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Symptoms of vulvovaginal inflammation or infection are among the most common problems encountered in gynecologic practice. Understanding of the causes of these symptoms has improved in the past decade; thus, accurate diagnosis and effective treatment are usually possible. When evaluating vaginal discharge or vulvar irritative symptoms, the clinician should consider sites other than the vagina as the source. Not all symptoms are caused by infection. For example, cervicitis often leads to an increase in discharge.
Normal vaginal discharge is white, nonhomogeneous, and odorless. It pools in the posterior fornix. The normal pH during the reproductive years is 3.5-4.2. The pH becomes more alkaline on exposure to semen.
With estrogen deficiency, the pH is usually in excess of 6. Microscopically, a normal discharge is characterized by superficial epithelial cells, flora composed of lactobacilli, and occasional leukocytes. The addition of 10% potassium hydroxide to the discharge does not change the odor (the amine test) vaginitis.
The microbiology of the normal vaginal flora is a complex composition of aerobic and anaerobic organisms. Organisms that are pathogens under some circumstances, such as Escherichia coli, Bacteroides fragilis, Staphylococcus aureus, group B streptococci, and Candida species.
The principal complaints that may signal an infection are an increase in the amount of discharge, irritative symptoms (itching, burning, or dysuria), and abnormal odor. Although individual infections have characteristic symptoms, it is inaccurate to establish a diagnosis based on symptoms alone or without seeing the patient. The history should include the chronology of the current infection, associated symptoms, current.
Physical examination should include careful inspection of the vulva and perirectal area, looking for nonspecific signs such as erythema, ulceration, or excoriation and for more specific lesions such as pigmentation suggesting intraepithelial neoplasia, satellite lesions (cutaneous candidiasis), condyloma acuminata, pediculosis pubis, genital herpes, or molluscum contagiosum.
Certain diagnostic tests should be routine, whereas the use of other tests depends on the clinical presentation. Routine tests include determination of vaginal pH, microscopic examination of the vaginal discharge (the "wet prep"), and the amine ("whiff") test. The vaginal pH can be determined easily by using pH.
Excessive Physiologic Discharge
Every gynecologist is familiar with women who complain of chronically increased vaginal discharge and who have been treated on several occasions with a diagnosis of non-specific vaginitis. However, these women have a normal vaginal discharge according to all the criteria described. This condition has been referred to as normal but excessive vaginal discharge.
The diagnostic approach to this problem should include careful clinical examination of the vulva and vagina, assessment of vaginal pH, and microscopic examination of the discharge. Cervical cultures for chlamydia and gonorrhea may be considered because these infections can be associated with increased secretions.