Int J STD AIDS 2008;19:859-860
doi:10.1258/ijsa.2008.008212
© 2008 Royal Society of Medicine Press
Is vaginal microscopy an essential tool for the management of women presenting with vaginal discharge?
R M Lascar MD MRCP * ,
H Devakumar MBBS 
,
E Jungmann FRCP MSc ,
A Copas PhD 
,
G Arthur MD MRCP and
D Mercey FRCP *
* The Mortimer Market Centre, Department of Genito-Urinary Medicine, Camden PCT;
Archway Sexual Health Clinic, Camden PCT;
Centre for Sexual Health and HIV Research, University College London, London, UK
Correspondence to: Dr R Monica Lascar, The Mortimer Market Centre, Camden PCT, London WC1H 6AU, UK Email: monix{at}doctors.net.uk
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Summary
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Point-of-care microscopy is the gold standard for the diagnosis
of vaginal discharge in genitourinary (GU) medicine clinics
but not used in primary care settings and reproductive health
clinics to which many patients present. In our GU medicine clinic
setting, we conducted an audit to assess the utility of microscopy
of vaginal secretions versus clinical diagnosis alone for the
differential diagnosis of uncomplicated lower vaginal infections.
Clinical diagnosis (including pH) of bacterial vaginosis had
a sensitivity between 85% and 88% at two clinic sites. Our results
suggest that it may be safe and more cost-effective to restrict
vaginal microscopy to a subgroup of women presenting with vaginal
discharge.
Key Words: diagnosis • women • microscopy • lower vaginal infections
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INTRODUCTION
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Vulvo-vaginal candidiasis (VVC) and bacterial vaginosis (BV)
alone represent 35% of diagnoses made in women attending genitourinary
(GU) medicine clinics.
1 Given the current recommendations to
provide an integrated contraception and GU medicine service
2 alongside pressure to increase capacity and tackle the increasing
rates of sexually transmitted infections (STIs), we investigated
the usefulness of point-of-care microscopy in the management
of women presenting with uncomplicated vaginal discharge.
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METHODS
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We conducted a prospective audit in two central London GU medicine
clinics (Clinic 1 and Clinic 2) over a three-month period. All
women presenting with uncomplicated vaginal discharge who were
offered investigations according to clinical protocol were enrolled.
This includes microscopy of vaginal secretions, Gram stain and
wet-mount microscopy, pH measurement, culture for
Candida species
and
Trichomonas vaginalis (TV).
During the study period, the attending clinician (doctor or specialist nurse) recorded a ‘best judgement’ clinical diagnosis based on history, examination and vaginal pH measurement before receiving microscopy results.
For BV, we defined as gold standard, the presence of three out of four Amsel criteria3 (vaginal discharge, pH > 4.5 and clue cells on Gram stain) and as ‘best judgement’ clinical diagnosis the presence of abnormal vaginal discharge together with pH > 4.5. For VVC, we defined as microscopy gold standard the presence of hyphae or spores on Gram stain of vaginal secretions and as best judgement clinical diagnosis the presence of thick white discharge and vulvo-vaginitis. These data were used to calculate the sensitivity and specificity of clinical diagnosis alone versus combined clinical diagnosis and same-day microscopy for each condition in both the clinics. A more detailed analysis of all BV clinical diagnoses including notes review was carried out in Clinic 1. Owing to time constraints this was not possible in Clinic 2.
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RESULTS
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We analysed 391 patients attending the clinic with vaginal discharge
(280 in Clinic 1 and 111 in Clinic 2). Patients were excluded
from analysis for BV if pH was not recorded, leaving 349 (89%)
patients, with 241 (86%) in Clinic 1 and 108 (97%) in Clinic
2. The prevalence of BV by gold standard criteria was 21% (50/241)
in Clinic 1 and 16% (17/108) in Clinic 2 and VVC prevalence
was 15% in Clinic 1 (41/280) and 13% in Clinic 2 (14/111). TV
prevalence was 1.4% (4/280) in Clinic 1 and 6.3% (7/111) in
Clinic 2.
Table 1 shows sensitivities and specificities of best clinical diagnosis for diagnosing BV and candida together with the rates of missed diagnosis in both clinics.
Further analysis of 72 women with a clinical diagnosis of BV
in Clinic 1 showed that microscopy was negative for clue cells
in 28 patients, but 19 of them had mixed flora (of which 11
patients were treated as BV) and three of 28 were TV-positive.
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DISCUSSION
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There is good evidence that vaginal pH is the most sensitive
single criterion for diagnosing BV
4 and some data have suggested
that using two clinical criteria (pH and amine test) does not
lead to loss of sensitivity or specificity for BV diagnosis.
5 Our data shows reasonable rates of sensitivity and specificity
for best judgement clinical diagnosis of BV in two clinical
settings with similar BV prevalence. We also found that negative
microscopy results may not change the clinician's treatment
decision (data not shown). Candida results were more difficult
to interpret, given that VVC may represent simple carriage or
disease and often clinical symptoms/signs are in fact due to
other conditions,
6 but clinical diagnosis can always be compared
with culture results.
Of the four TV cases in Clinic 1, three were given a BV clinical diagnosis and treated with metronidazole.
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CONCLUSION
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Our findings suggest that microscopy may add little to the clinical
diagnosis of vaginal discharge, especially in a setting with
low TV prevalence where pH is measured consistently. We do not
wish to suggest that microscopy be replaced by clinical judgement
alone. However, considerable time and money could be saved by
restricting microscopy to certain groups, such as patients presenting
with unclear history, or with recurrent or un-resolving symptoms.
(Accepted May 26, 2008)
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REFERENCES
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- de Souza-Thomas L, Dougan S, Emmett L, James L. HIV and other sexually transmitted infections in the United Kingdom: an update 2005. Euro Surveill 2005;10:E051222 5
- Adler MW, French P, McNab A, Smith C, Wellsteed S. The national strategy for sexual health and HIV: implications for genitourinary medicine. Sex Transm Infect 2002;78:83–6[Abstract/Free Full Text]
- Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med 1983;74:14–22[Medline]
- Eschenbach DA, Hillier S, Critchlow C, Stevens C, DeRouen T, Holmes KK. Diagnosis and clinical manifestations of bacterial vaginosis. Am J Obstet Gynecol 1988;158:819–28[Medline]
- Gutman RE, Peipert JF, Weitzen S, Blume J. Evaluation of clinical methods for diagnosing bacterial vaginosis. Obstet Gynecol 2005;105:551–6[Medline]
- White DJ, Vanthuyne A. Vulvovaginal candidiasis. Sex Transm Infect 2006;82:iv28–30[Free Full Text]
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Summary
INTRODUCTION
