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

Setting: Outpatient (any)

Study Design: Systematic review

Synopsis: The three major causes of vaginitis are vaginal candidiasis, bacterial vaginosis, and trichomoniasis. Investigators thoroughly searched MEDLINE and the bibliographies of recent reviews. They also contacted the 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/testwitharecognizedreference 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 studies received a score of 2 (from 1 = best to 3 = worst) and three studies received a score of 3. Symptoms useful in the diagnosis included a lack of itching (making candidiasis less likely; negative likelihood ratio [LR–] = 0.18 to 0.79) and a lack of perceived odor (making bacterial vaginosis unlikely; LR– = 0.07). Useful signs on physical examination were limited.

Findings predictive of candidiasis included the presence of inflammation (e.g., erythema, edema, excoriations; positive likelihood ratio [LR+] = 2.1 to 8.4) and a lack of odor (LR+ = 2.9). The presence of a strong “cheese” odor was predictive of bacterial vaginosis (LR+ = 3.2). The whiff test (a fishy odor from the slide after potassium hydroxide is applied) 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 patients with candidiasis and bacterial vaginosis. In the absence of trichomonads, it is important to consider other causes, such as gonorrhea or chylamydia.

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