Potassium hydroxide KOH preparation

1. Place a second sample on a slide, apply one drop of 10% potassium hydroxide (KOH) and a coverslip. A pungent, fishy odor upon addition of KOH--a positive whiff test--strongly indicates bacterial vaginosis.

2. The KOH prep may reveal Candida in the form of thread-like hyphae and budding yeast.

G. Screening for STDs. Testing for gonorrhea and chlamydial infection should be completed for women with a new sexual partner, purulent cervical discharge, or cervical motion tenderness.

III. Differential diagnosis

A. The most common cause of vaginitis is bacterial vaginosis, followed by Candida albicans. The prevalence of trichomoniasis has declined in recent years.

B. Common nonvaginal etiologies include contact dermatitis from spermicidal creams, latex in condoms, or douching. Any STD can produce vaginal discharge.

Clinical Manifestations of Vaginitis

Candidal Vaginitis

Nonmalodorous, thick, white, "cottage cheese-like" discharge that adheres to vaginal walls Presence of hyphal forms or budding yeast cells on wet-

mount microscopic evaluation Pruritus

Normal pH (<4.5)

Bacterial Vaginosis

Thin, dark or dull grey, homogeneous, malodorous discharge that adheres to the vaginal walls Elevated pH level (>4.5) Positive KOH (whiff test) Clue cells on wet-mount microscopic evaluation

Trichomonas Vaginalis

Copious, yellow-gray or green, homogeneous or frothy, malodorous discharge Elevated pH level (>4.5)

Mobile, flagellated organisms and leukocytes on wet-

mount microscopic evaluation Vulvovaginal irritation, dysuria

Atrophic Vaginitis

Vaginal dryness or burning

IV. Bacterial Vaginosis

A. Bacterial vaginosis develops when a shift in the normal vaginal ecosystem causes replacement of the usually predominant lactobacilli with mixed bacterial flora. Bacterial vaginosis is the most common type of vaginitis. It is found in 10-25% of patients in gynecologic clinics.

B. There is usually little itching, no pain, and the symptoms tend to have an indolent course. A malodorous fishy vaginal discharge is characteristic. The odor, a result of anaerobic bacteria, is exacerbated during menses and following intercourse due to the alkaline nature of blood and semen.

C. There is usually little or no inflammation of the vulva or vaginal epithelium. The vaginal discharge is thin, dark or dull grey, and homogeneous.

D. A wet-mount will reveal clue cells (epithelial cells stippled with bacteria), an abundance of bacteria of various morphologies, and the absence of homogeneous bacilli (lactobacilli).

E. Diagnostic criteria (3 of 4 criterial present)

2. Clue cells

3. Positive KOH whiff test

4. Homogeneous discharge.

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