CHAPTER 8 I



CHAPTER 8

Vaginal Microscopy

I. Vaginal microscopy explained.

A. The value.

1. Vaginal microscopy is an important laboratory tool for the differential diagnosis of vaginitis. It is also used to assess normal vaginal flora (Box 8-1).

2. It observes living vaginal organisms in order to study the ecology of the lower genital tract in women.

3. It is a direct, rapid, inexpensive test with high sensitivity and specificity for most conditions.

4. It acts as an accessory tool to the patient history, inspection of the vulvar and vaginal mucosa, and pH determination in order to arrive at a presumptive etiologic diagnosis.

5. The two components involved are saline wet mount and potassium hydroxide (KOH) wet mount.

B. The wet mount.

1. Nomenclature. Microscopy involves use of the wet mount.

a. Other similar terms include wet smear, wet prep, vaginal smear, vaginalysis, or hanging drop.

2. Basic principles.

a. A 5-minute microscopic search is required before stating that a slide is negative.

b. Examination under oil immersion is rarely needed.

c. The sample should be taken from the vaginal side walls, the vaginal pool, or both; never from cervix.

d. The sensitivity rate depends on the expertise of the clinician and the adequacy of equipment.

e. Remember to consider cervical factors when working up studies of a patient complaining of vaginal discharge; if in the differential diagnosis phase, also perform a cervical wet mount.

C. Indications. Should be performed

1. On every patient presenting with vaginal symptoms or with clinical features suggestive of a cervical or vaginal condition.

2. Even if the diagnosis is clinically obvious (such as with a curdlike discharge associated with candidiasis), because many conditions can mimic other conditions.

3. In a patient with a urine sediment that contains white cells and many squamous epithelial cells to determine the exact source of infection (vagina or urinary tract).

BOX 8-1

The Five Conditions Causing the Majority of Vaginal Discharge or Infection (in Order)

Bacterial vaginoses

Candida vulvovaginitis

Cervicitis (usually caused by Chlamydia)

Excessive but normal secretions

Trichomonas vaginitis

4. To determine the reason a routine Pap smear shows an inflammatory response.

5. As a follow-up test in a woman after treatment for a vaginal or cervical infection.

6. During the routine health maintenance visit to assess for normal flora or asymptomatic vaginal infection.

7. A thorough and comprehensive health history is necessary to establish a differential diagnosis (Box 8-2). Table 8-1 presents the differential diagnoses.

II. Comments on the vaginal ecology.

A. The vagina has minimal nerve endings; therefore, the symptoms of vaginal disorders may become evident only when the vaginal discharge bathes and irritates the sensitive vulvar skin.

B. Normally, the vagina cleanses itself by the discharge of acidotic se cretions.

C. The pH is acidotic, at 3.8 to 4.2.

1. Organisms live symbiotically in an acid environment.

a. Factors that increase the glycogen content (high levels of estrogen in pregnancy or medication) increase the acidity of the vaginal secretions.

b. Glycogen present in the epithelial cells is used by the peroxide-producing lactobacilli to produce lactic acid, which maintains an acid environment.

c. Acidity allows for the overgrowth of the yeast organisms.

2. This level of acidotic secretions is antagonistic to harmful bacterial organisms.

D. Factors affecting normal vaginal flora.

1. Role of hormones.

a. Estrogen.

(1) Affects vaginal epithelium.

(2) Causes glycogen to be deposited in the vagina, mainly in the intermediate cells.

(3) Glycogen is metabolized to become lactic acid.

|BOX 8-2 |

|Key History-Taking Questions ami Considerations |

|History and chronology |Sexual history |

|Onset of symptoms |Age of first sexual experience |

|Duration of current episode |Lifelong number of partners, gender(s), |

|Date, diagnosis, treatment, and |Ages |

|response of previous infection |STD exposure |

|Self-diagnosis and treatment |Current sexual partner, duration of |

|Monthly or seasonal variation |relationship, other partners |

|Impact on lifestyle |Partner history of STD, GU symptoms, |

|Evolution of chronicity |Circumcision |

|Sentinel events |Sexual practices (i.e., anal inter- |

|History of IV drug use |course, oral sex, order of activities, |

|Blood transfusion |hygiene) |

|Symptoms |Condom use |

|Description (use patient’s own |Sexual devices or toys |

|words) |Lubricants (specify brand) |

|Location (use patient guided |Date of last coitus or genital |

|Drawing) |contact |

|Radiation |Dyspareunia (superficial, deep; be- |

|Severity (use a rating scale of 0 to 3+) |fore, during, or after penetration) |

|Full review of systems |Obstetric and gynecologic factors |

|Aggravating factors |Last menstrual period |

|Allergies |Duration of menses |

|Activities |Tampons versus pads |

|Positions |Dysmenorrhea or dysfunctional |

|Dietary |bleeding |

|Self treatments |Pregnancy, birth, episiotomy, |

|Prescription and OTC medications |acerations |

|Clothing |Pain in pregnancy |

|Sexual activities |Infertility |

|Relieving factors |Pelvic or genital surgeries |

|Vulvar care measures |Pap smear history |

|Prescription and OTC medications |Vulvar care |

|Alternative or home remedies | |

|Stress reduction measures | |

|Vitamins, supplements, and diet | |

|GU, genitourinary; IV, intravenous; OTC, over the counter; STD, sexually transmitted disease. |

|Secor, Mi. (1997). Diagnosis and treatment of chronic vulvovaginitis. The Clinical Letter for |

|Nurse Practitioners, 1(3). |

|TABLE 8-1 Differential Diagnosis of Vaginal Conditions |

|Condition |Vulvovaginal Symptoms |Vaginal Discharge|Lactobacilli|PH |Microscopy |

|Candida |Mild to severe itching |Increased amount |Moderate |5 |Saline |

| |Petechiae of cervix and |Yellow-green May| | |Unicellar |

| |vagina Vulvar erythema |be frothy | | |trichomonads |

| | |Malodorous | | |Many WBCs |

|Atrophic |Pruritus, irritation |Red, tender |Rare |>5-6 |Saline |

|vaginitis |Vaginal dryness and |vestibule | | |Parabasal cells |

| |dyspareunia Smooth |and vagina Scant| | |Few to many WBCs |

| |vaginal walls |discharge Lack | | | |

| | |of rugae | | | |

|Desquamative |Petechiae of vulva, |Thick, profuse |Rare |20 WBC/hpf |>10:1 to TNTC |

|hpf, high-power field; TNTC, too numerous to count. |

|Note: May be influenced by the concentration of the smear. |

|If inflammation is present, observe for the presence or absence of parabasal cells. |

BOX 8-4

Causes of the Presence of Leukocytes (White Blood Cells) on Wet Mount

Moderate increase of leukocytes found with

IUD use

Postpartum reparative process

Atrophic vaginitis

Allergic reaction to spermicides and douches (may also see eosinophils)

Depo-Provera users with low estrogen levels

Marked increase of leukocytes found with

Trichomoniasis

Candidiasis

Chlamydia or gonorrhea

Atrophic vaginitis with bacterial superinfection

Hint: If many leukocytes are seen but neither Candida nor Trichomonas are present, consider a cervical culture for infections such as chlamydia or gonorrhea. Must also consider dysplasia or metaplasia as a possible cause.

C. Normal findings include

1. Absence of or ................
................

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