Week 10 Assignment: Special Examinations—Breast, Genital, Prostate, and Rectal/Genitalia assessment

1·• "- J' • I

·-' . Vaginal Discharge and Itching

nfectious causes of vaginal discharge or L ching include Trich?mona~ vc:ginalis, Candida spp., and bactenal vagmos1s (BV), which account for the majority of all vaginal infections in the United States. Sexually trans­ mitted causes of lower genital tract infections include Chlamydia trac homatis, Neisseria 'l(JllOrrhoeae, and Trichomonas vagina/is. - Posnnenopausal patients often have dis­ charge, itching and irritation related to atrophic 1'3ginitis, caused by the deficiency of estrogen in the vaginal tissues. Chemical vaginitis in ado­ le.scents and adults occurs because of the use of scented douches, lubricants, or hygiene sprays

Vulvar itching, burning, and a foul odor often accompany vaginal discharge. Pubic lice, scabies, pinworms, and genital warts (condylomata acuminata) can all cause itch­ ing. Common foreign bodies found in the va­ gina of adult patients are lost or forgotten tampons, which can produce a foul-smelling discharge.

ln childhood and adolescence, vulvar itch­ ing soreness, and vaginal discharge are com­ mon. The lack of estrogen stimulation, neutral pH of the vaginal secretions, lack of protec­ tive thick labia and pubic hair, and daily liv­ ing habits (e.g., wiping, clothing, play activi­ ties, environment, and baths) lead to this rondition. Additionally, the vaginal mucosa is thin and less resistant to infectious organisms. Chemical vaginitis in a child is u sually caused by sensiti vity to bubble bath.

DIAGNOSTIC REASONING: FOCUSED HISTORY

What kind ofvaginitis might this be?

Key Questions ' What is the amount, color, and consistency

of your discharge?

• Do you have itching, swelling, or redness? • Is there an odor?

Characteristics of Discharge Copious amounts of greenish, offensive­ smelling discharge are most consistent with T. vagina/is. Mucopurulent or purulent dis­ charges are associated wi.th gonorrhea and chlamydia. A moderate amount of white, curd­ like discharge is consistent with candida vul­ vovaginitis. BV typically produces a discharge that is thin and white, green, gray, or brown­ ish. Although characteristic symptoms associ­ ated with each type of vaginal discharge can be helpful in arriving at a diagnosis, they are not diagnostic in and of themselves. Micro­ scopic examination of the vaginal discharge is more sensitive than the clinical picture in con­ firming the diagnosis (Fig. 3 7 .1 ).

Itching, Swelling, and Redness Vaginitis causes inflammation of the tissues, resulting in erythema and edema. Because of the inflammatory process, the amount of discharge will produce a concomitant amount of swelling and redness of the vulva and va­ gina. Itching is consistently present with candidiasis. Scratching can lead to excoria­ tions and satellite les ions. BV does n ot in­ volve an inflammatory process and results in discharge with little vulvovaginal erytherna and edema.

Odor A fishy odor caused by the release of amines from organic acids is prominent with BV. It is accentuated by the addition of potassium hy­ droxide (KOH) to the wet mount s lide and is considered a positive "whiff" test. Odor com­ monly accompanies trichomonal infections. Retained tampons or other foreign bodies can also cause a foul odor.

505

Chapter 37 • Vaginal Discharge and Itching

0

FIGURE 37 .1 Microscopic differential diagnosis of vaginal infections. A, Clue cells (epithelial cells with c lumps of ba c teria) are evident in ba c terial vaginosis. B, Budding, branching hyphae characterize candi­ diasis . C, Motile tri c homonads are seen with tric ho moniasis. (From Zitelli BJ , Davis HW: Atlas of pediatric physical diagnosis, ed . 3 , St Louis, 1997, Mos by-Wolfe.)

Is this likely a sexually transmitted infection?

Key Questions • Are you sexually active? Do you have

multiple partners? Do you have a new partner?

• Have you had sex against your will? If a child, you might ask, "Has anyone touched your private parts?"

• What form of protection do you use? How often do you use protection?

• Have you or your partner(s) ever been tested or treated for a sexually transmitted infection (STI)?

• Do you have any rashes, blisters, sores, lumps, or bumps in the genital area?

Sexual History Early-age onset of sexual act1v1ty, multiple partners, and nonuse of barrier contracep­ tives, particularly condoms, increase the risk of vaginal infection. STis are common in patients of childbearing age (12- 50 years) who have acquired a new partner, but the highest prevalence is in sexually active young adults younger than age 24 years. The patient who frequently changes sexual partners or participates in risky sexual practices (e.g., anal intercourse without a condom) is at high risk for STls.

Do not ignore the possibility of an STI in older adults or children. About half of all children with an STI have been found to be sexually abused. T. vagina/is is rare in chil­ dren but can be transmitted to a neonate from an infected mother.

Recent Treatment for a Sexually Transmitted Infection Recent treatment for an STI may indicate treatme nt failure, a coinfection that was not covered by the prescribed drug, or recent exposure.

Lesions Vesicles usually indicate herpes infection. Pa­ tients typically notice them on the external labia and report that they itch or burn. Condy­ lomata lata, condylomata acuminata, and mol­ luscum contagiosum are a ll papular lesions found on the labia, perineum, and anal regions. Molluscum contagiosum, when occurring in the genital area, may extend to the inner thighs. Typically, condylo m ata acuminata (genital warts) are rough, verrucous lesions that are usually located inferiorly from the fossa na­ vicularis to the fourchette and perinea! area. A painless ulcer suggests syphilis and classically appears as a solitary les ion. However, there can be more than one chancre, especially if the patient is immunocompromised.

~

• 6t '"'ginitis tlrat is not related

'11

stions 'tyou ever been told that you have dia-

Cushing syndrome, or human im­ ~eficiency virus (HIV) infection? flave you been ill recently?

' AJC you taking antibiotics, hormones, or ' (fa! contraceptive pills? , Have you received chemotherapy? , ()oeS the itching seem to be worse at

night? , Can you describe some of your recent ~vities? Ifan adolescent: Have you had a menstrual pen'od?.

nocompromised States ory fungal vulvovaginitis may indicate osed diabetes or an imrnunocompro­

fever, and measles can lllSe vaginitis.

ledications or Chemotherapy 11th control pills, corticosteroids, antibiotics, llcbemotherapy are associated with candi­ 11 vulvovaginitis. Oral contraceptives can ierthe vaginal pH, and antibiotics can alter ~ nonnal vaginal flora; both predispose to

Chapter 37 • Vaginal Discharge and Itching

fungal infection. Corticosteroids and chemo­ therapy can produce an immunocompromised state and provide the opportunity for fungal infection.

Night Itching Pinworms are intestinal parasites that inhabit the rectum or colon and emerge to lay eggs in the skinfolds of the anus. Perianal pruritus, especially at night, along with pain or itching of genitals is common (Fig. 3 7 .2).

Activities Riding a bicycle, using pools or hot tubs, or wearing tight-fitting pants or pantyhose can lead to heat and moisture in the genital area, causing mechanical irritation and such infec­ tions as candidiasis or BV.

Premenarche Children who have not yet reached menarche are prone to vulvovaginal infections because of a nonestrogenized vagina and the lack of labial development and hair growth.

Is this condition acute, recurring, or chronic?

Key Questions • How long have you had these symptoms? • Are they getting better or worse? • Have you ever had these symptoms

before?

u

mature worm is shown sur­ (From Zitelli BJ, Davis HW: Atlas of

Chapter 37 • Vagin al Discharge and Itching

• How many episodes have you had in the past year?

• Are the episodes related to any particular activity or time?

Chronology of Symptoms The occurrence of vaginal discharge after having a new sex partner suggests an acute condition, such as an STI. Symptoms associ­ ated with use of condoms or spermicidal jelly suggest sensitivity to the product. Tf the discharge occurs monthly with worsening after menses, suspect a chronic condition, such as vulvovaginitis candidiasis. Recurrent episodes related to bathing activities point to chemical irritation.

Ifthis is acute, could it be related to a previous infection?

Ke y Questions • Have you been tested and treated for

this condition? What medication was pre­ scribed?

• Did you take all of the medication? • What other prescriptions were you taking

at that time? • What over-the-counter medications have

you taken?

Adequate Diagnosis Diagnoses made clinically on the basis of the color or appearance of discharge may be incor­ rect, or a concomitant vaginal infection may have been missed. However, self-diagnosis and treatment are common, especially with the over-the-counter medicines for "yeast infection."

Adequate Treatment Medication regimens that are not single dose present a challenge to treatment completion. Patients may stop u sing vaginal medications when menses begins and resume after it ends. They may also discontinue the medica­ tion early, as soon as symptom relief occurs, or if they have a drug side effect (e.g., the metallic taste of metronidazole). Drug inter­ actions may account for inadequate therapy, or the intake of certain foods or substances,

such as alcoholic beverages, may need to be restricted.

If this is chronic, what should I suspect?

Key Questions • Have any family members or sexual part.

ners reported itching, rashes, sores, lumps or bumps with any vaginal or urinary trac~ infections?

• Do you have a new or untreated partner? • What are your sexual practices (e.g., vagi­

nal , oral, anal sex)? • Have you had recurrent yeast infections in

the past year?

Transmission Caregivers, parents, and siblings can spread infections, such as candidiasis, molluscum contagiosum, herpes, lice, and pinworms, to children through poor hygiene practices. Autoinoculation is also possible, especially for herpes, genital warts, and molluscum contagiosum.

New or Untreated Partner The most common cause of reinfection is in­ tercourse with a new or untreated partner.

Sexual Practices Possible infection reservoirs are oral and anal cavities, which may need to be cultured for herpes or gonorrhea. Additionally, materials used during intercourse may need to be disin­ fected (e.g., diaphragm, sex toys). Less com­ mon modes of transmission include shared intimate clothing.

Recurrent yeast Infections Ifthe patient has had more than three separate episodes of candidal vulvovaginitis in l year, consider diabetes or the immunocompromised state of HIVI AIDS as the underlying cause. Yeast grows best in areas that are dark, moist, warm, and high in glucose, areas where the normal flora has been compromised. Oral contraceptives, hormone replacement therapy, antibiotics (e.g., tetracycline for acne), ste­ roids, diets high in carbohydrates or artificial sweeteners, and clothing that holds moisture

Chapter 37 • Vaginal Discharge and Itching

. the vulva (e.g., pantyhose, tight jeans) ~. factors associated with vulvovaginitis. , (1)1'

" 'rt otlrer possible causes for this ,.itis?

~uestions ltfWhat are your personal hygiene practices?

00 you douche? ffave you changed brands of contraceptive products?

' could you have forgotten to remove your diaphragm or tampon?

IJliene Practices fclllinine hygiene practices can contribute to lgirtitis by causing a local allergic reaction,

vaginal flora, or contamination of the · from the rectum. Perfumes in douches,

, lubricants, and bubble baths are fre­ t offenders in allergic vaginitis.

en a child is out of diapers, toileting is closely assisted, and wiping techniques be poor, leading to contamination of the

with bowel flora.

ing Frequent douching can change the balance of amal vaginal flora by altering the pH and is urecommended. This allows recolonization i the vagina with enteric bacteria, leading to imritus and discharge. Douching can cause 11 allergic reaction. Colored or perfumed toilet paper can irritate the perineum, causing redness and itching. Wiping with tissue after urination or defecation in the direction from fueanus toward the vagina can inoculate the vagina with rectal microbes .

Contraceptive Products Contraceptive products (e.g., spermicidal jellies, suPPositories, foam, and latex condoms) can l'ause an allergic inflammation of the sensitive lllucosa and produce itching, erythema, tender­ lless,and an increase in usual vaginal secretions.

foreign Body

Foul-smelling vaginal discharge can be caused b got _Y a lost tampon or condom or a for-

ten diaphragm. A child who puts a foreign

object into the vagina may have pruritus, burning, or foul, purulent vaginal discharge. Foreign bodies in the vagina are associated with vaginal bleeding or spotting. If the object is left for some time, it can imbed and perfo­ rate the vaginal wall.

Are there any associated symptoms that point to a cause?

Key Question!; • Do you have burning or pain with urina­

tion? Do you have urinary frequency or hesitation or nighttime urination?

• Is intercourse painful? • Do you have abdominal or pelvic pain? • If an infant: Does the infant have an eye

infection? • If an infant: Does the infant have a cough?

Urinary Tract Symptoms Atrophic vaginitis is often accompanied by dysuria, dyspareunia, and vaginal dryness. Estrogen deficiency affects the patient's entire lower genital tract and may produce symptoms that can be confused with a uri­ nary tract infection. Low estrogen levels may exacerbate stress and urge incontinence. Trichomonas and chlamydia may produce a coexisting urethritis that causes frequency and dysuria.

Dyspareunia and Pain Vaginal atrophy, genital warts, or vaginal infec­ tions can cause dyspareunia. A more likely reason for deep vaginal dyspareunia is endome­ triosis, pelvic inflammatory disease (PID), or fibroids. STis such as gonorrhea and chlamydia can cause cervicitis, which, if left untreated, can progress to PID and produce abdominal or pel­ vic pain (see Chapter 3).

Eye Infection Eye infections in a newborn may be associ­ ated with g onorrhea and chlamy dia (see Chapter 30).

Cough Pneumonia in the n ewborn may be an indica­ tion of chlamydia (see Chapter 11 ).

Chapter 37 • Vaginal Discharge and Itc hing

DIAGNOSTIC REASONING: FOCUSED PHYSICAL EXAMINATION

Note Vital Signs The presence of a fever may a lert you to a serious infection. such as PIO. Fever is un­ common with vaginitis.

Perform an Oral Examination Oral thrush may accompany v ul var candidia­ sis, particularly in childre n . Look for w hite patches that bleed when you try to scrape them off.

Perform an External Genitalia Examination Palpate for inguinal lyrnphadenopathy and tenderness, which can be present with vaginal infections. Inspect the vulva and labia, look­ ing for erythema, excoriations, and indura­ tion. The skin is often bright red and swollen with small fissures or excoriations from can­ d idiasis. A lso, thick white curds of discharge are often noted in the labial fo lds. BV often produces a profuse, thin, whitish discharge that will leak o u t of the vagina onto the perineum. Palpate Bartholin and Skene glands and milk the urethra for discharge. Palpable Bartholin glands often coexist with STis. If purulent discharge is seen, consider the diag­ noses of gonorrhea or chlamydia and obtain s pecimens for diagnostic tests.

Condylomata lata, condylomata acumi­ nata, and molluscum contagiosum are all papular lesions found on the labia, perineum, and anal regions. Molluscum contagiosum, when occurring in the genital area, may ex­ tend to the inner thighs. Herpes lesions are usually ulce rative in nature when seen clini­ cally and need to be differentiated from other s imila r lesions (e.g ., syphilitic chancre can be more than one lesion and tender if second­ ari ly infected). Herpetic lesions- painful vesicles on an erythematous base-are fou nd in clusters and can extend from the labia into the vagina. Typically, condylomata acumi­ nata (genital warts) are rough, verrucous les ions that ar e located inferiorly from the fossa navicularis to the fourchette and peri­ neal area.

In an overweight patient, vulvovaginitis candidiasis is frequen tly accompanied by

intertriginous candidiasis (e.g., under th breasts and the abdomina l apron). e

In a young chi ld, it is important to tell he in simple te~s what you ~e ~bout to do. ~ common pos1t1on for exammat1on is the fro leg position. Have the parent sit on a chair an~ then have the patient s it on her parent's lap for the examination. The most common problem (vulvovaginitis) of the younger child requires only the lower third of the vagina to be visual­ ized. A more detailed visual examinati on re­ quires labial separation and labial traction.

Perform an Internal Vaginal Examination Note the condition of the vaginal walls. A plastic speculum makes vaginal wall inspec­ tion easy and helps in the identification of a foreign body for removal. In children, the knee-chest pos ition is useful for inspecting the vagina. If a foreign body is suspected in c hildren, removal is done using sedation. Pale or mottled red splotches of the vaginal mu­ cosa with a sticky, yellow-brown discharge are associated with atrophic vaginitis. In se­ ver e cases of atrophic vaginitis, the pale, thin mucosa may have adhered to the opposing vaginal wall, and the speculum examination often causes an oozing bloo dy discharge.

The appearance of the cervix should be noted. A friable or "strawberry" appearance of cervical petechiae with a frothy, foul- smelling discharge is descriptive of a trichomonas in­ fection. A mucopurulent discharge from the cervical os requires an endocervical sample for gonorrhea and chlamydia testing. This discharge is yellowish-green when collected on a n endocervical swab . The character of the discharge does not con s istently identify com­ mon infectious causes of vaginitis. Treat vag­ ina l infections b efore the P apanicolaou test is obtained because BV and trichomoniasis may cau se inflammatory atypia resu lts .

Obtain a sample for testing. The wet mount is a valuable diagnos tic too l, and a sample of vaginal discharge is b est obtained from the lateral vaginal fornices. Three positi ve char­ acteristics for any one etiology can correctly identify the causative agent (e.g., increased pH; the presence of "clue cells ," which are epithelial cells fu ll of bacteria that obscure the cell border; and a thin gray discharge seen in

Chapter 37 • Vaginal Discharge and Itchingr e Differential Diagnosis). Molecular

~,·~ ~:~r culture may also be indicated (see r.-s1111~ tor)' and Diagnostic Studies). C ultures L~~~- fungal infections, and T. vagina/is are ~ir utinely recommended and are usually r.Jl ~ed for determining resistant organisms. reset'\

erlorm a Bimanual Examination p ess the condition of the uterus, fallopian A~ and ovaries by checking for uterine and !Urvi~al motion tenderness (CMT), ovarian ~e, and presence of masses. CMT or pain on ralpation of the uterus and adnexa confirms tlJe spread of vaginitis or cervicitis to the up­ r:r genital tr~ct and res~lts in PID. This war­ rants immediate evaluation and treatment or referral to prevent tubal scarring, ectopic pregnancy, and infertility.

Morm a Vaginal-Rectal Examination \'aginal-rectal examination is a technique in assessing the posterior uterus and condition of the cul-de-sac as well as the rectum. The in­ !fmal examination glove must be changed ~fore rectal insertion to prevent contamina­ tionof the rectum with vaginal discharge or­ ~ms. A rectal examination, u sing the fifth digi~ is used to palpate a foreign body and to rheck pelvic anatomy in the child.

lABORATORY AND DIAGNOSTIC HUDIES Potassium Hydroxide and Wet Mount or Preparation Obtain a discharge sample from the lateral fornices of the vagina using a cotton-tipped c~plicator. There are several acceptable tech­ niques for preparing a diagnoses and wet lllount. One is to prepare two slides with a ~ear of vaginal disch arge. To one slide, add

drop of l 0% KOH an d put a coverslip in Place. To the other s lide, add 1 drop of normal 1~ine and put a coverslip in place. The result Qfthe whiff test is positive when the addition ~ the 10% KOH produces a fishy odor, which .: caused by the release of amines. The whiff ~Vst has a positive predictive value of 76% for .. L rd 00k under the microscope at the KOH

·n: ~or the presence of branching and bud­ yPhae that are c haracteristic of yeast

infection. Examine the saline wet mount mi­ croscopically for motile trichomonads that signal the presence of trichomonas. Clue cells are characteristic of BV (see Fig. 3 7 . 1).

Test for pH Most litmus paper reads the pH range from 3.0 to 9 .0. This is a simple inexpensive test to aid in determining the cause of the vaginal discharge. Normal vaginal secretions have a pH less than 4 .5. A pH greater than 4.5 is consistent with BV, trichomoniasis, or atro­ phic vaginitis.

Fungal Culture or Sabouraud Agar Culture Fungal culture may be needed in the diagnosis of non- Candida albicans (e.g., C. glabrata, C. tropicalis, C. krusei) that are refractory to medication regimens.

Herpes Viral Culture Viral culture is the most specific method of diagnosing herpes. Res ults may take from 1 to 7 days, with maximum sensitivity achieved at 5 to 7 days. The herpes culture will probably not be able to identify the causative agent if the specimen is taken from a lesion that is 5 or more days old. It is important to document positive genital herpes infections in the preg­ nant patient and in skin lesions of the new­ born. Collect cells or fluid from a fresh sore with a cotton swab and place them in the cul­ ture container. You may need to unroof a vesicle to obtain a specimen.

Herpes Virus Antigen Detection Test This test detects antigens on the surface of cells infected with the h e rpes virus. Cells from a fresh sore are scraped off and then smeared onto a microscope s lide. This test may be d one in addition to or in place of a v iraJ c ulture.

Tzanck Smear Characteristic findings of a Tzanck smear are muJtinucleated gia nt cells that are like ly to be found if the specimen is from an intact herpes les ion. Prepare the Tzanck smear by remov­ ing the roof of the vesicle and scraping the skin with a scalpel blade. Make s ure that the base and the margins of the vesicle are scraped. Do not use the vesicular fluid for thi s

Chapter 37 • Vaginal Discharge and Itching

specimen. The cellular material is spread onto a g lass slide, fixed with absolute alcohol for 1 minute, and then stained with Wright s tain. Alternative staining methods are available, and guidelines can be obtained from local laboratories.

Modified Diamond Culture Diamond culture can be used to identify Tric homonas spp., but it is seldom needed to make the diagnosis.

Thayer-Martin Culture Thayer- Martin medium is a bacterial culture that identifies gonococcal infections. A cul­ ture is taken from the endocervical canal of the uterine cervix. First remove excess mucus from a portion of the cervix using a cotton ball held in ring forceps or a large cotton­ tipped procto-swab. Insert a sterile cotton­ tipped applicator (Q-Tip) into the endocervi­ cal canal and allow it to absorb the mucus for I 0 to 30 seconds before inoculating the me­ dium. Inoculate the medium bottle or plate in a zigzag manner while simultaneously rolling the small cotton-tipped applicator. When opening the Thayer-Martin culture bottle, avoid holding the bottle totally upright, which will allow for the loss of the carbon dioxide from the specimen collection bottle.

A meta-analysis of 21 studies and more than 6100 paired samples estimated the accuracy of self-collected samples compared with clinician­ collected samples for diagnosing ch lamydia and gonorrhea. Six studies compared se lf-collected vaginal samples with clinician-collected c ervical samples. When the studies were pooled , sensi ­ tivity was 0 .92 (95% confidence interval [Cl] , 0 .87-0 .95), and specificity was 0.98 (95% Cl, 0.97- 0 .99) . Taking into account that urine samples may be less sensitive than cervical samples, eight c hlamydia studies that compared urine self-collected versus c linician - collected cervical samples had a sensitivity of 87% (9 5% Cl, 81 - 91) and high specificity of 99% (95% Cl , 0.98-1.00).

For gonorrhea in women, three studies com­

num

an

pared self-collected urine samples with clinician­ col lected cervical swabs. The poo led sensitivity was 0. 79 (95% C l , 0. 70-0.88), and spec ificity was 0.99 (95% Cl, 0.99- 1.00). One cross­ sectional study (n = 309) compared self· collected vaginal samples with clinician-collected cervica l samples. The reported sensitivity was 0. 98 (95% C l , 0.88- 1.00), and the specificity was 0.97 (95% Cl , 0.94- 0.99).

The authors concluded that the high se r1 sitiv­ ity and specificity of vaginal self-collected .:,wabs compared with swabs collected by cl .. :1c1ans supports the use of vaginal swab se lf -cc ·; .'•:t1 on for chlamydia and gonorrhea testing i n vv, 1 ien.

Molecular Testing for Infectious Organisms Molecular testing using a sample taken the vagina provides r a pid, sensitive, and s cific results. Molecular testing has large ly re placed the need for culture methods. A ber of products are available. Tests incl ud DNA probes, nucleic acid amplification tes (NAATs), and polyme rase chain reac tio (PCR) assays. Tests are available for C. tra chomatis, N. gonorrhoeae, T vagina/is, Gard nerella vagina/is, Candida spp., and herpe simplex virus. Samples for chlamydia gonorrhea testing can be obtained by the clini cian or by the patient. Urine NAATs can b used to screen for possible STis in both adults and children.

Syphilis Testing Serology tests are used for screening and diag­ nosing syphilis and are recommended if other STis are found or suspected. The screening tests are nontreponemal and include Venereal Disease Research Laboratory, rapid plasma reagin, and enzyme immunoassay tests. Diag­ nostic tests are T pallidum- specific and include FTA-ABS (fluorescent treponemal antibody absorption test) and T pallidum particle agglu­ tination assay. Detection of T. pallidum can also be done using PCR molecular testing.

2_ EVIDENCE-BASED PRACTICE Se(f-collected J/aginal Su•ahs Co111pared 1vith Cli11icia11-Collectetl S1vahs

Reference: Lunny et a l , 2015.

Chapter 37 • Vaginal Discharge and Itching

. 1ysis ·s should be obtained if the patient

p3 l)'SI l . . ,fl ria However, externa pam on un­ . dysu . fr . .

~. may originate om unne on 1n­ pnond vulvar tissue, e liminating the need i'Jllle . . urinalysis. !Jf

~;croscopy and S~in Scraping . . . ;no a skin scrapmg under the rmcroscope is

\!(II :> • th diffi . I ct• . f .111 10 assist with e erentla 1agnos1s o ; bies and pubic lice (see Chapter 28).

icotchTape Test l.'se this test when you suspect pinworrns ,£nterobius vermicularis), which occur most '°mmonly in children. Instruct the adult to IPPIY clear adhesive cellophane tape to the .IDld's perianal region early in the morning rben the child awakens. The tape i s then re­ ool'ed, placed in a plastic bag, and brought i1IO the clinic. Place it on a glass slide and l!allli ne it under a microscope for the pres­ m of eggs. Parents may also be able to see !he wom1s by shining a flashlight on the ex­ itmal anus of the child at night. A female ionn is about 10 mm long (see Fig. 3 7 .2).

Acetic Acid Test (Acetowhite) Theaceti c acid test is best used to detect sub­ :linical lesions caused by human papilloma­ •llUs (HPV) when a genita l wart has been ident ified, when there has been sexual con­ iact, or when the Pap test indicates dysplasia. ~e application of 5 % acetic acid (vinegar) to :ne. cervix, labia, or perianal area causes the csion to tum white (acetowhite). Saturate a ~~e pad with vinegar and place it on the esion for 5 to IO minutes. After this soaking, ihe white wart will have a s h arp circumscribed lllacular or pa pular border. The surface will ~!>ear verrucous. False-positive results can ~ur with candidiasis, psoriasis, lichen pla­

, and sebaceous g lands.

follicle-Stimulating Hormone Follicle · · gr -sttmulatmg h ormone levels that are Pe~ter than 30 mU/ mL are diagnostic of hightnenopau se, and leve l s of 40 mU/ mL or Panjcr represent menopause . This test is hvPocuJarly helpful in establishing the . Cst

rogenic s tatus of a you n g patient

who is experiencing premature menopause and atrophic vaginitis (see Evidence-Based Practice box).

DIFFERENTIAL DIAGNOSIS Discharges

Physiological discharge

Normal vaginal discharge, produced by the cervical and vulvar glands, is mucoid, clear or white in color, and has no foul odor. Throughout the menstrual cycle it varies in consistency and amount from scant to profuse, depending on the amount of estrogen stimulation to the tissues. On occasion, physiological discharge can lead to slight vulvar irritation and mild itching sec­ ondary to wetness. The vaginal pH is less than 4.5. Wet mount reveaJs up to 3 to 5 white blood cells (WBCs)/high-power field (HPF) and the presence of epithelial cells and lactobacilli.

Bacterial vagi11osis

Bacterial vaginosis is the most common cause of vagina l discharge and is considered a dis­ turbance in normal vaginal flora. Many pa­ tients are asymptomatic. BY is often found after intercours e with a new partner or in con­ junction with other STis. Infection is a ssoci­ ated with increased preterm labor in patients who are pregnant. The diag nosis of BY in premenopausal women is usually base d on the presence of at least three Amse l criteria: characteristic homogeneous, thin, grayis h­ white vagina l discharge. and a vaginal pH greater than 4 .5; fishy odor (whiff tes t) when a drop of 10 °/o KOH is added to a sample of vaginal discharge; a n d the presence of clue cells on saline wet mount ( s e e Fig. 37.1 ).

Ca11dida v 11ll•a •'oginitis

Ninety percent of patients with cand ida vul ­ vovaginiti s present with vu lva r pruritus. i n chi ldre n , it may be acco mpanied b y oral thrush. The discharge is often thick, w hite , and "'curdy"; the labia are erythematous and edematous. Vaginal pH is 4.0 to 4 .7. A KOH wet mount shows pseudohyphae and spores (see Fig. 37. l ).

Chapter 37 • Vaginal Discharge and Itching

According to this systematic review, approxi ­ mately 33% of patients w ith vaginal discharge will have bacterial vaginosis (BV), 25% w i ll have candidiasis, and 10% will have trichomoniasis. The lack of a perceived odor makes candidiasis m ore likely (likelihood ratio, 2.2) , but the ab­ sence of the symptom is not conclusive. No symptoms reliably identify trichomoniasis. A thick or "curdy" discharge is compatible with

yeast but does not rule out additional infect ion. Microscopic evaluation is required to identify clue cells (BV), yeast forms (vaginal candidia ... sis) , or trichomonads (vaginal trichomoniasis). The authors concluded that diagnosis is best established by measuring the pH of t he dis-­ charge, performing the whiff test, and using microscopic examination .

Reference: Piscitelli and Simel, 2009.

Trichomoniasis

Trichomoniasis is often asymptomatic. It is usu­ ally trans mitted via sexual contact but can also be spread by fomites. Patients with chronic in­ fections will have copious amounts of discharge and little or no inflammation of the vaginal tis­ sues. When there is an acute infection, they will report vulvar itching, swelling, and rednes s. The pH is greater than 5 ; the discharge is white, grayish-green, or yellow and sometimes frothy; infrequently, there will be a "strawberry cervix" (cervical petecbiae). If the patient has douched within the past 24 hours, the sensitivity of tests will be greatly decreased. Wet mount shows "gyrating" motile protozoa and often greater than 10 WBCs/HPF ( see Fig. 37.1).

Atrophic vaginitis

In atrophic vaginitis, there is a dry (shiny), pale, thin vaginal wall caused by an insuffi ­ cient amount of endogenous estrogen. During menopause, the vaginal mucosa and vulva, which lack glycogen, become fragile and are s usceptible to injury and infection. Patients may experience burning, dryness, irritation, or dyspareunia . This also occurs in postpartum patients, those who are breastfeeding, and prepubertal adolescents . The pH is a lkaline and ranges from 6.5 to 7 .0. Wet mount shows a few WBCs and is negative for pathogens.

Allergic vaginitis

The causes of allergic vagm1tl s are different in children and adults. In children, the most common offending agents are bubble baths

and perfumed soaps. Vulvovaginitis in adults involves any harsh or caustic substance that has direct contact with the area. Often a new brand of vaginal lubricant, douche, spermi­ cide, or condom will cause the inflammation and edema. Vinegar douches stronger than I to 2 tablespoons per quart of water may also irritate tissues. The wet mount is positive for WBCs and negative for pseudohyphae.

Foreign body

The presenting symptom in foreign body re­ tention is a very malodorous, whitish dis­ charge. In children, the foreign body is as variable as objects found in the ears and nose. However, children younger than 12 m o nths do not have the coordination to insert any­ thing into their vaginas, s o suspect c hild abuse in such cases and inspect for bruis ing or excoriations. Wet mount reveal s many WBCs.

Chlamydia

Ch lamydia is the most prevalent STI in the United States . About 30% of infected p a tie nts are asymptomatic. Gonorrhea and chlamydia coexist in up to 60% of patients. Women with ch lamydia have an increasing amount of vag­ inal discharge and blee ding afte r inte rcourse. Those at greatest risk for infection are younger than 25 years, sexually active with three or more partners, and not using barrie r methods of contraception. Wet mount s h o w s g reater than I 0 WBC s/ HPF and few microscopic bacteria. molecu lar tes ting confirms the diag­ nosis. E xcept for perinatal syndromt~s. non­ sexual trans mission has not been r!;! portcd:

Chapter 37 • Vaginal Discharge and Itching

. uspect child abuse in children with tofl!• s .

J! d·a infection . ~)' I

r;trl'ea rrh a is one of the most common report­

l;f/J. eases Patients are asymptomatic 50% ~~e . . ,.•. , of the time. However, the patient may 11 !iO'}ourulent discharge that originates from ;fe P I d . . ldocervical co umnar an trans1tlona ~ en . . fl .

patients often experience in arnrnatton ~ene glands, Bartholin glands, or the ure­ i which causes pain and dysuria. Molecu­ ~esting or culture confirms the diagnosis. A ~gofgonorrhea in children is considered ~c evidence of sexual abuse.

fr1rit inflammatory disease

rtJvic inflammatory disease is most com­ IOJ]y caused by C. trachomatis and N. gon­ ,moeae (see Chapter 3) and can produce Mceding, abdominal pain, fever, and vaginal jscbarge. Patients with PID have an increas­ .g amount of vaginal discharge and bleeding mintercourse. Infection begins intravagi­ ally in most cases and then spreads upward, :ming salpingitis. In the early stages, pa­ :ms may be asymptomatic. Patients may n a purulent discharge that originates from k endocervical columnar and transitional * With gonorrhea, patients often experi­ u inflammation of Skene glands, Bartholin glands, or the urethra, which causes pain and ~lllria. On examination , abdominal tender­ rtss, CMT, and adnexal tenderness are pres­ ent. As with peritonitis, patients may also taveguarding and rebound tenderness. WBCs t'ld erythrocyte sedim e ntation rate are usually dtvated. Cultures, Gram staining, and rno­ ~lar testing can assist with diagnosi s. ?a~ents with s uspected PID should have a ~tgnancy test to rule out ectopic pregnancy ~id complications of an intrauterine preg­ ~cy. All pati e nts diagnosed with acute PID 1luld also be teste d for HIV infection.

~hing and Lesions \!'Philis

~:echa~cre of primary syphi I is is an ulcer­ lesion that most often develops at the

site of initial inoculation. The syphilitic chan­ cre begins as a papuJe and progresses to a painless, tender, hard, indurated ulcer. The infection causes inguinal lymphadenopathy. Even without treatment, the Jesion wilJ heal in 3 to 6 weeks. Many chancres go unnoticed until the appearance of condylomata lata, the warty papule of secondary syphi lis, or a maculopapular rash on the palms of the hands and soles of the feet. The diagnosis is con­ firmed with serological or molecular testing for syphilis.

Genital warts

Genital warts (condylomata acuminata) are caused by the HPV and may be precursors to genital cancers. The warts may involve the vagina, cervix, perineum, or perianal areas. Condylomata can be flat or raised verrucous lesions (Fig. 3 7 .3 ). The patient usually notices a bump in the genital region accom­ panied by itching and leukorrhea. A wet mount should be performed to rule out any coexisting vaginal infections. An acetic acid test is helpful in identifying flat warts. Refer­ ral to a dermatologist or gynecologist is indi­ cated for treatment of warts of the urethra or anus. High-risk HPV testing of genital warts is not recommended.

FIGURE 37.3 Condylomata acum inata . (From Morse S A , Holmes KK, Ballard R : Atlas of s exually trans­ mitt.ed diseases and AIDS, e d . 3 , St Louis , 2003, Mosby.)

l

Chapter 37 • Vaginal Discharge and Itching

Herpes

Herpetic lesions can be difficult to distin­ guish from ulcerative lesions. The most typical presentation is that of grouped vesi­ cles on an erythematous base that rupture and erode (Fig. 37.4). A prodrome of tin­ gling or itching occurs before the outbreak of the vesicles . On the vulva, the erosions are covered with a whitish, exudative layer. Herpetic outbreaks can involve the cervix, vagina, vulva, anus , or extragenital organs, such as the pharynx. Molecular testing, cul­ ture, antigen test, or Tzanck smear confirms the diagnos is.

If the mother has an active primary herpes simplex virus infection at the time of birth, the infant has a 50% risk of becoming in­ fected. Recurrent maternal infections impart a less than 5o/o risk of transmission. C linical signs of the infant's infection b ecome appar­

FIGURE 37.5 Molluscum contagiosum. (From Black ent in the firs t week of life and pose the pos­

M , Ambros- Rudolph C, Edwards L, et al: Obstetric sibility of death.

and gynecologic dermatology, London, 2008, Mosby.)

Molluscum contagiosum Vu/var intraepithelial neoplasia

Molluscum are s mall (2- 5 mm in diameter), umbilicated, flesh - tone papules (Fig. 3 7 .5). A premalignant condition of the vulvar skin, These characteristic les ions are the hallmark is a condition associated with a hig h risk of of the diagnosi s. Scratching can spread the m . recurrence and the pote ntial to progress to Molluscum is an STf of adults and a likely vulvar cancer. The condition is complicated findin g in HIV-infected patients. When c hil­ by its multicentric and multifocal na ture. The dren are found to have genital molluscum , incidence appears to be rising, partic ularly in s us pect child abuse. the younger age group.

FIGURE 37.4 Herpes. ( Leftfrom H abif. TP: Clinical dermatology, ed 4 , St. Louis, 2004, M osby. Rightfrom Morse SA, H olmes KK, Ballard R: Atlas of sexually transmitted diseases and AIDS, ed. 3, St Louis, 2003 , Mosby.)

Chapter 37 • Vaginal Discharge and Itching

~ES "'1)1DlogicaI

cischarge

:¢ial •;'3ginosis

:Jndida vutvovaginit is

;ncoomoniasis

t.:rophic vaginitis

:.'lagic vagin itis

'i:c'eign body

Alamydia

:1Joorrhea

?elvic inflamma­ tory disease

Increase in discharge; no foul odor, itching, or edema

Foul -smelling discharge

Pruritic discharge

Watery discharge; foul odor

Dyspareunia; vaginal dryness

Examples: new bubble bath, soap, douche

Red and swollen vu Iva; vaginal discharge; his­ tory of tampon, con­ dom, or diaphragm use

Partner with nongonococ­ cal urethritis; asymp­ tomatic; discharge or bleeding after inter­ course

Partner with STI; often asymptomatic

Bleeding, abdominal pain, fever, and vaginal discharge; increasing amount of vaginal discharge and bleeding after intercourse

Clear o r mucoid; pH < 4.5

Homogeneous thin white or gray dis­ charge; pH > 4.5

White, curdy dis­ charge; pH 4.0­ 5.0

Profuse, frothy, green ­ ish discharge; red friable cervix; pH 5.0-6.0

Pale, thin vaginal mucosa; yellow­ brown discharge pH > 4.5

Foul smell, erythema, "lost tampon, " pH < 4.5

Bloody, foul-smelling discharge

May or may not have purulent discharge

Purulent discharge; inflammation of Skene or Bartholin gland

CMT and adnexal ten­ derness; may also have guarding and rebound tenderness

Up to 3-5 WBCs/ HPF; epithelial cells, lactobacilli

Presence of KOH "whiff" test; pres­ ence of clue cells; few lactobacilli (see Fig. 37.1)

KOH prep: mycelia, budding, branching yeast, pseudohy­ phae (see Fig. 3 7 . 1)

Round or pear-shaped protozoa; motile "gyrating" flageI la (see Fig. 37 .1)

Folded , clumped epithelial cells

WBCs

WBCs

Molecular testing; > 10 WBCs/HPF

Molecular testing, Gram stain; culture

WBC ; Gram stain; DNA testing (chla­ mydia and gono­ coccus), culture; syphilis testing; ESR,CRP; pregnanc y, HIV

Continued

Chapter 37 • Vaginal Discharge and Itching

ITCHING AND LESIONS Syphilis

Genital warts

Herpes

Molluscum contagiosum

Vu Ivar I ntraepithel ial Neoplasia

History of painless ulcer­ ative lesion; rash on palms and soles of feet; warty growth on vagina or anus

Mild to moderate itching, foul vaginal discharge; c hild : history of sexua l abuse; adult: new or multiple partners; history of warts

History of prodromal syn­ drome, paresthesias, burning, itching; may have mucoid vaginal discharge

H istory of contact with infected person; if inflamed: itching

Vulvar itching

Chancre: usually one but can be more, painless ulceration; condy lomata lata: flat, whitish papule or plaque; maculo­ papular rash : palm, so les, body

Moist, pale- pink, verrucous projec­ tions on base; located on vu Iva, vagina, cervix, or perianal area

Grouped vesicles on red base, erode to an ulcer; if on mu­ cous membrane, exudates form; if on skin , crusts form; redness, edema, tender in­ guinal lymph nodes

Flesh-colored, dome­ shaped papules, some with umbili­ cation; usually 2 - 5 mm in diameter

Usually elevated lesion found on vulva

Syphilis and molecular testing

Acetic acid test: white

Molecular testing; vira l culture; Tzanck smear

None

Refer for biopsy

GMT, cervical motion tenderness; CRP, C-r eactive protein; ESR, erythrocyte sedimentation rate; HIV. human immu­ nodeficiency virus; HPF, high- power field; KOH, potassium hydroxide; ST/, sexually transm itted infection ; WBC, white blood cell.