Guidelines 2016 – Vaginal Discharge Workup
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. SUBJECTIVE DATA
A. Social history
1. Age
2. Occupation
3. Partner status
a. Frequency of sexual contact
b. Last sexual act and type
c. Age of first sexual experience with a partner
4. Pregnancy history, including elective or spontaneous abortion
5. Sexual preference
6. Number of sexual partners over lifetime, known partner history, history of new partner(s) within past month
7. Documented sexually transmitted infection (STI) history, includ- ing HIV status
8. Recent weight change
B. Previous gynecologic surgery, including surgical abortion, tubal ligation, dilation and curettage (D&C), cesarean section, cone biopsy, loop electrosurgical excision procedure (LEEP)
C. Past or current medical illness; chronic diseases
D. Family history of diabetes, personal history of type 1 or type 2
E. Diet; alcohol; cigarettes, including electronic; recent change in habits; use of street drugs, including injectables, inhalants; use of sex toys, stimulants, genital jewelry—self and partner(s)
F. Medications (past and present); recent antibiotics; use of vaginal medications (over the counter [OTC] and prescription)
G. Past history of similar problems
1. Dates
2. Treatment
3. Follow-up
H. Vaginal discharge
1. Onset
2. Color
3. Odor
4. Consistency
5. Amount
6. Constant versus intermittent
7. Related to sexual contact
8. Relationship to menses
9. Relation to other life events
10. Wears pads, tampons, menstrual cup
I. Pap history: last Pap smear, any history of abnormal Pap smears, any interventions
J. Human papillomavirus (HPV) vaccine, testing
K. Sores anywhere on the body; rashes
L. Genital itching, swelling, or burning; genital sores or tears
M. Abdominal and/or pelvic pain
N. Fever, chills
O. Achy joints
P. Nausea and vomiting; diarrhea
Q. Dyspareunia
R. Known contact with STI; HIV/AIDS risk (see Appendix D for AIDS risk assessment tool)
S. Birth control (including recent changes in method or products used previously and currently)
1. Hormonal contraception, vaginal ring, patch, implant, intrauterine device (IUD), pills; type and length of use
2. IUD: type, how long in place
3. Diaphragm; cervical cap; FemCap
4. Depo-Provera
5. Implant
6. Condom (male or female); foam, jelly, gel, cream, vaginal film, tablets, suppositories, gels, sponge
7. Tubal ligation; occlusion
T. History of douching; use of soaps, chemicals
U. Personal hygiene
1. Use of feminine hygiene sprays or deodorant tampons, panty liners, or pads
2. Poor personal hygiene
V. Clothing: consistent wearing of tight-crotched pants; type of underwear; panty hose; panty hose under slacks or jeans
W. Last menstrual period (LMP); last normal menstrual period
X. Urinary problems
1. Frequency
2. Dysuria
3. Urgency
4. Hematuria: other debris in urine
5. Odor
6. Dark or cloudy urine; color
Y. Allergies to drugs: reactions
Z. Partner(s) problems, symptoms
II. OBJECTIVE DATA
A. Vital signs: blood pressure, pulse, respiration, temperature
B. Inguinal lymph nodes
C. Abdominal examination: rebound, bowel sounds, suprapubic tenderness, masses, organomegaly, enlarged bladder, costovertebral angle (CVA) tenderness
D. External genitalia: Bartholin’s glands, Skene’s glands, sores, rash, genital warts, swollen and reddened urethra, urethral discharge; lesions on labia, between labial folds; signs of scratching
E. Vaginal examination (speculum)
1. Inspection of vaginal walls, vaginal lesions, tears, discharge
2. Inspection of cervix: friability, ectropion, cervical erosion, discharge from os, cervical tenderness; color
3. Discharge: if present, characteristically is thick, mucus at cervical os, difficult to remove
F. Bimanual examination: pain on cervical motion, fullness or pain in adnexa, tenderness of uterus, size and shape of uterus
III. ASSESSMENT AND PLAN
A. Normal discharge: usually clear or white, nonirritating or nonpruritic, pH is 3.8 to 4.2, does not pool, has body, can write initials in it
B. Diagnosis
1. Wet prep will be negative.
2. Gram stain will be negative.
3. pH within normal range
4. Card test for elevated pH and trimethylamine and for proline amino-peptidase (e.g., FemExam pH and Amines TestCard, FemExam Gardnerella vaginalis Proline Imino-Peptidase [PIP] Activity TestCard)
C. Treatment: none required
D. Patient education
1. Reassurance
2. If clinical and/or laboratory findings are not within normal limits, refer to protocol for suspected organism(s) for further workup.
IV. HINTS ON PREPARATION OF A WET SMEAR1
A. Collect a copious amount of vaginal discharge from the lateral walls with a wooden Pap spatula (some recommend a cotton swab moist- ened with saline); repeat so you have two samples to work with.
B. Place a drop of the specimen mixture at each end of a clean glass slide, or on two separate slides, when you are ready to read the slides; or place a drop of saline on one slide and a drop of potassium hydroxide (KOH) on the second slide before collecting specimens; place in cardboard slide holders if available.
C. Add a drop of KOH2 (10%) to one specimen or stir one specimen into the KOH on the slide and sniff immediately for the characteristic “fishy” odor of bacterial vaginosis (BV; positive whiff test).
D. Cover both specimens with coverslips once you reach the microscope. Plan to view the plain saline specimen first to allow time for the KOH to lyse cells prior to looking for Candida, noting that Candida torulopsis does not have the same characteristics as Candida albicans, so KOH will
be negative. If you suspect Trichomonas, you may want to examine the slide without a coverslip because the slip can sometimes immobilize the organism. Warming the slide will also increase the possibility of seeing trichomonads.
E. With the ×10 objective in place on the microscope, the light on low power, and the condenser in the lowest position, place the slide on the stage and lower the objective until it is as close to the slide as possible.
F. Adjust the eyepieces until a single, round field is seen. Turn the coarse focus knob until the specimen is focused. Use the fine focus knob to bring the specimen into sharp focus.
G. Be sure to use subdued light and a lowered condenser for a wet specimen. Try increasing the light and raising the condenser while viewing the specimen to see how the cells and bacteria disappear from view.
H. Move the slide until you have a general impression of the number of squamous cells. Switch to high power (×40); it may be necessary to increase the amount of light slightly.
I. Evaluate the slide for bacteria, white blood cells (WBCs), clue cells, trichomonads, hyphae, and yeast buds. Even if one organism is identified, continue to scan the slide systematically to fully evaluate the specimen. Vaginitis/vaginosis may have multiple causes.
J. Move the KOH slide into position; switch back to low power to scan the slide for Candida. If hyphae are noted, switch to high power to confirm the impression.
K. Be sure to wipe spilled fluid from the stage. If the objective becomes contaminated, clean it only with special lens paper.
L. To perform Gram staining:
1. Spread a thin smear of the specimen on a glass slide. Air dry the slide completely or dry it carefully high above a flame.
2. After the specimen is dry, fix it by passing it through a flame several times (with the specimen side away from the flame). Allow it to cool completely; otherwise, the reagents used in the staining process may precipitate on the slide.
3. Flood the slide with Gram crystal violet. Wait 10 seconds and then rinse with tap water.
4. Flood the slide with Gram iodine. Wait 10 seconds and then rinse with tap water.
5. Wash the slide with decolorizer just until the fluid dripping from the slide changes from blue to colorless and then immediately rinse the slide with tap water. This step is crucial to ensure correct decolorizing.
6. Flood the slide with Gram sufranin. Wait 10 seconds and then rinse the slide with tap water.
7. Allow the slide to air dry or blot dry. Place the slide on the microscope stage and put a small drop of oil on the stained specimen. With the oil power objective in place, the condenser tip and the diaphragm open (for bright-field illumination), focus and examine several fields on the slide.
8. When finished, remove the oil from the lens with lens paper.
Appendix I contains information on vaginal discharge to copy or adapt for your patients.
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