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Vaginal Discharge and Itching : DIAGNOSTIC REASONING: FOCUSED PHYSICAL EXAMINATION

Note Vital Signs


The presence of a fever may alert you to a serious infection, such as PID. Fever is uncommon with vaginitis.


Perform an Oral Examination

Oral thrush may accompany vulvar candidiasis, particularly in children. Look for white patches that bleed when you try to scrape them off.


Perform an External Genitalia Examination

Palpate for inguinal lymphadenopathy and tenderness, which can be present with vaginal infections. Inspect the vulva and labia, looking for erythema, excoriations, and induration. The skin is often bright red and swollen with small fissures or excoriations from candidiasis. Also, thick white curds of discharge are often noted in the labial folds. BV often produces a profuse, thin, whitish discharge that will leak out of the vagina onto the perineum. Palpate Bartholin and Skene glands and milk the urethra for discharge. Palpable Bartholin glands often coexist with STIs. If purulent discharge is seen, consider the diagnoses of gonorrhea or chlamydia and obtain specimens for diagnostic tests. Condylomata lata, condylomata acuminata, and molluscum contagiosum are all papular lesions found on the labia, perineum, and anal regions. Molluscum contagiosum, when occurring in the genital area, may extend to the inner thighs. Herpes lesions are usually ulcerative in nature when seen clinically and need to be differentiated from other similar lesions (e.g., syphilitic chancre can be more than one lesion and tender if secondarily infected). Herpetic lesions—painful vesicles on an erythematous base—are found in clusters and can extend from the labia into the vagina. Typically, condylomata acuminata (genital warts) are rough, verrucous lesions that are located inferiorly from the fossa navicularis to the fourchette and perineal area. In the overweight patient, vulvovaginitis candidiasis
is frequently accompanied by intertriginous candidiasis (e.g., under the breasts and the abdominal apron). In a young child it is important to tell her in simple terms what you are about to do. A common position for examination is the frog leg position. Have the parent sit on a chair and then have the patient sit on her parent’s lap for the examination. The most common problem (vulvovaginitis) of the younger child requires only the lower third of the vagina to be visualized. A more detailed visual examination requires labial separation and labial traction.


Perform an Internal Vaginal Examination

Note the condition of the vaginal walls. A plastic speculum makes vaginal wall inspection easy and helps in the identification of a foreign body for removal. In children, the knee-chest position is useful for inspecting the vagina. If a foreign body is suspected in children, removal is done using sedation. Pale or mottled red splotches of the vaginal mucosa with a sticky, yellow-brown discharge are associated with atrophic vaginitis. In severe cases of atrophic vaginitis, the pale, thin mucosa may have adhered to the opposing vaginal wall, and the speculum examination often causes an oozing bloody discharge. The appearance of the cervix should be noted.
A friable or “strawberry” appearance of cervical petechiae with a frothy, foul-smelling discharge is descriptive of a trichomonas infection. A mucopurulent discharge from the cervical os is an indication to obtain an endocervical sample for gonorrhea and chlamydia testing. This discharge is yellowish-green when collected on an endocervical swab. The character of the discharge does not consistently identify common infectious causes of vaginitis. Treat vaginal infections before the Papanicolaou test is obtained because BV and trichomoniasis may cause inflammatory atypia results. Obtain a sample for testing. The wet mount is a valuable diagnostic tool, and a sample of vaginal discharge is best obtained from the lateral vaginal fornices. Three positive characteristics for any one etiology can correctly identify the causative agent (e.g., increased pH; the presence of “clue cells,” which are epithelial cells full of bacteria that obscure the cell border; and a thin gray discharge seen in BV) (see Differential Diagnosis). DNA testing and/or culture may also be indicated (see Laboratory and Diagnostic Studies). Cultures for BV, fungal infections, and T. vaginalis are not routinely recommended and are usually reserved for determining resistant organisms.


Perform a Bimanual Examination

Assess the condition of the uterus, fallopian tubes, and ovaries by checking for uterine and cervical motion tenderness (CMT), ovarian size, and presence of masses. CMT or pain on palpation of the uterus and adnexa confirms the spread of vaginitis or cervicitis to the upper genital tract and results in PID. This warrants immediate evaluation and treatment or referral to prevent tubal scarring, ectopic pregnancy, and infertility.


Perform a Vaginal-Rectal Examination

Vaginal-rectal examination is an important technique in assessing the posterior uterus and condition of the cul-de-sac as well as the rectum. The internal examination glove must be changed before rectal insertion to prevent contamination of the rectum with vaginal discharge organisms. A rectal examination, using the fifth digit, is used to palpate a foreign body and to check pelvic anatomy in the child.