vaginal discharge

Normal vaginal flora: which organism maintains the acidic vaginal environment?

Lactobacilli.

What produces the acidic vaginal pH normally?

Lactic acid produced by Lactobacilli.

Vaginal discharge + no odor, itching, or irritation → normal or abnormal?

May be physiologic/normal discharge.

First things to assess in vaginal discharge?

Color, consistency, odor, associated symptoms, sexual history, and risk factors.

Basic bedside tests for vaginitis?

pH + KOH/whiff test + wet mount microscopy.

Vaginal pH ≤4.5 strongly favors which infection?

Candida.

Vaginal pH >4.5 suggests which major causes?

BV or Trichomoniasis.

Fishy odor after adding KOH → what test is positive?

Whiff test.

Thin homogeneous gray-white discharge + fishy odor + pH >4.5 → diagnosis?

Bacterial vaginosis.

BV: what happens to the normal Lactobacillus-dominant flora?

Lactobacilli decrease and anaerobic bacteria increase.

BV is associated with overgrowth of which type of organisms?

Mixed anaerobic flora.

Classic BV microscopy finding?

Clue cells.

What are clue cells?

Vaginal epithelial cells coated with bacteria.

BV diagnosis by Amsel requires how many criteria?

≥3 of 4.

Amsel: abnormal discharge + pH >4.5 + positive whiff + what?

Clue cells.

BV: positive whiff test indicates what?

Fishy amine odor after adding KOH.

BV: vaginal pH is usually what?

4.5.

BV: is marked vulvar inflammation typical?

No; inflammation is usually minimal.

BV: first-line treatment options?

Metronidazole or clindamycin.

BV: should sexual partners routinely be treated?

No, not routinely.

BV: Gram stain can be used for what?

Laboratory diagnosis/assessment of bacterial morphotypes.

BV in pregnancy: why is recognition clinically important?

It is associated with adverse pregnancy outcomes.

Thick white adherent “cottage-cheese” discharge + intense itching + normal pH → diagnosis?

Vulvovaginal candidiasis.

Candida: is a fishy odor typical?

No.

Candida: what is the usual vaginal pH?

Normal/acidic.

Candida: most common species?

Candida albicans.

KOH showing budding yeast/pseudohyphae → diagnosis?

Candidiasis.

Candida risk factor after recent antibiotics → why?

Alteration of normal vaginal flora promotes Candida overgrowth.

Other important Candida risk factors?

Pregnancy, diabetes, immunosuppression, corticosteroids, and recurrent antibiotic exposure.

Candida is usually classified as what type of infection regarding sexual transmission?

Not usually an STI.

Uncomplicated Candida: typical severity?

Mild-to-moderate disease in an otherwise healthy patient.

Recurrent Candida is defined as how many episodes/year?

≥4 episodes/year.

Recurrent Candida: what should you consider beyond simply repeating treatment?

Risk factors, alternative diagnosis, and non-albicans Candida.

Severe Candida + extensive erythema/fissures → complicated or uncomplicated?

Complicated/severe candidiasis.

Recurrent or complicated Candida may require what diagnostic approach?

Culture/speciation.

Why can non-albicans Candida be clinically important?

It may respond differently to standard therapy.

Uncomplicated Candida treatment: common topical class?

Topical azole antifungals.

Common topical azoles for Candida?

Clotrimazole or miconazole.

Oral option commonly used for uncomplicated Candida?

Fluconazole.

Pregnancy + Candida: which route is generally preferred?

Topical therapy rather than oral fluconazole.

Candida treatment fails repeatedly → what should you reconsider?

Diagnosis, adherence, recurrent/complicated disease, and non-albicans Candida.

Frothy yellow-green discharge + foul odor + pH >4.5 → diagnosis?

Trichomoniasis.

What organism causes trichomoniasis?

Trichomonas vaginalis.

Trichomonas is a bacterium, fungus, or protozoan?

Flagellated protozoan.

Trichomonas wet mount: what characteristic organism may be seen?

Motile trichomonads.

Trichomonas: typical vaginal pH?

4.5.

Strawberry cervix strongly suggests what diagnosis?

Trichomoniasis.

Is strawberry cervix sensitive enough to exclude Trichomonas if absent?

No.

Best highly sensitive test for Trichomonas?

NAAT.

Trichomoniasis is transmitted primarily by what route?

Sexual transmission.

Trichomonas treatment: oral metronidazole or what alternative?

Tinidazole.

Trichomoniasis: what crucial partner-management step prevents reinfection?

Treat sexual partner(s).

After diagnosing Trichomonas, what additional evaluation should be considered?

Testing for other STIs.

Untreated Trichomonas can be associated with what pregnancy complications?

PROM, preterm birth, and low birth weight.

Thin gray discharge + fishy odor + clue cells → BV or Candida?

BV.

Severe itching + thick white discharge + pseudohyphae → BV or Candida?

Candida.

Frothy yellow-green discharge + motile organisms → BV or Trichomonas?

Trichomonas.

Which two common vaginitis causes usually have pH >4.5?

BV and Trichomoniasis.

Which common vaginitis cause usually preserves normal acidic pH?

Candida.

Postmenopausal dryness + burning + dyspareunia + pH ≥5 → diagnosis?

Atrophic vaginitis.

Why does vaginal pH rise after menopause?

Estrogen decreases → glycogen/lactic acid decrease → pH rises.

Atrophic vaginitis is mainly related to deficiency of which hormone?

Estrogen.

Atrophic vaginitis: expected vaginal pH?

Usually ≥5.

Atrophic vaginitis: typical symptoms?

Dryness, burning, dyspareunia, and urinary symptoms.

Atrophic vaginitis may cause which urinary complaints?

Urgency, frequency, recurrent UTI, or incontinence.

Atrophic vaginitis microscopy: which cells increase?

Parabasal/intermediate cells.

Atrophic vaginitis: what happens to superficial cells?

They decrease.

Postmenopausal dryness + high pH + no infectious organism → think of what?

Atrophic vaginitis.

Atrophic vaginitis treatment may include what local therapy?

Topical vaginal estrogen.

What nonhormonal treatment can help vaginal dryness?

Vaginal moisturizers/lubricants.

Purulent discharge + burning + vaginal erythema + high pH + parabasal cells → diagnosis?

Desquamative inflammatory vaginitis (DIV).

DIV is more commonly seen in which group?

Perimenopausal/postmenopausal women.

DIV: would you expect motile Trichomonas organisms?

No.

High pH + parabasal cells + negative Trichomonas testing → what should you consider?

DIV.

Which finding favors Trichomonas over DIV?

Motile Trichomonas organisms/positive Trichomonas testing.

A patient has discharge but microscopy is negative; should diagnosis be based on symptoms alone?

No; correlate with pH, microscopy, testing, and clinical findings.

A patient repeatedly self-treats “yeast infection” but symptoms persist → what is the key exam lesson?

Reassess the diagnosis rather than repeatedly treating empirically.

Which vaginitis classically causes minimal inflammation despite prominent discharge?

BV.

Which vaginitis classically causes intense vulvar pruritus?

Candida.

Which vaginitis is an STI requiring partner treatment?

Trichomoniasis.

Which vaginitis is strongly associated with hypoestrogenism?

Atrophic vaginitis.

Which diagnosis gives you “fishy odor + clue cells”?

BV.

Which diagnosis gives you “pseudohyphae + normal pH”?

Candida.

Which diagnosis gives you “motile protozoa + strawberry cervix”?

Trichomoniasis.

Which diagnosis gives you “parabasal cells + hypoestrogenic symptoms”?

Atrophic vaginitis.

CASE: 24-year-old, thin gray discharge, pH 5.0, positive whiff, clue cells → diagnosis?

Bacterial vaginosis.

CASE: 22-year-old, severe itching, thick white discharge, pH 4.2, pseudohyphae → diagnosis?

Candida.

CASE: 25-year-old, frothy yellow-green discharge, pH 5.5, motile organisms → diagnosis?

Trichomoniasis.

CASE: 67-year-old, dryness, dyspareunia, pH 5.5, parabasal cells → diagnosis?

Atrophic vaginitis.

CASE: Trichomonas diagnosed but partner untreated → most likely problem?

Reinfection.

CASE: recurrent Candida despite appropriate treatment → next thought?

Confirm diagnosis/culture and assess for complicated or non-albicans Candida.

CASE: vaginal discharge + pH >4.5 + no clue cells + no motile organisms → which two diagnoses remain important?

Consider non-BV causes such as Trichomonas, atrophic vaginitis, or DIV based on the clinical picture.