Useful signs and symptoms to evaluate vaginal complaints

Journal of Family Practice, June, 2004

Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA 2004; 291:1368-1379.

* CLINICAL QUESTION

How useful are the history, physical examination, and routine office-based laboratory studies in the diagnosis of vaginitis?

* BOTTOM LINE

In the diagnosis of vaginitis, useful symptoms include information about itching. Useful signs include odor and the presence of inflammatory changes. Office microscopy is the most accurate laboratory test. (LOE=3a)

* STUDY DESIGN

Systematic review

* SETTING

Outpatient (any)

* SYNOPSIS

The 3 major causes of vaginitis include vaginal candidiasis, bacterial vaginosis, and trichomoniasis. The authors thoroughly searched Medline and the bibliographies of recent reviews, and contacted primary authors of identified studies, for articles evaluating the usefulness of the history and physical examination in conjunction with routine office-based laboratory testing in the diagnosis of vaginitis.

Articles were included if they involved original research on symptomatic premenopausal women in a primary care setting, compared a diagnostic sign/symptom/test with a recognized reference standard, and allowed the calculation of sensitivity and specificity. A total of 18 studies met the established criteria. All 18 studies were evaluated for quality: of these, 15 received a score of 2 (i= best, 3=worst), and 3 studies received a score of 3.

Symptoms useful in diagnosis included a lack of itching (making candidiasis less likely; negative likelihood ratio [LR-] = 0.18-0.79) and a lack of perceived odor (making bacterial vaginosis unlikely; LR- = 0.07). Useful physical examination signs were limited. Findings predictive of candidiasis included the presence of inflammation (eg, erythema, edema, excoriations; positive likelihood ratio [LR ] range = 2.1-8.4) and a lack of odor (LR = 2.9).

The presence of a high "cheese" odor was predictive of bacterial vaginosis (LR = 3.2). The whiff test (fishy odor from the slide after the application of potassium hydroxide) is part of the reference standard for bacterial vaginosis and was therefore not evaluated independently.

Of the various office laboratory tests available, microscopy of vaginal discharge was the most useful. The presence of many leukocytes was uncommon in candidiasis and bacterial vaginosis. In the absence of trichomonads, it is important in this instance to consider other causes, such as gonorrhea or chlamydia.

DRUG BRAND NAMES

Ciprofloxacin * Cipro

Ketorolac * Toradol

Prochlorperazine * Compazine