AUBF 27: VAGINAL SECRETIONS

is one of the most common conditions diagnosed by health-care providers for female patients, particularly women of childbearing age

Vaginitis

It is characterized by abnormal vaginal discharge or odor, pruritus, vaginal irritation, dysuria, and dyspareunia

Vaginitis

vaginitis is secondary

acterial vaginosis(BV), vulvovaginal candidiasis, or trichomoniasis

can also occur with non-infectious conditions such as vaginal atrophy, allergies, and chemical irritation

Vaginitis

saline wet mount examination, potassium hydroxide (KOH) examination, and the Gram stain, which is considered the gold standard

microscopic method to diagnose various syndrome of vaginitis

tests are performed on vaginal secretions to detect the __________________ protein to diagnose ruptured fetal membranes, or fetal fibronectin enzyme to assess the risk of preterm delivery

placental a 1-microglobulin (PAMG-1)

A speculum moistened with warm water is used to visualize the vaginal

fornices

The specimen is collected by swabbing the _______________ and __________________ to collect epithelial cells along with the vaginal secretions using one or more sterile, polyester-tipped swabs on a plastic shaft or swabs specifically designated by the manufacturer.

vaginal walls and vaginal pool

Cotton swabs should not be used because cotton is toxic to

Neisseria gonorrhoeae

the wood in a wooden shaft may be toxic to

Chlamydia trachomatis

_______________ can inactivate herpes simplex virus (HSV) for viral cultures

calcium alginate

The vaginal swab should be vigorously twirled in the ____________ to dislodge particulates from the swab

saline

Failure to dislodge particles may lead to erroneous result

normal saline solution directly on a microscope slide second sample is then placed in 10% KOH solution

alternative method of specimen preparation

Specimens must be kept at _____________ to preserve the motility of Trichomonas vaginalis and the recovery of N. gonorrhoeae

room temperature

specimens for C. trachomatis and herpes simplex virus must be ______________ to prevent overgrowth of normal flora

refrigerated

Specimens for T. vaginalis should be examined within ___hours of collection

2

Normal vaginal fluid appears

white with a flocculent discharge

_______________vaginal flora includes a predominance of large, rod-shaped, gram-positive lactobacilli and squamous epithelial cells

normal

White blood cells may be present and ________________ will be present if the patient is menstruating

red blood cells

homogeneous white-to-gray discharge often seen in

bacterial vaginosis

white "cottage cheese"-like discharge particular for

Candida infections

an increased yellow-green, frothy, adherent discharge associated with

T. vaginalis

___________________ may present with a yellow, opaque cervical discharge

C. trachomatis

The test should be performed before placing the swab into saline or KOH solutions

pH

normal ph of vaginal discharge

3.8 to 4.2

normal amine (whiff) test of vaginal discharge

negative

normal WBC present in vaginal discharge

2+

normal lactobacilli in vaginal secretion

predominant

normal clue cells in vaginal secretion

absent

normal cells seen in vaginal secretion

RBC during mestruation

other organisms normally seen in vaginal secretion

lactobaciili subgroups, occasional yeasts

cervical mucus, semen, and blood

can interfere with ph testing

The vaginal pH is usually about _____ in women with vulvovaginal candidiasis

4.5

ph above ____ in women with bacterial vaginosis, trichomoniasis, desquamative inflammatory vaginitis (DIV), and atrophic vaginitis

4.5

As described previously, normal vaginal flora includes a predominance of the bacteria lactobacilli, which produce the end product _________ from glycogen metabolism

lactic acid

provides an acidic vaginal environment with a pH value between 3.8 and 4.5.

lactic acid

This acidity suppresses the overgrowth of infectious organisms such as

Mobiluncus, Prevotella, and Gardnerella vaginalis

Some lactobacilli subgroups also produce ___________________, which is toxic to pathogens, and helps keep the vaginal pH acidic to provide protection from urogenital infections

hydrogen peroxide

________________ has been associated with the absence of hydrogen peroxide-producing lactobacilli

Bacterial vaginosis

____________ production also is necessary to preserve an acidic vaginal environment

Estrogen

initial microscopic screening tests for vaginal secretion

Saline wet mounts and KOH mounts

confirmatory examination for yeast or bacterial vaginosis

Gram stain

Typical constituents found in vaginal fluid wet mounts include

squamous epithelial cells, white blood cells, red blood cells, clue cells, parabasal cells, basal cells, bacteria, motile Trichomonas vaginalis, yeast, and hyphae/pseudohyphae

________________might leave oil droplets that can interfere with the interpretation of wet mounts

Intravaginal medications

measure 25 to 70 µm in diameter and exhibit a polygonal "flagstone" appearance

Squamous epithelial cells

They contain a prominent centrally located nucleus about the size of a red blood cell and a large amount of irregular cytoplasm, lacking granularity, with distinct cell margins.

Squamous epithelial cells

Less than 10 organisms or cells/slide

Rare

Less than 1 organism or cell/hpf

1+

1 to 5 organisms or cells/hpf

2+

6 to 30 organisms or cells/hpf

3+

30 organisms or cells/hpf

4+

Clumps of epithelial cells are an indication of the presence of increased numbers of

yeast

an abnormal variation of the squamous epithelial cell and are distinguished by coccobacillus bacteria attached in clusters on the cell surface, spreading past the edges of the cell, making the border indistinct or stippled

Clue Cells

This gives the cell a granular, irregular appearance sometimes described as "shaggy."

Clue Cells

Clue cells are diagnostic of bacterial vaginosis caused by

G. vaginalis

measure 14 to 16 µm in diameter and exhibit a granular cytoplasm

White blood cells (WBCs)

They are often described as polymorphonuclear white blood cells (PMNs) because of their characteristic multi-lobed nucleus

White blood cells (WBCs)

Greater than ___ WBCs in vaginal secretions suggest vaginal candidiasis, atrophic vaginitis, or infections with Trichomonas, Chlamydia, N. gonorrhoeae, or Herpes simples

3+

appear as smooth, non-nucleated biconcave disks measuring approximately 7 to 8 µm in diameter

Red blood cells (RBCs)

can be somewhat distorted in vaginal specimens.

RBCs

________ can be confused with yeast cells and are distinguished from yeast cells by KOH

RBCs

which will lyse the RBCs but allow the yeast cells to remain intact

are round to oval shaped and measure 16 to 40 µm in diameter

Parabasal Cells

The nucleus to cytoplasm ratio is 1:1 to 1:2, with marked basophilic granulation or amorphic basophilic structures ("blue blobs") in the surrounding cytoplasm.

Parabasal Cells

They are located in the luminal squamous epithelium of the vaginal mucosa

Parabasal Cells

less mature _______________cells may be found if the patient is menstruating and in postmenopausal women

Parabasal

Increased numbers of parabasal cells, if present with large numbers of WBCs, can indicate

desquamative inflammatory vaginitis

are located deep in the basal layer of the vaginal stratified epithelium

Basal Cells

These cells are round and measure 10 to 16 µm in diameter and have a nucleus to cytoplasm ratio of 1:2

Basal Cells

Basal cells are distinguished from ____________that are similar in size by their round rather than lobed nucleus.

WBCs

if basal cell is present and accompanied by large numbers of WBCs and altered vaginal flora can suggest

desquamative inflammatory vaginitis.

normally comprise the largest portion of vaginal bacteria

Lactobacillus spp

They appear as large gram-positive, nonmotile rods on Gram stain and produce lactic acid, which maintains the vaginal pH at 3.8 to 4.5

Lactobacillus spp

anaerobic streptococci, diphtheroids, coagulase-negative staphylococci, and a -hemolytic streptococci.

Other bacteria commonly present

When conditions are present that cause an imbalance in the normal flora, ______________can occur

vaginitis

Absent or decreased numbers of lactobacilli relative to the number of squamous epithelial cells suggests an alteration in the

normal flora

The lactobacilli are often replaced by increased numbers of

Mobiluncus spp (thin, curved, gram-negative, motile rods), Prevotella spp., Porphyromonas spp., Bacteroides spp. (anaerobic gram-negative rods), Gardnerella vaginalis (short, gram-variable coccobacilli), Peptostreptococcus spp. (gram-positive cocci), Enterococcus spp. (gram-negative cocci), Mycoplasma hominis, and Ureaplasma urealyticum

is an atrial flagellated protozoan that can cause vaginal inflammation and infection in women

Trichomonas vaginalis

The organism is oval shaped, measures 5 to 18 µm in diameter, and has four anterior flagella and an undulating membrane that extends half the length of the body.

Trichomonas vaginalis

An axostyle bisects the trophozoite longitudinally and protrudes from the posterior end, which enables the organism to attach to the vaginal mucosal and cause tissue damage

Trichomonas vaginalis

The __________ motion of the flagella and undulating membrane characteristic of T. vaginalis can be observed in a wet mount

"jerky"

. Care must be taken to not confuse T. vaginalis with __________, which only have a single tail, a much smaller head (approximately one half the diameter of a RBC), and no axostyle

sperm

quickly lose their viability after collection

T. vaginalis organisms

cause most fungal infections but an occasional yeast in vaginal secretions is considered part of the normal flora.

Candida albicans and non-Candida spp

appear on a wet mount as both budding yeast cells (blastophores) (Fig. 15-10) or as hyphae, which are long filaments that grow and form a mycelium

Yeast cells

multiple buds that do not detach and form chains

Pseudohyphae

Yeast cells stain gram______________

positive

is performed by placing a drop of the saline specimen prepared from the collection swab onto a properly labeled clean slide and adding one drop of 10% KOH solution

KOH slide is prepared and the amine (Whiff) test

The slide is immediately checked for a "fishy" amine odor

KOH slide is prepared and the amine (Whiff) test

positive KOH slide is prepared and the amine (Whiff) test

presence of fishy odor

negative KOH slide is prepared and the amine (Whiff) test

absence of fishy odor

Increased numbers of anaerobic bacteria in the vagina produce ______________ that are released into the vaginal fluid

polyamines

a positive volatile amines test result suggests bacterial vaginosis caused by increased numbers of _____________ in conjunction with _________________ and _____________

G. vaginalis; Mobiluncus spp. and with T. vaginalis

specimen culture, DNA probe testing, Gram stain, proline aminopeptidase assay, and point of care test kits

other tests may be required for a confirmatory diagnosis for bacterial vaginosis

considered the gold standard in identifying the causative organisms for bacterial vaginosis

Gram Stain

nugent score of 0 to 3

normal

nugent score of 4 to 6

intermediate

nugent score of 7 or more

diagnistic of bacterial vaginosis

the gold standard test for detecting yeast and Trichomonas

Culture

Diamond's medium

required for T. vaginalis

have been developed to specifically identify the causative pathogen for vaginitis

DNA hybridization probe