signs and symptoms of vaginitis are not specific, but a cause can usually be diagnosed on office microscopy.

• Speculum exam is not necessary for diagnosis of vaginitis; a blind swab in the vaginal vault is equally sensitive

• Self-diagnosis of vaginal infection by the patient is unreliable.

Vaginitis is the most common gynecologic diagnosis made in the primary care setting. Common symptoms include increased vaginal discharge without pelvic pain or systemic symptoms, vulvar itching and burning, dysuria, and possible odor. Physiologic leukorrhea varies and may change with a woman's menstrual cycle. If purulent cervicitis is present on examination, testing for Chlamydia and Neisseria gonorrhoeae should be performed (French et al., 2004). In postmenopausal women, vaginal irritation, dryness and superficial bleeding are often caused by atrophic vaginitis (see Menopause). A medication history is important because isotreti-noin and some contraceptives may also cause dryness and itching. Personal hygiene habits of excessive washing with soap and use of highly absorbent panty liners may cause irritation. If a woman has self-diagnosed and treated with an antifungal and symptoms persist, a clinical examination should be encouraged (ACOG, 2006). Table 25-3 and Box 25-4 review differential diagnosis and findings in vaginitis.

Office microscopy is used most often to make a diagnosis of vaginitis. A finding of many leukocytes is uncommon in candidiasis or bacterial vaginosis (BV) and suggests trichomoniasis. If trichomonads are not present, consider gonorrhea or chlamydial infection (Anderson et al., 2004). Fem V, an over-the-counter (OTC) diagnostic kit, can be used; a positive test suggests BV or trichomoniasis; a negative test is likely a yeast infection (Prescriber's Letter, 2006).

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