Деякі причини вульвовагінального свербежу та вагінальних виділень

Women of reproductive age

Bacterial vaginosis

Malodorous (fishy), thin, yellow-green or gray, frothy vaginal discharge

Sometimes with vulvovaginal irritation

Amsel criteria for diagnosis (3 of 4):

• Yellow-green or gray discharge

• Vaginal secretion pH > 4.5

• Fishy odor on the whiff test (application of potassium hydroxide)

• Clue cells seen during microscopic examination (of saline 0.9% wet mount)

NAAT

Sometimes detected on Papanicolaou (Pap) test†

Candidal vulvovaginitis

White, thick, curd-like vaginal discharge that adheres to the vaginal wall

Vulvar and vaginal irritation, edema, pruritus

Sometimes worsening of symptoms after intercourse and before menses

Sometimes recent antibiotic use

Uncomplicated (all of the following): Sporadic, infrequent episodes; mild to moderate symptoms; pathogen is usually Candida albicans; immunocompetent patients

Complicated (any of the following): Recurrent episodes (4 or more); severe symptoms; non-albicans Candida,;immunocompromised patient (eg, diabetes, HIV, immunosuppressant therapy)

Criteria for diagnosis:

• Typical white, thick, curd-like discharge

• Vaginal pH > 4.5

• Budding yeast, pseudohyphae, or mycelia visible on wet mount, especially with potassium hydroxide (KOH)

Fungal culture, especially if non-albicans Candida suspected

DNA probe test with PCR

Sometimes detected on Pap test†

Trichomonal infection

Yellow-green, frothy vaginal discharge, often with a fishy odor

Often irritation, erythema, and edema of the vulva and vagina

Sometimes dysuria or dyspareunia

Sometimes punctate, red “strawberry” spots on the vaginal walls or cervix

NAAT (the preferred test)

Vaginal pH and wet mount with motile, pear-shaped flagellated organisms seen on microscopy

Rapid diagnostic test, immunochromatographic flow dipstick

Culture

Sometimes detected on Pap test†

Pelvic inflammatory disease

Abdominal or pelvic pain

Mucopurulent cervical discharge

Sometimes fever

Cervical motion, uterine, and adnexal tenderness

Gonorrhea and chlamydia tests

White blood cell count

Sometimes pelvic imaging

Foreign bodies (often a forgotten tampon)

Extremely malodorous, often profuse vaginal discharge, often with vaginal erythema, dysuria, and sometimes dyspareunia

Object visible during examination

Pelvic examination

Postmenopausal women

Genitourinary syndrome of menopause

Scant white or pale yellow discharge, sometimes with blood

Vaginal dryness and/or dyspareunia

Sometimes vulvovaginal fissures or spotting with sexual activity

Vulvovaginal atrophy with fragile, dry, sometimes mildly tender vulvovaginal tissue

Pelvic examination plus the following findings:

• Vaginal pH > 6

• Discharge has no odor

• Increased number of neutrophils, parabasal cells, and cocci and decreased number of bacilli seen during microscopic examination

Chemical vulvitis due to irritation from urine or feces

Diffuse vulvar erythema

Risk factors (eg, incontinence, restriction to bed rest)

Pelvic examination

All ages

Hypersensitivity reactions

Vulvovaginal erythema, edema, pruritus (sometimes intense), vaginal discharge

History of recent exposure of vulvovaginal tissue to new product or medication (eg, hygiene sprays, lubricants, bath water additives, topical treatment for candidal infections, fabric softeners, bleaches, or laundry soaps)

Pelvic examination

Inflammatory (eg, pelvic radiation, chemotherapy, chronic use of vaginitis medications)

Scant white or pale yellow vaginal discharge

Sometimes dyspareunia

Sometimes pruritus, erythema, burning pain, mild bleeding

Sometimes vaginal stenosis (after pelvic radiation)

Diagnosis of exclusion based on history and risk factors plus the following findings:

• Vaginal pH > 6

• Negative whiff test

• Granulocytes and parabasal cells seen during microscopic examination

Enteric fistulas (complication of obstructed labor, pelvic tumors, pelvic surgery, or inflammatory bowel disease)

Malodorous vaginal discharge with passage of feces from vagina

Direct visualization or palpation of the fistula in the lower part of the vagina

Dye test (methylene blue instilled into rectum, then visualized in the vagina)

Skin disorders (eg, psoriasis, lichen sclerosus, lichen planus, lichen simplex chronicus)

Characteristic genital and extragenital skin findings

Pelvic examination

Sometimes biopsy