The evaluation of vaginal discharge in the adolescent should include obtaining a history of symptoms (pruritus, odor, quantity, color), other illnesses such as diabetes or HIV infection (5), recent oral medications such as broad-spectrum antibiotics or hormonal contraceptives, previous similar episodes of vulvovaginal symptoms, and treatments. A history of broad-spectrum antibiotics or poorly controlled diabetes mellitus is frequently a clue to the diagnosis of Candida vaginitis. Candida vaginitis and bacterial vaginosis (BV) often recur despite compliance with a standard treatment course. In a sensitive manner, the provider should inquire about sexual activity, a past history of sexually transmitted infections (STIs), and condom use. A patient may not disclose or remember all previous STI episodes, so it is important to check the chart or electronic medical record for evidence of prior infections. The patient should be questioned about recent sexual experiences with both men and women, since treatment failure in an adolescent girl often occurs because of reexposure to an untreated contact. Women who have sex with women are also at risk for STIs and BV related to sexual behaviors, practices, and partners (male and female) (1). It should be remembered that several infections may coexist; a patient may be adequately treated for one infection and still have a second or third infection. For example, an adolescent may have C. trachomatis cervicitis, Trichomonas vaginitis, and vulvar condyloma. In addition, the use of oral broad-spectrum antibiotics for the treatment of one type of vaginitis may be followed by a second infection with Candida.

An adolescent may have symptoms for weeks or months before seeking medical help because of anxiety about a possible pelvic examination or because of guilt or trauma from a previous episode of rape, intercourse, or sexual abuse. Therefore, it is important to explain carefully to her the details of obtaining vaginal swabs and a speculum examination (if indicated), and the possible causes of vaginal discharge.

The microbiologic flora of the adolescent vagina and cervix are shown in Fig. 17-1 (6). Assessment usually includes a visual inspection of the vulva, wet preparations of the vaginal discharge, pH, and testing for STIs as indicated. A speculum examination is usually omitted in the young virginal adolescent who has a whitish mucoid discharge. Samples for wet preparations and pH can be obtained with a saline-moistened, cotton-tipped applicator or Calgiswab gently inserted through the hymenal opening to confirm the diagnosis of physiologic discharge and exclude Candida vaginitis.

In sexually active patients, several different strategies for diagnosing vaginitis are employed. The traditional technique has been to perform a speculum examination to obtain specimens of the vaginal discharge, pH, and endocervical tests for N. gonorrhoeae and C. trachomatis (see Chapters 1 and 18). Recent studies have focused on whether vaginal complaints can be diagnosed on the basis of urine testing for N. gonorrhoeae, C. trachomatis (and Trichomonas) (7,8), and/or provider- or patient-obtained vaginal swabs (8,9,10,11,12). Numerous studies have found that adolescent girls and women can successfully obtain vaginal samples (a Dacron swab placed 1 in. into the distal vagina for 10 seconds) and find them highly acceptable (13,14,15,16,17,18,19). Nucleic acid amplification testing (NAAT) of vaginal swabs for detection of N. gonorrhoeae and C. trachomatis has a sensitivity and specificity that rivals endocervical samples and is slightly superior to urine (10,13,15,20,21). Blake and colleagues found that specimens obtained with or without a speculum were equally sensitive in diagnosing vulvovaginal infections (12). Although there are many advantages to less invasive testing, the vulva, vagina, and cervix may not be visualized, missing dermatoses, condyloma acuminata, genital herpes, and cervical friability or mucopus. Symptoms are not sufficient to distinguish between etiologies, although lack of itching makes candidiasis less likely, and lack of perceived odor makes bacterial vaginosis less likely (22). Thus, careful selection of patients with symptoms of vaginitis that might be appropriate for vaginal swabs, preferably done by a provider, without a speculum examination is important. Any symptoms of abdominal pain and dyspareunia should lead to a full pelvic examination to assess the patient for pelvic inflammatory disease (PID) (23).

Inspection of the vulva is often helpful in the differential diagnosis of vulvovaginitis. A small magnifying glass can be of help. A red, edematous vulva with satellite red papules is characteristic of acute Candida vulvovaginitis. Fissures and excoriations are seen with subacute or chronic Candida infections. Vulvar dermatoses, such as psoriasis (see Chapter 5), may present with red, scaly, cutaneous plaques. Small vesicles or ulcers are typical of herpetic vulvitis (see p. 313). Symptomatic gonococcal cervicitis and pelvic inflammatory disease may be accompanied
by a gray or greenish-yellow discharge from the vagina and urethra.

The appearance of the vaginal secretions often gives a clue to the diagnosis. A thick, curdy discharge is typical of Candida; a yellow or white, bubbly, frothy discharge can be typical of Trichomonas vaginalis. In patients with Trichomonas infections and those with cervicitis, the cervix may be friable and may bleed during collection of the samples. A cervical ectropion is present in many adolescents; large ectropions may be responsible for persistent vaginal discharge in adolescents, even in the absence of infection. Cervical ectopy has been associated with younger age, C. trachomatis, and oral contraceptive use (24).

Mucopurulent cervicitis (MPC) has been variably defined by the presence of mucopurulent discharge, quantitation of leukocytes in cervical exudate, easily induced cervical bleeding, and histologic examination of the cervix. The Centers for Disease Control and Prevention (CDC) identifies two major diagnostic signs of cervicitis as (a) the presence of mucopurulent secretion visible in the endocervical canal or on an endocervical swab (termed MPC) and/or (b) “sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os” (1). Women with MPC may have abnormal vaginal discharge or bleeding after intercourse. Mucopus is evident if a yellow color is noted on a white cotton-tipped applicator inserted into the endocervical canal and twirled. The yellow color has been associated with C. trachomatis cervicitis in clinics that treat STIs but has a low positive predictive value (1). N. gonorrhoeae may also cause MPC, but often other infectious agents such as Trichomonas, herpes simplex virus (HSV), Mycoplasma genitalium, and BV and frequent douching may cause persistent mucopus that persists despite courses of antibiotics. Most persistent cervicitis is not caused by gonorrhea or chlamydia.

Microscopic examination of the wet preparations usually provides the diagnosis (see Chapter 1, Fig. 17-2, and Table 17-1). On the saline preparation slide, trichomonads are seen as motile flagellated organisms. Sheets of normal epithelial cells are characteristic of physiologic discharge. So-called clue cells (epithelial cells coated with large numbers of refractile bacteria that obscure the cell borders) are seen in bacterial vaginosis. The potassium hydroxide (KOH) preparation is used to demonstrate the pseudohyphae of Candida. If the discharge is itchy or cheesy and yet no pseudohyphae are seen on the KOH preparation, a culture for Candida on Biggy agar is helpful.

A finding of >10 white blood cells (WBCs) per high-power field on microscopic examination of vaginal fluid may be seen in the presence of Trichomonas, to a lesser extent with Candida vaginitis, and with cervicitis (including gonorrhea and chlamydia) and PID. The presence of leukocytes in the absence of a diagnosis suggests that further tests and a follow-up visit in 2 weeks may be necessary to assess the problem. For example, the wet preparation may miss the diagnosis of Trichomonas because of a sensitivity of only 50% to 75%.

An amine fishy odor when a drop of discharge is mixed with 10% KOH is a positive “whiff” test result; it occurs most commonly with bacterial vaginosis but may sometimes occur with Trichomonas as well. The pH of the vaginal secretions is helpful in the differential diagnosis. A normal pH of <4.5 is found in patients with normal discharge and Candida vaginitis, whereas the pH is elevated above 4.5 (4.7 in some studies) in patients with Trichomonas vaginitis and bacterial vaginosis. Gram stain of the vaginal discharge (difficult to perform in the office because of regulations) can be used to identify lactobacilli, typical of normal discharge, and to detect alterations in the flora seen in bacterial vaginosis in which gram-variable coccobacilli and curved gram-negative rods are observed. Gram stain of the endocervical mucopus can be examined for increased numbers of polymorphonuclear leukocytes and the presence of gram-negative intracellular diplococci (see Chapter 18). In the sexually active adolescent with vaginal discharge, NAATs should be done to detect C. trachomatis and N. gonorrhoeae (depending on the community prevalence) and, if available, Trichomonas.

Papanicolaou (Pap) tests are typically initiated at age 21 and are not recommended for the diagnosis of vaginitis (25). However, some findings reported on Pap test results are associated with particular infections. Herpes simplex is associated with intranuclear inclusions and multinucleate giant cells. Chlamydia has been associated with inflammation, cytoplasmic inclusions, and transformed lymphocytes or increased histiocytes. Trichomonas may be seen on Pap test, but false positives are not infrequent. The Pap test has been noted to have a sensitivity of 17% to 58% for the detection of C. trachomatis, 3% to 49% for Candida, 25% for bacterial vaginosis, 33% to 79% for Trichomonas, and 25% to 66% for herpes simplex (26,27). Fluid from liquid-based Pap tests may also be used to detect C. trachomatis (28,29,30). Multiple tests from the same specimen may be available in the future. In a study of STI clinic patients, Paavonen
and colleagues (31) found on colposcopic evaluation that endocervical mucopus was associated with N. gonorrhoeae, C. trachomatis, and herpes simplex; ulcers, necrotic areas, and increased surface vascularity with herpes simplex; strawberry cervix (uniformly arranged red spots or stippling of a few millimeters in size, located on the squamous epithelium covering the ectocervix) with Trichomonas; hypertrophic cervicitis with C. trachomatis; and immature metaplasia with C. trachomatis and cytomegalovirus.

Therapy is aimed at the specific cause. Patients should avoid douches because douching has been associated with an increased risk of STIs (32) and PID (33,34) and reduced fertility (35,36). When one STI has been detected, the clinician should
test the patient for others, including HIV and syphilis. Counseling about prevention, abstinence, safer sex, partner treatment (if diagnosis of an STI), and the use of condoms is essential. Clinicians should obtain a confidential contact number for notification of positive test results. Provision of written materials may be especially helpful. Excellent patient resources are available at www.cdc.gov and http://www.youngwomenshealth.org

In addition to medical treatments outlined in the next sections, general therapies for significant vulvitis may include the following: