SOAP note AHA Week 7

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ealthcare practitioners must be proficient in the effective diagnosis and treatment of the three most common vaginal infections: vulvovaginal candidi-

asis (VVC) or yeast infection, bacterial vaginosis (BV), and trichomonas. NPs who see sexually active women of child- bearing age in their practice need the skills to diagnose and treat common vaginal infections. Office-based testing relies on education, specific office practice, and available resources including cost of testing, access to external lab facilities, and availability of vaginal cultures.

For many practices, the most commonly used office test is the microscopic evaluation of a sample of vaginal dis- charge using Amsel criteria (see Sensitivity and specificity of Amsel criteria for the diagnosis of BV). Amsel criteria include findings of a homogenous discharge, a positive amine (whiff) test, pH over 4.5, and the presence of clue cells. These gen- erally suffice for the evaluation of symptomatic women.1

In a study, researchers estimated the accuracy of the clin- ical diagnosis of BV, VVC, and trichomonas using a tradi- tional, standardized clinical diagnostic protocol compared

H

By Cynthia Ricci McCloskey, DNS, WHNP-BC

Vaginal infections

with a DNA probe lab standard. They found that, compared with a DNA probe standard, clinical diagnosis was 81% to 85% sensitive and 70% to 99% specific for BV, VVC, and tri- chomonas.2 Many NPs work in settings where DNA probe testing is not available or access to outside labs is limited due to financial issues. It is imperative that NPs understand how to effectively utilize in-office testing to maximize the sensi- tivity and specificity of their tests and provide their patients with accurate diagnosis and treatment.

■ Sensitivity and specificity In recent years, there has been some discussion in the litera- ture regarding the sensitivity and specificity of common of- fice tests for vaginitis.1,2 Sensitivity is the ability of a test to correctly identify individuals who have a specific disease.3

Lowe et al.2 compared clinical diagnosis of vaginitis with the DNA probe standard. Results showed clinical diagnosis sen- sitivity between 81% and 85% for vaginal infections.

Specificity is the ability of a test to correctly exclude in- dividuals who do not have a specific disease.3 The specificity for diagnosing common vaginal infections using clinical diagnostics was 70% to 99%. Researchers, for example, re- ported the predictive value of Amsel criteria for the diagnosis of BV and found that the criteria had 70% sensitivity and 94% specificity.1,4

This information regarding sensitivity and specificity must be balanced with the expense and availability of newer testing methods as well as an NP’s experience in these other techniques. According to French et al.,1 the gold standard test for BV is gram-stain assessment using Nugent criteria. Nugent criteria involves scoring a gram-stained vaginal spec- imen from 0 to 10 based on a semiquantitative assessment of three classes of bacteria: large gram-positive rods (lacto- bacilli), small gram-positive rods (Gardnerella and Bacteroi - des spp.), and small curved gram-variable rods (Mobiluncus spp.).1 A Nugent score of 7 or greater reflects a minority of the lactobacilli and supports a diagnosis of BV. Gram stain- ing is more objective and reproducible compared with the wet-mount exam with a sensitivity of 93% and specificity of 70%. It is useful for the evaluation of asymptomatic women.1

■ Incidence, etiology, and symptoms Bacterial vaginosis According to the CDC, BV is the most common vaginal infection for women of childbearing age and is common in pregnancy.5 It is not an inflammatory condition and can be associated with sexual activity or douching due to a shift in vaginal flora from the normal condition in which lactobacilli predominate to a polymicrobial flora in which gram-positive anaerobes predominate.1 (See Examples of vaginal infections.)

Despite the fact that BV accounts for 40% of all vaginitis- related office visits, this common disorder is still not well identified or understood. Originally called “nonspecific vaginitis,” it was later named “Haemophilus vaginalis vagini- tis” and then “Gardnerella vaginalis vaginitis.” BV is a syn- drome characterized by an overgrowth of anaerobic bacteria, genital mycoplasmas, and Gardnerella spp., including Bac- teroides and Mobiluncus spp.6

G. vaginalis is present in 30% to 40% of all women, but in order to cause infection, and the associated characteristic amine odor, it must interact with at least three other bacteria, and the entire group must proliferate sufficiently to wipe out healthy organisms such as lactobacilli. Causes for this are still unclear, but researchers suspect it is related to sexual intercourse due to alterations in vaginal pH associated with exposure to se- men.6 This semen exposure can cause the shift in preexisting vaginal flora, which can result in the development of BV.

Trichomonas Trichomonas primarily affects sexually active women. Regarding trichomonas, the CDC estimates that in North America, more than 8 million new cases of trichomonas are reported yearly.7 Approximately 40% of infected women are asymptomatic. Because they are unaware of their infection, it is unwittingly spread to their partners. The most striking symptoms are vulvar and vaginal burning and itching. The burning may be most apparent after intercourse and can affect the vaginal mucosa. In addition, there may be vulvar swelling and frequent and uncomfortable urination.8

Yeast infection The majority of adult women have experienced VVC. The CDC reports that nearly 75% of all adult women have had at least one genital “yeast infection” in their lifetime. Symp- toms of yeast infection include intense itchiness in the vagi- nal area, often accompanied by burning and redness of the vulva and vagina. A thick, white, odorless discharge may be noted by the woman or found on the vaginal walls dur- ing the exam.9 Women at risk are those with a weakened

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Sensitivity and specificity of Amsel criteria for

the diagnosis of BV1,4

Diagnostic method Sensitivity (%) Specificity (%)

Total Amsel criteria 70 94

Components of the criteria – Vaginal pH of > 4.5 – Clue cells present – Positive amine (whiff) test – Characteristic vaginal

discharge

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immune system, corticosteroid use, or pregnancy.9 Yeast infections are caused by an overgrowth of normally grow- ing fungi in the vagina. Usually, yeast is kept under control by normally growing bacteria in the body. If the natural balance of microorganisms is disrupted, the yeast grow out of control.10

■ Patient history The goal of NP encounters with women seeking care for vaginal infections is correct diagnosis and treatment, as well as identification of health behaviors that may contribute to the development of these infections. Thus, adequate history taking including questions about sexual practices, contra- ception, nutrition, personal hygiene, underwear preferences, and medical history is important.

The following are examples of topics to discuss and rationale when taking a patient history: • Sexual history and practices: male or female partners,

use of sex toys, and number of sexual partners. Infor- mation provides insight into factors responsible for in- fection (increased frequency of intercourse can upset pH balance of vagina; having numerous sex partners in- creases risk of STDs, and can indicate the need for addi- tional cultures for chlamydia, gonorrhea, herpes, HIV, and syphilis). Exposure to new sex partners can put women at risk for BV; receptive oral sex is a risk factor for VVC.1,11,12

• Contraceptive use: condom use has both benefits and risks. It can help protect against STDs, but women who use hormonal contraceptives for pregnancy prevention may not think to use condoms to protect against STDs. However, for some women, condom, spermicide, and diaphragm use have been associated with yeast infec- tions.11,12 The use of oral contraceptives can alter vaginal estrogen levels and lead to increased glycogen produc- tion, which may elevate vaginal pH and facilitate yeast production.13

• Other medications: in addition to corticosteroid use, recent use of antibiotics has been associated with yeast infections.

• Dietary review: women who report a diet high in refined sugar are at risk for developing yeast infections, as are women who have undiagnosed or uncontrolled diabetes.14

• Personal hygiene: douching disrupts the vaginal ecosys- tem by upsetting the balance of normal flora in the vagina and can kill lactobacilli, which help to maintain the pH balance of the vagina.15

• Exercise habits/attire: wearing tight clothing or being in exercise clothes for extended periods can contribute to yeast infections.14

• Underwear preferences: thongs can cause transmission of bacteria from the anal region to the vagina resulting in BV; the use of nylon underwear increases heat in the perineal region and can contribute to yeast infection; wearing underwear to bed decreases ventilation to the perineum, often contributing to yeast infections.

• Medical history: women with undiagnosed or uncon- trolled diabetes are more likely to develop yeast infec- tions due to the increased glucose content of the vaginal secretions. (See Pertinent questions on history related to the vaginal infection symptoms.)

■ Physical exam After taking the history and providing health promotion and infection prevention guidance based on the history, the phys- ical exam should include an abdominal exam, palpation of inguinal lymph nodes, inspection of the external genitalia for discharge, rash, ulcers, and parasites. Any complaint of external burning, especially associated with urination, should be followed up by careful exam of external and internal genitalia for possible herpes lesions. Any suspicious lesions should be cultured and sent to the lab for viral analysis. The speculum exam should include inspection of vaginal walls and the cervix for discharge, redness, and appearance. NPs should “talk” patients through the physical exam by describ- ing what they are about to do, what is being done, and per- tinent findings discovered along the way. It is essential to provide feedback about normal findings and progress of the

Vaginal infections

Pertinent questions on history related to the

vaginal infection symptoms14

Discussion topics Details

Vaginal discharge Onset, color, odor, consistency, and amount; intermittent, or constant appearance

Relationship of symp- Sexual contact, menses, toms to other events stressful life events

Associated discomforts Itching, burning dyspareunia, in self or partner urine frequency or urgency,

burning upon urination

Hygiene habits and Use of scented panty liners, cleansing products tampons, soaps, fabric softeners

Self-help measures Over-the-counter creams, medications, additional dietary supplements

Reflection What has helped or hindered the vaginal symptoms?

Vaginal infections

exam to facilitate patient relaxation and comfort with the exam and examiner.

■ Exam findings Vaginal discharge can be evident at the introitus, and data gathering on the characteristics of discharge continues here. The presence of redness and discharge externally is often a precursor to the finding of significant discharge on the vaginal walls and cervix. Observation of vaginal discharge and sampling for office testing and cultures should continue as the healthcare practitioner inserts the speculum into the vagina, noting the amount, character, and odor of the discharge on the vaginal walls and cervix. If additional cultures for STDs are to be obtained and sent for out-of-office testing, they should be taken at this time. Samples of the discharge are collected from the vagi- nal walls and/or from the speculum once it is removed. Depending on the routine of the particular provider and practice, discharge can be collected using a moistened cot- ton swab and slides can be prepared in the exam room, or the swab can be placed in a test tube containing a small amount of 0.9% sodium chloride and the slide prepared at the microscope.

Data gathering for the diagnosis of vaginal infection continues during the exam, based on odor and characteris- tics of the discharge. The finding of thick, white, clumpy discharge on the vaginal walls can indicate the presence of VVC. (See Examples of vaginal infections) This finding is often con- nected back to patient history of vul- var itching, redness, and irritation, and even urethral inflammation caus- ing urine frequency. Exam of the vulva may reveal swelling and fine breaks or fissures. The finding of inflammation of the vulva and vagina, combined with the discharge, is often connected with painful intercourse (dyspareunia).6

Diagnosis of VVC is assisted by the observation of the characteristic discharge described above, but should be confirmed through microscopic evaluation.

The discharge of BV is typically thin, homogenous, and whitish gray.16 According to Hawkins et al.,14 BV is associ- ated with little or no inflammation of the epithelium. The American Social Health Association reports that the dis- charge can be accompanied by an odor, as well as itching in or around the vagina, along with pain during sex and pain when urinating.8

The discharge of trichomonas varies from none to a mal- odorous, purulent discharge with vulvovaginal erythema.6

The discharge can also be frothy or bubbly.8 During the speculum exam, the finding of punctuate hemorrhagic cer-

vical lesions is considered pathognomonic of trichomonas, but is seen in a minority of cases.7,17

■ In-office diagnostic testing Determining the pH of vaginal fluid is an essential aspect of determining organisms causing vaginitis. The normal pH of vaginal fluid is 3.8 to 4.2, which is relatively acidic; it is kept in this range by the presence of lactobacilli, part of the nor- mal flora of the vagina. If lactobacilli are present in sufficient number, the excretion of hydrogen peroxide keeps the pH in the normal range. The presence of lactobacilli is essential to maintaining this acidic pH and, in turn, inhibits the growth of Escherichia coli, Peptostreptococcus, mobiluncus sp,and other undesirable bacteria, such as Gardnerella spp. If lactobacilli are overpowered by the presence of competing bacteria such as Gardnerella spp., the pH increases toward the basic range.18

According to researchers, an easily performed vaginal specimen pH test helps to further differentiate specific types of vaginitis when present. A vaginal pH less than 4.5 indi- cates the normal vagina or VVC; a pH greater than 4.5 sug- gests BV or vaginal trichomonas. These tests comprise the standard for the office lab diagnosis of vaginitis.16

The most common criteria utilized to diagnose BV are Amsel criteria. The presence of three of the following four indicators is sufficient to diagnose BV: homogenous vaginal

discharge, positive amine test, pH over 4.5, and the finding of clue cells.1

As mentioned above, the amine odor may be apparent in the exam room, or may be elicited by the addition of a few drops of 10% potassium hydroxide (KOH) solution to the vaginal fluid on the slide or speculum (whiff test).1 In a study reported by French, Horton and Matousek1, a positive whiff test followed by culture predicted the presence of anaerobic bacteria such as Bacteroides spp., with 67% sen- sitivity and 94% specificity. Exam of the discharge best occurs in the office lab, next to the microscope. Testing the sample for pH and performing the whiff test is commonly done at this point in the diagnostic work-up.

■ Microscopic evaluation Ferris et al. note that clinicians need more education in the lab diagnosis of vaginitis.16 They should carefully scrutinize each microscopic slide, systematically examine the slide for

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It is essential to provide feedback about

normal findings and progress of the exam

to relax and comfort the patient.

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Vaginal infections

Examples of vaginal infections

Cause

Discharge

Other symptoms

Vulva and

vaginal mucosa

Lab

evaluation

Trichomonas vaginalis, a protozoan, is often but not always acquired sexually

Yellowish green or gray, possibly frothy; often profuse and pooled in the vaginal fornix; may be malodorous

Pruritus (usually not as severe as with yeast infection); pain on urination (from skin inflammation or possibly urethritis); dyspareunia

Vestibule and labia minora may be reddened. Vaginal mucosa may be diffusively reddened, with small red granular spots or petechiae in the posterior fornix. In mild cases, the mucosa looks normal.

Scan saline wet mount for trichomonads

Candida albicans is a yeast (normal overgrowth of vaginal flora). Many factors may predis - pose a patient to this infection including antibiotic therapy.

White and curdy; may be thin but typically thick; not as profuse as in trichomonal infection; not malodorous

Pruritus; vaginal soreness; pain on urination (from skin inflammation); dyspareunia

The vulva and even the surrounding skin are often inflamed and sometimes swollen to a variable extent. Vaginal mucosa is often red - dened, with white, tenacious patches of discharge. The mucosa may bleed when these patches are scraped off. In mild cases, the mucosa looks normal.

Scan potassium hydroxide (KOH) preparation for branching hyphae of Candida.

Trichomonal vaginitis Candidal vaginitis Bacterial vaginosis

The vaginal discharge from vaginitis must be distinguished from a physiologic discharge. The latter is clear or white and

may contain white clumps of epithelial cells; it is not malodorous. It is also important to distinguish vaginal from

cervical discharges. Use a large cotton swab to wipe off the cervix. If no cervical discharge is present in the os, suspect

a vaginal origin and consider the causes below.

Source: Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009:550.

Bacterial overgrowth due to anaerobic bacteria; may be transmitted sexually

Gray or white, thin, homogeneous, malodorous; coats the vaginal walls; usually not profuse, may be minimal

Unpleasant fishy or musty genital odor

Vulva and vaginal mucosa are usually normal.

Scan saline wet mount for clue cells (epithelial cells with stippled borders); sniff for fishy odor after applying KOH (“whiff test”); vaginal secretions with pH >4.5

Vaginal infections

each type of vaginitis, and consider specimen pH and the presence of leukocytes, lack of lactobacillus organisms, or amine odor as additional clues to infection. An essential skill connected to in-office diagnosis and testing for vaginal infections is preparation and analysis of wet mounts for microscopic evaluation. The reliability of office testing for vaginal infections can be connected to the availability and quality of equipment as well as the skill of the healthcare practitioner in preparing and interpreting slides.

According to French et al., the cor- rect procedure for wet mounts is as follows: Dilute the vaginal discharge with 1 or 2 drops of 0.9% saline and place it on a slide. Examine the slide under low- and high-powered fields (HPFs) for vaginal squamous cells, white blood cells (WBCs), lactobacilli, clue cells, and trichomonads. An increased number of WBCs can be defined as over 5 to 10 WBCs/HPF or WBCs exceed- ing the number of vaginal epithelial cells.1

To prepare the KOH slide, place a generous amount of vaginal discharge on a slide with 10% KOH solution. Air or flame drying the slide before exam may improve sensitivity. A positive KOH preparation will reveal hyphae, or spores, if present.1

NPs may create a slide for each of the tests, saline and KOH. Many NPs choose to utilize one slide for both tests, applying the specimen mixture at either end of a clean slide, as advocated by Hawkins et al.14 Applying a few drops of 10% (KOH) solution to the slide makes it easier to see the yeast spores and hyphae that are diagnostic of a VVC.1 A micro- scopic KOH exam allows recognition of pseudohyphae and buds indicative of VVC.16

KOH is also essential to the office testing for BV. The characteristic “fishy” odor of BV may be readily apparent in the exam room, or may not be detected until the application of KOH to the vaginal discharge. As noted above, the saline part of the slide is assessed for the presence of clue cells, leuko- cytes, lactobacilli, and trichomonas. Clue cells are small ad- herent bacteria (coccobacilli) that coat the vaginal squamous epithelial cells, giving the appearance as if coated with ground black pepper.1,16 Clue cells on a wet-mount preparation is considered the most accurate of the Amsel diagnostic crite- ria for BV. As noted above, the reliability of this finding is based on the practitioner’s microscopic skills.1 French notes that a lack of leukocytes in the vaginal fluid supports a diag- nosis of BV. A finding of WBCs in excess of the number of vaginal epithelial cells suggests an inflammatory process.1

Some office practices have access to gram staining, an evaluation of vaginal secretions that utilizes Nugent criteria. Gram staining is more objective and reproducible compared

with wet-mount exam, with a sensitivity of 93% and speci- ficity of 70%.1 According to French, when compared with gram stain, Amsel criteria tend to underdiagnose cases of BV.1

Also, the plated vaginal specimen is assessed for the pres- ence of the motile trichomonad. The trichomonad is a tiny teardrop-shaped, one-cell parasite. It has three tails at its narrow end. By whipping these tails back and forth the or- ganism moves in a brisk, jerky fashion. It is often seen sur- rounded by the host’s WBCs. Presumably, symptoms occur

only when the body’s defense forces cannot keep up with the numbers of rapidly reproducing trichomonads.8

According to French, the gold standard test for VVC is culture.1 The KOH wet mount is only 40% to 75% sensitive. The pH of the discharge is usually not more than 5 with Candida albicans but may be higher with other nonalbicans species such as C. glabrata.19

■ Diagnosis The determination of a diagnosis of vaginitis is based on the patient history, presenting signs and symptoms, physical exam, and the following findings from in-office testing: • BV—gray, homogenous, adherent vaginal discharge; find-

ing three of four of Amsel criteria (positive amine test, pH of over 4.5, and/or the presence of clue cells upon micro- scopic evaluation of the wet prep slide)

• Trichomonas—malodorous green/yellow discharge; pH over 5.0 (5.0 to 7.0); cervix presents with strawberry ap- pearance; microscopic finding of motile cells (trichomonas protozoan); slightly larger than leukocytes and smaller than epithelial cells; over 10 WBCs/HPF

• VVC—erythematous vaginal walls, with white patches along side walls, odorless thick curd-like vaginal discharge; pH within normal range of 3.8 to 4.2 (nitrazine paper).1,14

■ Conclusion As the current literature shows, vaginal infections are com- mon among sexually active women of reproductive age. Care for women with vaginal complaints includes focused history and exam. In-office testing can provide accurate diagnosis with relatively high rates of specificity and sensitivity.3 As VVC, trichomonas, and BV are so common, in-office testing facilitates early diagnosis and treatment. Practitioners who combine knowledge of vaginal ecology, effective history

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In-office testing can provide accurate

diagnosis with relatively high rates

of specificity and sensitivity.

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taking, and skilled physical exam with competence in mi- croscopy can detect and treat the majority of women who present with the most common vagina infections. NPs car- ing for women can also offer individualized guidance about causative factors and ways to prevent further infections.

REFERENCES 1. French L, Horton J, Matousek M. Abnormal vaginal discharge: using office

diagnostic testing more effectively. J Fam Pract. 2004;53(10):805-814. http:// jfponline.com/Pages.asp?AJD=1788&UID.

2. Lowe NK, Neal JL, Ryan-Wenger NA. Accuracy of the clinical diagnosis of vaginitis compared with a DNA probe laboratory standard. Obstet Gynecol. 2009;113(1):89-95.

3. Lab testing online. How Reliable Is Laboratory Testing? http://www.labtests online.org/understanding/features/reliability-2.html.

4. Sha BE, Chen HY, Wang QJ, Zariffard MR, Cohen MH, Spear GT. Utility of Amsel criteria, Nugent score and quantitative PCR for Gardnerella vaginalis, Mycoplasma hominis, and Lactobacillus spp. for diagnosis of bacterial vagi- nosis in human immunodeficiency virus-infected women. J Microbiol. 2005;43(9):4607-4612.

5. CDC. Bacterial Vaginosis-CDC Fact Sheet. http://www.cdc.gov/std/bv/ STDFact-Bacterial-Vaginosis.htm#HowCommon.

6. Health Square. Curing Vaginal Infections: Best Ways to Fend Off Infections. http://www.healthsquare.com/fgwh/wh1ch04.htm.

7. CDC. Division of Parasitic Diseases—Fact Sheet Trichomonas Infection. http:// www.cdc.gov/ncidod/dpd/parasites/trichomonas/factsht_trichomonas.htm.

8. American Social Health Association. Learn About STI/STDs—Vaginitis, Tri- chomonas. http://www.ashastd.org/learn/learn_vag_trich.cfm.

9. CDC. Division of Foodborne, Bacterial and Mycotic Diseases. http://www.cdc. gov/nczved/dfbmd/disease_listing/candidiasis_gi.html#21.

10. Vaginal Yeast Infection. http://www.emedicinehealth.com/vaginal_yeast_ infections/page2_em.htm.

11. Geiger AM, Foxman B. Risk factors for vulvovaginal candidiasis: a case-control study among university students. Epidemiology. 1996;7:182-187.

12. Sobol J, Faro S, Force R, et al. Vulvovaginal candidiasis: epidemiologic, diag- nostic, and therapeutic considerations. Am J Obstet Gynecol.1998;178:203-211.

13. Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Phys. 2000;62(5):1095-1104.

14. Hawkins JW, Roberto-Nichols DM, Stanley-Haney JL. Guidelines for Nurse Practitioners in Gynecologic Settings. 9th ed. New York: Springer; 2008:43-63.

15. Hawes SE, Hillier SL, Benedetti J, et al. Hydrogen peroxide-producing lacto- bacilli and acquisition of vaginal infections. J Infect Dis. 1996;174:1058-1063.

16. Ferris DG, Hendrich J, Payne PM, et al. Office laboratory diagnosis of vagini- tis. Clinician-performed tests compared with a rapid nucleic acid hybridiza- tion test. J Fam Pract. 1995;41(6):575-581. http://findarticles.com/p/articles/ mi_m0689/is_n6_v41/ai_17913634/?tag=content;col1.

17. Fouts AC, Kraus SJ. Trichomonas vaginalis: reevaluation of its clinical presen- tation and laboratory diagnosis. J Infect Dis. 1980;141:137-143.

18. Harrison-Hohner J. Vaginal Discharge: Normal or Not? http://blogs.webmd. com/womens-health/2008/06/vaginal-discharge-normal-or-not.html.

19. Ekert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK. Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. Obstet Gynecol. 1998;92:757-765.

Cynthia Ricci McCloskey is an associate professor of nursing and graduate program director, Wegmans School of Nursing at St. John Fisher College, Rochester, N.Y.

Vaginal infections