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Vaginal Discharge and Itching

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 vaginal discharge. Not all symptoms are caused by infection. For example, cervicitis often leads to an increase in discharge without irritative symptoms. Vulvovaginal infections, ure-thrifts, and cystitis may be accompanied by the same voiding symptoms, and various dermatologic conditions may be confused with either vulvar or vaginal infections.

Normal vaginal discharge is white, nonhomogeneous, and odorless. It pools in the posterior fomix. The normal pH during the reproductive years is 3.5-4.2. The pH becomes more alkaline on exposure to semen or menstrual blood.

Table 14. Common Causes of Abnormal Vulvovaginal Discharge
Diagnosis	pH	Pathogen	Background
Bacterial vaginosis	>4.5	Clue cells	Decreased lactobacilli
Candida albicans	<4.5	Hyphae and spores	Normal
Trichomoniasis	>4.5	Motile trichomonads	Leukocytes, decreased lactobacilli

Patient Evaluation

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.

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.

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. If these test results are negative, it is helpful to reexamine the patient during a different part of her menstrual cycle or when the symptoms intensify.