Analysis of Vaginal Secretions

Why would one analyze vaginal secretions

• diagnose infections

• look for pregnancy complications

• forensic testing in sexual assult

Lactobacilli

• 50-90% of microbes of healthy vaginal area

• maintain normal acidic pH

What do Lactobacilli produce

• lactic acid

• hydrogen peroxide

Other bacterial organisms that are not lactobacilli are what? 

• abnormal 

Vaginitis symptoms 

• abnormal discharge

• odor

• vaginal irritation 

Vaginitis is secondary to what? 

• bacterial vaginosis - bacterial 

• candida albicans - yeast 

• trichomoniasis - parasite

How do bacterial vaginosis, candida albicans, and trichomoniasis differ

• they could have similar clinical presentations but different treatments 

Normal vaginal pH

• 3.5 to 4.5

Hydrogen peroxide

• bactericidal

• prevents overgrowth of some microbes 

What is the ph of vulvovganinal candidiasis

• 4.5 

What conditions can be indicated due to a pH greater than 4.5

• bacterial vaginosis

• trichomoniasis

• atrophic vaginitis 

What tests help differentiate different conditions

• wet mount examination 

• amine or “whiff” test 

• potassium hydroxide (KOH) exam

• Gram stain 

What elements are reported in Wet Mounts?

• RBC

• WBC

• predominant bacterial morphotypes

• yeast, hyphae/pseudohyphae

• trichomonads

• clue cells  

What is added to KOH test

• 1 drop 10% KOH and 1 drop vaginal suspension 

• immediately causes fishy odor 

what causes the fishy odor in the KOH test? 

• trimethylene released from polyamines when pH changes 

What happens in bacterial vaginosis

• altered flora produces polyamines 

What does a positive KOH test result indicate

• bacterial vaginosis 

  • Gardnerella vaginalis 

  • Trichomonas vaginalis

What else does the KOH test do?

• digests cellular elements inorder to visualize fungal elements 

• allows observation of yeasts 

When would RBC be seen in vaginal collection

• during menses 

  • otherwise not usually present 

When are WBC seen at a higher level in vaginal collecton 

• ovulation and menses 

When collecting a vaginal sample what else is important to have? 

• current patient history 

RBC

• distorted

• confused with yeast cells

• KOH is used to distinguish 

WBC

• neutrophils: multilobed nucleus 

What can increased WBC mean

• candidiasis

• atrophic vaginitis 

• infections

  • Trichomonas

  • Chlamydia

  • Neisseria gonorrhoeae

  • Herpes simplex

Squamous Epithelial Cells

• originate from linings of vagina and female urethra

• prominent centrally located nucleus

Lactobacillus spp

• large, gram positive non motile rods

What can alterations in normal flora cause

• overgrowth of opportunistic flora 

What are examples of bacteria

• anaerobic streptococci

• Diphtheroids

• Coagulase-negative staphylococci

• A-hemolytic streptococci

Clue Cells

• coccobacillus bacteria attached in clusters on the cell surface 

• diagnostic of bacterial vaginosis 

Clue cells could indicate what 

• Gardnerella vaginalis 

  • bacteria should cover at least 75% of cell surface 

bacterial vaginosis

• lactobacilli replaced by overgrowth of Gardnerella vaginalis

• often asymptomatic except for foul discharge

• presence of clue cells. no lactobacilli  

What indicates bacterial vaginosis

• presence of clue cells, no lactobacilli

• positive amine whiff test 

• vaginal pH > 4.5

Candidiasis

• Candida albicans responsible for majority of cases

• part of normal flora 

How does overgrowth of candidiasis occur

• changes in pH

Symptoms of Candidiasis

• vaginal itching

• soreness

• external dysuria

• white, curd like discharge

Candidiasis results from Wet Mount and KOH

• budding yeast or pseudohyphae

• increased WBC

what causes candidiasis

• broad spectrum antibiotics 

• oral contraceptives 

• diabetes

• HIV

• immunosuppression presispores

Trichomonas Vaginalis

• most common parasitic gynecologic infection 

• sexually transmitted 

• recurrence is common after treatment 

  • partners need to be treated

What can Trichomonas vaginalis cause in pregnant women 

• premature labor

• rupture of membranes 

How many women with Trichomonas vaginalis are asymptomatic 

• 50% 

Symptoms of Trichomonas vaginalis that are not asymptomatic

• frothy, bad smelling yellow-green discharge

• sourness of vulva, external dysuria

• pucinate hemorrhages on exocervix 

• numerous WBC

• amine/whiff test is positive

Evaluating Trichomonas Vaginalis 

• they quickly lose viability after collection 

  • examine in max 2 hrs 

• can be seen in urine microscopy 

• stains are toxic to trichomonads

Trichomonas vaginalis can NOT be reported unless what? 

• motility is observed

Trichomonas vaginalis structure

• oval or pear shaped, flagellated protozoan 

  • “jerky” motion of flagella 

• infect and inflamate vaginal epithelium 

What do nonmotile or dead trichomonads look like? 

• WBC 

Atrophic Vaginitis

• syndrome in postmenopausal women

  • causes thinning of vaginal mucosa due to decreased estrogen and glycogen 

Symptoms of Atrophic Vaginitis

• vaginal dryness, soreness, inflamed vaginal mucosa, purulent discharge

What comes up on microscopic evaluation of atrophic vaginitis? 

• RBC, WBC, and squamous epithelial cells

pH of Atrophic Vaginitis

• >5 

  • due to lack of estrogen