Diagnosis and Evaluation

The evaluation of vaginitis requires visual inspection of the vaginal discharge, the vagina, and the cervix, as well as the collection and evaluation of a discharge specimen under the microscope.

The following characteristics of the vaginal discharge should be noted during examination:

• Color,
• Viscosity,
• Adherence to vaginal walls, and
• Presence of an odor.

Visualization of the cervix is important in order to rule out cervicitis as a source of abnormal vaginal discharge.

A discharge specimen should be collected from the lateral wall of the vagina. A specimen slide, called a wet mount, can be made with a drop of warm 0.9% saline and a drop of the discharge specimen.  An alternative method of wet mount preparation is to place the discharge swab into a test tube with <1ml of saline and place a drop onto a specimen slide. With a cover slip overlaid, the slide should be examined immediately under a microscope at both low (10x) and high (40x) power.

The use of the following diagnostic steps can be helpful in the diagnosis of vaginitis:

1. Examination under the microscope of the 0.9% saline wet mount;
2. Examination of the wet mount under the microscope for hypae after adding a drop of 10% KOH to the slide;
3. Assessment of a fishy odor, called the "whiff" test, from the discharge after placing a drop of 10% KOH on the slide; and
4. Determination of the vaginal pH.

The following two slides of a microscopic examination of a vaginal specimen illustrate common characteristics of normal vaginal fluid. Note the squamous epithelial cell, polymorphonuclear (PMN) leukocyte, and red blood cell (RBC) in the first slide and the lactobacilli and squamous epithelial cell in the second slide.

(Click on image for larger view)

(Click on image for larger view)

The following chart, vaginitis differentiation, is useful in the differential diagnosis of vaginitis. Given the differences in microscopic appearance of vaginal specimens, pH, and visual characteristics of discharge, the three common causes of bacterial vaginosis, Candida albican, and T. vaginitis (Trichomonas vaginalis can be distinguished. In symptomatic patients in whom these have been excluded, one must consider hypersensitivity, irritant and allergic vulvovaginitis, or physiologic leukorrhea as a cause of symptoms.

(Click on image for larger view)

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