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  Vaginal discharge is a common presenting complaint in reproductive-age women.

  
  
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  Possible diagnoses include vaginitis, cervicitis, or pelvic inflammatory disease (PID).

  
  
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  Clinical evaluation for the diagnosis of PID is not sensitive. Maintain a high suspicion and low threshold to treat.

Many women come to the emergency department (ED) with the chief complaint of vaginal discharge. It may be accompanied by other symptoms such as fever, abdominal or pelvic pain, malodor, itching, and dysuria. Vaginal discharge is usually due to vaginitis, cervicitis, or pelvic inflammatory disease (PID).

Vaginitis is a spectrum of diseases causing vulvovaginal symptoms including burning, irritation, and itching, with or without vaginal discharge. Normal vaginal flora maintains the vaginal pH at 3.8–4.5. Changes in the pH or disruption of the vaginal flora may result in the overgrowth of pathogenic organisms, ultimately resulting in a change in the appearance, consistency, or odor of vaginal secretions. Noninfectious causes like atrophy and contact vaginitis are fairly common—particularly in sexually inactive and postmenopausal women. The most common infectious causes of vaginitis in descending order of frequency include bacterial vaginosis (BV), vaginal candidiasis, and trichomonas vaginitis. BV is caused by a pathologic overgrowth of normal vaginal flora—Gardnerella vaginalis.

Infections of the upper reproductive tract (cervix, uterus, fallopian tubes, adnexa) will also cause discharge. Cervicitis is the term used when infection is present within the cervix only. Pelvic inflammatory disease (PID) is a spectrum of upper genital tract infections that includes endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis, are implicated in the majority of cases of both cervicitis and PID; however, other organisms (Gardnerella vaginalis, Haemophilus influenza, anaerobic and gram-negative bacteria, and Streptococcus agalactia) are also causative. PID affects 11% of women of reproductive age and requires hospital admission in 20%. Inflammation and infection can lead to scarring and adhesions within the fallopian tubes, leading to major long-term sequelae including infertility, ectopic pregnancy, and chronic pelvic pain. The risk of ectopic pregnancy is 12–15% higher in women who have had PID. Tubal factor infertility is increased 12–50% in women with a past diagnosis of PID. Prevention of complications is dependent on early recognition and effective treatment.

History

Any complaint of vaginal discharge or pelvic pain requires a detailed gynecologic history. Inquire about history of sexually transmitted infections (STIs), intrauterine device use, pregnancies, last menstrual period, and any previous gynecologic procedure. History should include details of vaginal discharge, odor, irritation, itching, burning, bleeding, dysuria, and dyspareunia. In addition, determine the presence of abdominal pain, nausea, vomiting, fevers, rash, or joint aches.

Patients with vaginitis lack significant abdominal pain or fevers and do not appear systemically ill. BV typically presents with thin, whitish gray discharge that has a fishy smell. In candidiasis, pruritus is the most common and specific symptom; discharge tends to be white and occasionally thick and “cottage-cheese” like. It is important to ask about risk factors for candidal colonization: uncontrolled diabetes mellitus, recent antibiotic use, immunosuppression, and pregnancy. Patients with trichomonas vaginitis (a sexually transmitted protozoan parasite) are asymptomatic in 50% of cases, but the classic discharge is described as yellow, frothy and malodorous.

Vaginal atrophy is present in 60% of women 4 years after menopause. Symptoms of atrophic vaginitis include vaginal dryness, soreness, itching and occasional thin, scant, yellowish discharge.

Acute PID can be difficult to diagnose because of the wide variation in symptoms and signs. The most common presenting symptom is lower abdominal pain that tends to be bilateral, dull or crampy. Approximately 75% of patients with PID have abnormal vaginal discharge. Unilateral pain should raise suspicion for a tubo-ovarian abscess or an alternate diagnosis like appendicitis. Dyspareunia may be present as well as urinary tract symptoms. Only one third of patients with PID will have fever >100.4° F.

Physical Examination

Obtain the patient’s vital signs, particularly noting blood pressure, pulse, and temperature. Before performing a pelvic exam, perform a focused general exam, including the abdomen and flank. During the pelvic exam, inspect the external genitalia. Make note of vulvar edema or erythema, which can be a sign of vaginitis. On the speculum exam, determine the presence of blood or discharge in the vaginal vault. Visualize the cervix, looking for inflammation, foreign body, and discharge originating from the os. Mucopurulent cervicitis is a common finding in both cervicitis and PID (Figure 44-1). On bimanual exam it is important to note cervical motion tenderness (CMT) as well as adnexal fullness or tenderness. CMT, also referred to as the chandelier sign, is elicited by moving the cervix up and down or laterally with the index and middle finger. This causes movement of the uterus and tubes, which will significantly reproduce pain in patients with PID. CMT is sensitive but lacks specificity, as it can be positive in patients with other sources of inflammation (appendicitis, ruptured cysts, or ectopic pregnancy). Adnexal tenderness appears to be the most sensitive finding (95%) for PID.