Again, the female genital tract can be infected by all sizes of organisms, thus a useful method for recalling the causes of a purulent vaginal discharge is to work from the smallest to the largest organism. Thus, we begin with herpes progenitalis and proceed to gonorrhea and nonspecific bacterial infection (now known as Gardnerella vaginalis), trichomoniasis, and, finally, moniliasis. This, however, does not cover all the causes of a nonbloody vaginal discharge. Consequently, anatomy is applied as well.
At the vulva, one encounters vulvitis, bartholinitis, and vulval carcinoma. In the vagina, the conditions mentioned above are formed in addition to senile vaginitis, foreign bodies, and vaginal carcinomas. One should also not forget vesicovaginal, rectovaginal, and enteric fistulas. At the cervix, cervicitis and endocervicitis (gonorrheal or nonspecific), cervical polyps, and carcinomas need to be mentioned. In the uterus, endometritis, polyps, and carcinomas are recalled, but the latter two conditions are usually associated with a bloody discharge. Finally, salpingitis produces a mucopurulent discharge.
|
|
|
Vaginal discharge |
Approach to the Diagnosis
To workup a vaginal discharge, simply examining a fresh wet saline and KOH (10%) preparation will expose the most common offenders, namely Trichomonasand Candida. Some physicians treat all patients with negative findings on these examinations as a nonspecific bacterial vaginitis, but this is not a particularly scientific procedure. It is best to do a smear and culture (especially for gonococci). Cultures are also available for Trichomonas and Candida. If gonorrhea is suspected, material from the endocervix should be cultured. Chlamydia cultures are routinely done in some clinics.
Obviously, if the cervix is eroded and the discharge seems to be coming from there, biopsy and conization may be indicated. Referral to a gynecologist is preferred if this procedure is deemed necessary; however, the primary physician may prefer to cauterize the superficial lesions. Patients with discharges thought to be due to lesions beyond the cervix should probably be referred.
Other Useful Tests
1. CBC (PID)
2. Sedimentation rate (PID)
3. VDRL test
4. Tuberculin test (pelvic tuberculosis)
5. Rectal culture (gonorrhea)
6. Vaginal and cervical cytology after infection subsides (carcinoma of the cervix or endometrium)
7. D & C and biopsy (endometrial carcinoma)
8. Sonogram (PID)
9. Laparoscopy (PID)
10. Trial of systemic antibiotics
Case Presentation #85
A 28-year-old black woman complained of a chronic vaginal discharge and lower abdominal pain for several months. She admits to promiscuous sexual behavior.
Question #1. Utilizing the size of organisms in recalling various causes of vaginal discharge, what is your differential diagnosis?
Vaginal examination revealed tender adnexal masses and a mucopurulent discharge.
Question #2. What is your diagnosis now?
