Abnormal vaginal discharge: Using office diagnostic testing more effectively

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Abnormal vaginal discharge: Using office diagnostic testing more effectively

J Fam Pract. 2004 October;53(10):805-814

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References

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43. Ferris DG, Hendrich J, Payne PM, et al. Office laboratoAE_French.1004.final 9/20/04 3:18 PM Page 813 ry diagnosis of vaginitis. Clinician-performed tests compared with a rapid nucleic acid hybridization test. J Fam Pract 1995;41:575-581.

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53. Ohlemeyer CL, Hornberger LL, Lynch DA, Swierkosz EM. Diagnosis of Trichomonas vaginalis in adolescent females: InPouch TV culture versus wet-mount microscopy. J Adolesc Health 1998;22:205-208.

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60. Donder GG, Vereecken A, Bosmans E, Dekeersmaecker A, Salembier G, Spitz B. Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis. Bjog 2002;109:34-43.

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Vulvovaginal Candidiasis

Candidiasis is the second most commonly diagnosed vaginitis in the United States. Some experts estimate that 75% of women will have a yeast infection at some point in life and 5% will have recurrent infections.²⁴ However, 10% to 30% of asymptomatic women with normal flora have positive culture results for Candida.^25-29 The proportion of symptomatic women with positive culture results is 20% to 40%.^4,30,31 Complications of VVC are rare,³² though vulvar vestibulitis³³ and chorioamnionitis in pregnancy³² have been reported.

Risk factors. Symptomatic yeast vaginitis has been associated with condom and diaphragm use, recent antibiotic use, receptive oral sex, oral contraceptive use, spermicide use, diabetes, and immunosuppression including AIDS.^31,34-37 The associations with antibiotic use and oral contraceptives are not consistent.^30,38Although pregnancy has been postulated as a risk factor for symptomatic VVC, prevalence of yeast on culture in pregnant women is similar to that of nonpregnant women.³⁰

Suggestive symptoms. Among women with a culture result positive for Candida, the most common symptom is pruritus or burning.²⁸ Abnormal discharge is a complaint for most symptomatic women with VVC confirmed by culture.² In addition, women may complain of a thick, odorless, cottage cheese–like discharge.³⁹ A thick, curdled-appearing discharge points to a diagnosis of Candida because it is rarely present with BV or trichomoniasis. In one study,²⁸a thick curdled discharge had a positive predictive value of 84% for diagnosis of VVC by culture (SOR: B). However, a thin discharge does not rule out VVC; in another study, clinicians described discharge as thin in about half of women ultimately diagnosed with VVC by culture in another study (SOR: B).² On exam, vulvar and vaginal erythema are often present but are not specific findings. The accuracy of the clinical exam for VVC is poor compared with culture (SOR: A).^2,30

Pathogens. Candida albicans is present in 80% to 90% of patients with VVC.^5,40 remainder have non-albicans species, including C glabrata and others.²⁸ An increase to almost 20% of non-Candida species in a vaginitis clinic by the mid-1990’s may be related to increased use of imidazoles available over-the-counter.^40,41 Wet mount results are typically negative in the presence of non-Candida VVC.²⁸

Diagnosis of VVC

The gold standard test for diagnosis of VVC is culture. The potassium hydroxide (KOH) wet mount is only 40% to 75% sensitive.^28,29,42,43 False-positive results are also observed with variable frequency.⁴⁴The pH of the discharge is usually not more than 5.0 with Candida albicans, but may be higher with non-albicans species such as C glabrata.⁴⁵ Culture is recommended for patients with recurrent or persistent symptoms and a negative wet mount result (SOR: B).^5,28,46 Rapid slide latex agglutination testing is not better than microscopy (SOR: B).⁴²

Trichomoniasis

Trichomonas, a motile protozoan with 4 flagella, causes the third most common form of vaginitis in the United States and is more common in some developing countries. Trichomoniasis accounts for no more than 10% of all cases of vaginitis, and it appears to be decreasing since the introduction of metronidazole.^47,48 It is classified as an STD, although transmission is possible by other means if the organism is protected from desiccation—for example, in dirty washcloths or towels and contaminated water. Nonsexual transmission is thought to be uncommon.

Trichomoniasis is associated with GC and Chlamydia infections, and, like them, has been associated with seroconversion to HIV-positive status.⁴⁹ Trichomonads are identified in 30% to 80% of male sexual partners of infected women. In men, trichomoniasis most often is an asymptomatic carrier state.⁵⁰ However, it is the cause of about 10% of cases of nongonococcal urethritis in men.⁵¹

Limited epidemiologic knowledge

Our knowledge of the epidemiology of abnormal vaginal discharge is limited. Studies of vaginitis may exclude patients with vaginal discharge due to cervicitis; studies performed in sexually transmitted disease clinics are not representative of primary care practice; women who do not complain of abnormal vaginal discharge may have positive cultures for Gardnerella vaginalis and Candida albicans; and self-treatment of presumed yeast vaginitis with antifungals available over-the-counter further limits our knowledge of the prevalence and causes of vaginal discharge.

Clinical presentations. Women with trichomoniasis have variable presentations ranging from an asymptomatic carrier state to a malodorous, purulent discharge with vulvovaginal erythema. Punctate hemorrhagic cervical lesions are considered pathognomonic of trichomoniasis, but are seen in only about 2% of cases (SOR: B).⁵²

Diagnosis. Culture for trichomoniasis is the gold standard. Several culture media have been used, most commonly the Diamond medium. Recently introduced is a transport and culture medium for detection of Trichomonas (InPouch TV), which performs as well as Diamond medium (SOR: A).^53-55 A DNA probe is also available and accurate (SOR: A).