Guidelines 2016 – Vaginal Discharge With Odor Workup
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Vaginal discharge with or without a distinctive odor may result from vaginitis or vaginosis. Discharge may also be caused by cervicitis (see Cervical Aberrations, Chapter 10).
A. Vaginitis: Inflammation of the vagina, characterized by increased vag- inal discharge containing many WBCs
B. Vaginosis: Characterized by increased discharge without inflammatory cells (WBCs)
II. ETIOLOGY
A. Foreign body (e.g., forgotten tampon, retained cap, condom, or diaphragm)
B. Allergy to soap or feminine hygiene spray
C. Deodorants
D. Scented toilet tissue; scented or deodorant menstrual products
E. Vaginal contamination through oral or rectal intercourse
F. Poor personal hygiene
G. Sensitivity to contraceptive spermicides or lubricants
H. Condom allergy (Hint: If the woman is allergic to latex, then use latex condom with animal skin or polyurethane condom rather than latex condom; if the man is allergic to latex, use animal skin condom or polyurethane with a latex condom rather than animal skin or polyurethane condom.)
I. Presence of a pathogen
III. HISTORY
A. What the patient may present with
1. Vaginal discharge; may be chronic
2. Vaginal odor
3. Vulvar/vaginal irritation, pruritus, and/or burning made worse by urination, intercourse
4. Postcoital bleeding
5. Difficulty urinating or pain with urination
CHECKLIST FOR VAGINAL DISCHARGE WITH ODOR WORKUP 269
B. Additional information to be considered
1. Relationship of discharge to birth control method; any recently discontinued method
2. Relationship of discharge to sexual contact: recency, partner affected, recent change in partners
3. Relationship of discharge to personal hygiene: any recent change in hygiene products or toiletries, douching
4. Any history of vaginal infection associated with STI or pelvic inflammatory disease (PID)
5. History of
a. Previous infection or STI
b. Chronic cervicitis
c. Cervical surgery
d. Abnormal Pap smear; positive test for HPV
e. Diethylstilbestrol (DES) exposure
6. Description of discharge
a. Color
b. Onset
c. Odor
d. Consistency
e. Constant versus intermittent
f. Color of discharge on underwear; changes
IV. PHYSICAL EXAMINATION
A. External examination: external genitalia
1. Erythema
2. Excoriations
3. Lesions
4. Edema
B. Vaginal examination (speculum)
1. Presence of foreign body
2. Erythema and edema of the vaginal vault
3. Inspection of cervix
a. Erythema
b. Erosion
c. Severe physiologic ectropion
d. Friability
e. Serous sanguineous discharge
f. Lesions
C. Bimanual examination if indicated
V. LABORATORY EXAMINATION
A. As indicated by findings
1. Wet saline prep; KOH slide
2. Gram stain
3. Gonorrhea culture if indicated
4. Chlamydia test if indicated
5. Urinalysis if indicated
6. Herpes culture if indicated
7. Cervical culture
8. pH with nitrazine paper, Affirm VPIII, QuickVue Advance pH and Amines Test, QuickVue Advance Gardnerellavaginalis Test
9. HIV testing
VI. DIFFERENTIAL DIAGNOSIS
A. Normal physiologic discharge
B. DES exposure
C. Chlamydia
D. Neisseria gonorrhoeae
E. C. albicans or other Candida infection; BV
F. Urinary tract infection
G. Condylomata
H. Herpes simplex
I. Contact dermatitis
J. Tinea or other fungus
K. Cervicitis symptomatic for Chlamydia infection, gonorrhea, trichomoniasis, genital herpes
VII. TREATMENT
A. General measures
1. Removal of causative factor
2. Education about
a. Personal hygiene
b. Avoidance through the use of alternatives to causative factors
B. Medications
1. No treatment, depending on evaluation of clinical data
2. If a pathogen is identified, treat through appropriate protocol
3. If after 1 week of no treatment, try Aci-Jel to restore and maintain normal vaginal acidity, one applicatorful intravaginally at bedtime for 7 to 14 days or until tube is used up
VIII. COMPLICATIONS
Abnormal Pap smear resulting from continuing irritation, reparative process
IX. CONSULTATION/REFERRAL
In case of unresolved symptomatology
X. FOLLOW-UP
A. One week if indicated, then as needed
B. If no improvement at 1 week after treatment of Aci-Jel, refer to a physician
See Appendix I and Bibliographies.