• • Patient complaints and sexual history.
  
• • Appearance of the discharge (character and color).
  
• • Vaginal pH higher than 4.5.
  
• • Presence of motile trichomonads, yeast or pseudohyphae, or clue cells on light microscopy.
  
• • Positive “whiff” test.

Vaginal discharge is a common complaint that is often considered trivial and thus incorrectly managed by the clinician. Empiric diagnosis and treatment based on either history or appearance of the discharge alone is inadequate and frequently results in inappropriate treatment and repeated visits by the patient. When considering the etiology of vaginitis it is important to take into account the patient’s age and sexual history. Lactobacilli, the predominant bacteria in the vagina of a healthy premenopausal woman, are typically absent in women who are menopausal and not receiving estrogen replacement therapy. The estrogen-deficient vaginal epithelium in postmenopausal women is also thinner; thus, atrophic vaginitis is a consideration in this age group. For sexually active women, sexually transmitted diseases (STDs) such as trichomoniasis, genital herpes, gonorrhea, and chlamydia should be considered.

The three major causes of vaginal discharge during the reproductive years are candidiasis, bacterial vaginosis, and trichomoniasis. The latter is the only one of the three that is known to be sexually transmitted; however, bacterial vaginosis is clearly associated with sexual activity. In addition, vaginal candidiasis is frequently seen in the setting of increased sexual activity, likely due to colonizing organisms that gain entry to the epithelium via microabrasions from sexual intercourse. In older women, as previously mentioned, atrophic vaginitis should be considered.

Other STDs, such as gonorrhea, chlamydia, and genital herpes, may lead to vaginal complaints. However, the physical signs of gonorrhea and chlamydia are cervical inflammation, not vaginal discharge. Genital herpes may cause discharge along with ulceration.

Some other causes of vaginal discharge include retained foreign body, cytolytic vaginosis, and desquamative inflammatory vaginitis. It should be noted that some women perceive their vaginal discharge to be abnormal when it is simply physiologic.

Use of condoms is protective against STDs and also appears to protect against acquisition of bacterial vaginosis. If an STD is diagnosed, the patient’s sex partners should be treated to avoid reinfection. Episodes of recurrent bacterial vaginosis may be prevented by use of twice weekly intravaginal metronidazole gel. Similarly, recurrent vaginal candidiasis can be controlled with use of once weekly fluconazole (150 mg). Estrogen replacement therapy will prevent atrophic vaginitis.

Symptoms and Signs

Patients should be asked about the consistency and color of the discharge and whether it is accompanied by pruritus (internal and external), irritation, or a fishy odor. Another useful question is whether a fishy odor is present after unprotected intercourse (a characteristic finding in bacterial vaginosis). During the examination, the clinician should note the presence or absence of vaginal ulcerations, erythema, characteristics (color and consistency) of the discharge, and the appearance of the cervix (mucopus at the os may suggest gonorrhea or chlamydia).

Laboratory Findings

The most widely used tests for the diagnosis of vaginitis are vaginal pH evaluation, the so-called “whiff” test, and light microscopy (see Table 2–1). Light microscopy is the most helpful of the three tests.