Usefulness of History, Physical, and Laboratory in Evaluating Vaginal Complaints

Abstract & Commentary

Synopsis: In working up vaginitis symptoms, useful signs are inflammation and odor, information concerning odor and itching are useful symptoms, and office microscopy is the most accurate laboratory test.

Source: Anderson MR, et al. JAMA. 2004;291: 1368-1379.

This exhaustive literature summary included a MEDLINE search as well as a survey of the bibliographies of recent reviews. In addition, the primary authors of various studies were contacted for articles which evaluated the usefulness of the history, physical, and laboratory evaluations in the diagnosis of vaginitis. Criteria for inclusion were: original research, symptomatic premenopausal patients, primary care setting, comparison of a diagnostic symptom or sign with a standard, and ability to calculate sensitivity and specificity. Among symptoms, the most useful findings were a lack of itching (negative likelihood ratio, 0.18-0.79) and a lack of perceived odor (negative likelihood ratio, 0.07). The former finding made candidiasis less likely and the latter made bacterial vaginosis less likely. Physical findings predictive of candidiasis were inflammation (LR+, 2.1-8.4) and a lack of odor (LR+ = 2.9). Because the whiff test is a part of the reference standard for bacterial vaginosis, it was considered for purposes of this endeavor. Among laboratory tests, it is most useful to find a lack of leukocytes in candidiasis and bacterial vaginosis.

Comment by Frank W. Ling, MD

This study takes us back to our earliest clinical experiences in obstetrics and gynecology. It also gives us something that few articles do: a way to make our office practice more efficient. How many patients have presented to us over the years with complaints of vaginitis? How many questions have we asked about the nature of the discharge? How many examinations have we done and how many times have we gone to the microscope with slides and coverslips in hand? How many cultures have we performed? I’m sure the answer to all the above is, "A bunch." How much of this effort was useful? This literature review helps us focus the questions we ask, the examinations that we do, and the laboratory tests that we perform.

I feel as though my day in the office has now been given some relief! What says "love" better than the gift of time? The questions that I need to ask can now focus on itching and odor. On examination, I can mainly look for erythema/ edema/excoriations. My wet prep can remain my primary lab evaluation. Of course, we need to remain vigilant for gonorrhea and/or chlamydia when a wet prep doesn’t show trichomonads. In a previous issue of OB/GYN Clinical Alert, we wrote about alternative treatment for resistant yeast infections, so we shouldn’t forget the those outliers.1 Remember, however, that common things occur commonly; ie, when you hear hoofbeats, think horses, not zebras.

Another implication for this paper is how you choose to manage your phone calls concerning vaginitis. Whether it’s to benefit you or your office staff, if a patient is not to be seen in the office for her vaginal complaints, the questions and answers implicit in the findings here could increase the effectiveness of trying to diagnose and treat without being able to see the patient. Of course, many of our patients already self-diagnose and treat, so even these women can be better served when they call about treatment failures.

Reference

1. Ling F. OB/GYN Clinical Alert. 2004;20(10):79.

Frank W. Ling, MD, Women’s Health Specialists, PLLC, Memphis, Tennessee, is Associate Editor for OB/GYN Clinical Alert.