A slide for microscopy is prepared by mixing a sample

of discharge with 1-2 drops of normal saline and then

applying a coverslip. Vaginal secretions may also be

prepared with l Oo/o potassium hydroxide (KOH), often

producing a fishy odor, or positive whiff test, which may

provide evidence for a diagnosis (Table 44-l).

During the speculum exam, endocervical cultures

should be obtained by placing a swab l em into the cervix

and rotating it. DNA probe swabs have a high sensitivity

and specificity for both gonorrhea and chlamydia; however, the results of these tests are not immediately available

in the ED.

In patients with abdominal pain or toxic appearance,

blood tests may be helpful. An elevated white blood cell

(WBC) count, erythrocyte sedimentation rate (ESR), or

C-reactive protein (CRP) can support the diagnosis of

PID. Urinalysis should be part of the laboratory e valuation;

VAGINAL DISCHARGE

Table 44-1. Distinguishing ca uses of vagin itis.

however, a positive urinalysis finding does not exclude PID,

as inflammation in the pelvis can produce WBCs in the

urine. Testing for other STis such as human immunodeficiency virus, hepatitis, and syphilis may also be warranted.

Frequency

Discharge color

Quantity

pH (normal �4.5)

Amine/fishy odor

(discharge +

KOH prep)

Microscopy

(discharge +

normal saline

drops)

Treatment

Bacterial

Vaginosis

40-501\'o

Gray, white

Moderate

2:4.5

Positive

Clue cells

(epithelial

cells with

adherent

bacteria)

Metronidazole

500 mg BID

x 7 days

Candidiasis

20-25%

White, clumped

Scant to moderate

�4.5

Negative

Mycelia or

hyphae

with KOH

Fluconazole

1 50 mg x

1 dose

Vulvovaginal

discomfort

No cervical findings,

abdominal pain, CMT,

dnexal tenderness, or

History and microscopy

to determine between

infectious (BV, candida,

trichomonas), atrophic,

and chemical

Trichomonas

1 5-20%

Gray, greenyellow

Profuse

2:5

usually positive

Moti le trichomonads

Metronidazole

2g x 1 dose

OR

Metronidazole

500 mg BID X

?days

...,._ Imaging

Imaging may improve the accuracy of PID diagnosis.

Transvaginal pelvic ultrasound demonstrates thickened,

fluid-filled fallopian tubes or pelvic free fluid in severe PID.

Complex adnexal masses signifying tubo-ovarian abscesses

are seen on ultrasound as well. Abdominopelvic computed

tomography (CT) scans can also be used for patients with

toxic appearance, pain, and suspicion of tubo-ovarian

abscess. CT findings in PID include cervicitis, oophoritis,

salpingitis, thickening of uterosacral ligaments, simple or

complex pelvic fluid, or abscess collections.

MEDICAL DECISION MAKING

In patients presenting with vaginal discharge, use the history and pelvic exam to determine the cause (Figure 44-2).

Patients presenting with vulvovaginal discomfort, without

evidence of cervicitis on pelvic exam or concern for STI,

can be treated for vaginitis. The cause of vaginitis can be

determined based on historical factors as well as composition of vaginal discharge. If there is evidence of cervical

Vaginal discharge

History, exam, GU cultures, and

urine pregna ncy test

Cervical discharge and

erythema

No abdominal

pain/tenderness, CMT,

or toxic appearance

Cervi(itis

Figure 44-2. Vaginal discharge diagnostic algorithm. BV, bacterial vaginosis; CMT,

Cervical motion tenderness; GU, genitourinary.

CHAPTER 44

Table 44-2. Treatment of cervicitis: Treat for both

gonorrhea and chlamydia.

Gonorrhea

Chlamydia

First line

Ceftriaxone 250 mg IM

OR

Cefixime 400 mg PO

Azithromycin 1 g PO

Alternate

Cefpodoxime 400 mg PO

OR

Azithromycin 2 g PO

Doxycycline 1 00 mg PO

BID X 7 days

discharge or erythema without abdominal tenderness or

toxic appearance, the patient should be treated for cervicitis. It is important to rule out PID in these patients. Given

the difficulty of diagnosis and potential complications, the

20 10 Centers for Disease Control and Prevention guidelines recommend that providers maintain a low threshold

to treat PID. Empiric treatment for PID should be initiated

in sexually active young women and other women at risk

for STis if they are experiencing pelvic or lower abdominal

pain, if no other cause of pain can be identified, and if one

or more of the following minimum criteria are present on

pelvic exam: CMT, adnexal tenderness, or uterine tenderness.