The classic approach to diagnosis of vulvovaginitis:a critical analysis

Jacob Bornstein1, Yaniv Lakovsky1, Idit Lavi2, Amiram Bar-Am3

and Haim Abramovici1

1Department of Obstetrics and Gynecology, and 2Department of Community Medicine and Epidemiology,Carmel Medical Center and the Rappaport Faculty of Medicine, Hatechnion University, Haifa, Israel

3Department of Obstetrics and Gynecology, Lis Maternity Hospital and the Sackler Faculty of Medicine,Tel Aviv University, Tel Aviv, Israel

Objective: To correlate the symptoms, signs and clinical diagnosis in women with vaginal discharge, based on thecombined weight of the character of the vaginal discharge and bedside tests, with the laboratory diagnosis.Methods: Women presenting consecutively to the women’s health center with vaginal discharge wereinterviewed and examined for assessment of the quantity and color of the discharge. One drop of the materialwas then examined for pH and the whiff test was done; a wet mount in saline and in 10% KOH was examinedmicroscopically. The clinical diagnosis was based on the results of these assessments. Gram stain and cultures ofthe discharge were sent to the microbiology laboratory.Results: One hundred and fifty-three women with vaginal discharge with a clinical diagnosis of vulvovaginitis partic-ipated in the study. Fifty-five (35.9%) had normal flora and the other 98 (64.1%) had true infectious vulvovaginitis(k agreement = 18%). According to the laboratory, the principal infectious micro-organism causing the vulvo-vaginitis was Candida species. Candida infection was associated with pH levels of less than 4.5 (p < 0.0001, oddsratio = 4.74, 95% confidence interval: 2.35–9.5, positive predictive value 68.4%). The whiff test was positive inonly a small percentage of bacterial vaginosis (BV) (p = not significant (NS)). Clue cells were documented in 53.3%of patients with a laboratory diagnosis of BV (p < 0.02, positive predictive value 26.7%).Conclusions: The current approach to the diagnosis of vulvovaginitis should be further studied. The classical andtime-consuming assessments were shown not to be reliable diagnostic measures.

Key words: VULVOVAGINITIS, CANDIDA, BACTERIAL VAGINOSIS, TRICHOMONAS VAGINALIS

The diagnosis of vulvovaginitis (VV) has beena matter of controversy. Many texts warn thepracticing gynecologist to avoid diagnosing VVbased exclusively on the patient’s presentingsymptoms of vaginal discharge with or withoutpruritus or on speculum examination, but ratherto rely on the ‘bedside’ tests – pH, whiff test andwet mount microscopy1–3. However, in practice

many gynecologists make the diagnosis of VVwithout resorting to any of the recommendedtests. Another controversy surrounds the questionof whether a culture of the discharge is obligatoryin order to diagnose VV. Culture is considered the‘gold standard’ in the diagnosis of vulvovaginalcandidiasis (VVC)2,4 and for Trichomonas vaginalisvaginitis5. While some authors are convinced that

Infect Dis Obstet Gynecol 2001;9:105–111

Correspondence to: Jacob Bornstein, MD, Department of Obstetrics and Gynecology, Carmel Medical Center, 7 Michal Street,Haifa 34362, Israel. E-mail: mdjacb@tx.technion.ac.il

Clinical study 105

in most cases the bedside tests are sufficient todiagnose all types of VV, others advocate perform-ing a culture in most cases in order to make theproper diagnosis4,5. But is that necessarily so? Arethe bedside tests sensitive and specific, or are they awaste of money and time? Is culture necessary orredundant?

The present study correlates each of thesymptoms and signs seen in women with vaginaldischarge, as well as the clinical diagnosis whichwas based on the combined weight of the symp-toms and findings, with the laboratory diagnosis,i.e. the culture result or the Gram stain finding.

SUBJECTS AND METHODSConsecutive women presenting to the women’shealth center between January 1993 and Decem-ber 1998, in a medium-income suburb, withtroublesome vaginal discharge, with or withoutvulvar pruritus or abnormal odor, were consideredfor enrollment to the study. Only those who hadnot received treatment for vaginitis during theprevious month were enrolled. All data weredocumented on a special form. The local andnational Helsinki review boards approved thestudy and informed consent was obtained frompatients appropriate for enrollment to the study.Initially the physician questioned the womanabout the symptoms of vaginitis, then examinedher for assessment of the quantity and color of thevaginal discharge. A drop of the discharge was thenexamined for pH, and a whiff test was done. Thiswas followed by microscopic examination of a wetmount, prepared by immersing one drop of dis-charge in normal saline and one drop in 10% KOHsolution. Based on the results of these tests a clinicaldiagnosis was established (Table 1). A Gram stain

of the discharge was sent to the microbiologicallaboratory for interpretation, and cultures of thedischarge taken. Definitive isolation of Candidastrains was also available. The vaginal dischargewas cultured on (1) blood agar base + 5% humanblood; (2) McKonkey agar for isolation and defini-tion of Candida species; (3) immediate culture intoa glass tube containing modified Diamond agar6,for isolation of Trichomonas. An endocervical smearwas obtained for the detection of gonorrhea onThayer Martin chocolate agar and, in a differenttube, for the detection of Chlamydia by the Gen-probe method. All microbiological isolations werecarried out in the hospital laboratory, which usesquality control measures and is National ExternalQuality Assessment Schemes (NEQAS) approved.

For the purpose of the study the diagnosismade by the physician was referred to as the‘clinical diagnosis’ while the diagnosis based onthe laboratory cultures and Gram stain was referredto as the ‘laboratory diagnosis’. Table 1 introducesthe parameters used to establish the clinical andlaboratory diagnoses of the three main infectiousetiologies of VV. The clinical diagnosis of CandidaVV was based on the finding of a white vaginaldischarge, pH of less than 4.5, negative whiff testand – essential to the diagnosis – the findings in wetmount of budding hyphae with or without thepresence of spores, while the laboratory diagnosisof Candida infection rested on the finding ofCandida strains on culture.

The clinical diagnosis of Trichomonas infectionwas based on the finding of a yellow or greenishvaginal discharge with a pH of 4.5 or higher, and –essential and sufficient to the diagnosis – a wetmount showing mobile protozoa and an increasednumber of leukocytes. The laboratory diagnosisof Trichomonas vaginalis rested on the growth ofTrichomonas in Diamond agar.

Diagnosis of vulvovaginitis Bornstein et al.

106 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY

Etiology of vulvovaginitis Clinical diagnosis Laboratory diagnosis

Candida vulvovaginitis

Bacterial vaginosis

Trichomonas vaginitis

White discharge, vulvar pruritus, pH < 4.5, whiff test ( ), hyphae (+)on wet-mount microscopy*Gray–white homogeneous discharge, pH ³ 4.5, whiff test (+),clue cells > 20% in wet-mount microscopy**Yellow-green discharge, pH ³ 4.5, wet-mount – motiletrichomonads*, leukocytes in smear

Growth in culture

Gram stain

Growth in Diamond agar

*Criterion essential and sufficient for diagnosis; **documentation of at least three of the four criteria necessary for diagnosis

Table 1 Criteria of clinical and laboratory diagnosis

The clinical diagnosis of bacterial vaginosis (BV)was based on the Amsel’s criteria7, i.e. the presenceof at least three of the following: a homogeneousgray–white vaginal discharge, pH of 4.5 or higher,positive whiff test and wet mount showingclue cells in more than 20% of epithelial cells.The laboratory diagnosis of BV was based on thefinding of clue cells in the Gram stain.

If the essential criteria for two infections – forexample Candida and Trichomonas – were clinicallydocumented, a diagnosis of ‘mixed infection’ wasmade.

Excluded from the study were women in whomgonorrheal or chlamydial infection was detectedin the endocervical specimens, or in whom pelvicinflammatory disease, condylomata acuminata,herpes genitalis or urinary tract infection was diag-nosed during the examinations. Other exclusioncriteria were pregnancy or breastfeeding, a signifi-cant medical disease such as diabetes mellitus orrenal failure, antibiotic treatment and cortico-steroid or immunosuppressive medication in theprevious 3 weeks. Women using an intrauterinecontraceptive device (IUCD) were not enrolledsince the vaginal discharge sometimes associatedwith IUCDs could have affected the evaluation ofthe discharge. No women currently menstruatingwere enrolled into the study. The clinical diagno-ses as well as each symptom and sign werecorrelated with the laboratory diagnosis bymeasurement of agreement of k. In addition, socialand demographic parameters were comparedbetween groups of patients with the various labo-ratory diagnoses. Differences between the groupswere examined for significance using the t test forcontinuous parameters with a normal distribution,

and c2 and Fisher’s exact tests for categoricalparameters. Positive predictive values, sensitivity,specificity and odds ratio with 95% confidenceintervals (CI) of the bedside tests were calculated.

RESULTSOne hundred and fifty-three women with vaginaldischarge with a clinical diagnosis of VV of oneof the following infectious etiologies – Candida,Trichomonas or BV – participated in this study. Thelaboratory tests revealed that 55 (35.9%) of thewomen with a clinical diagnosis of VV in fact hadnormal flora, and the other 98 (64.1%) did indeedsuffer from infectious vulvovaginitis, the principalinfectious micro-organism being Candida species(Table 2). Of 68 patients with a positive Candidaculture, 61 had a clinical diagnosis of candidiasis.Candida non-albicanswas diagnosed in 10.3% of allcandidal infections (data not tabulated). Bacterialvaginosis was less frequent, and Trichomonas andmixed infection were diagnosed only rarely. Table2 also depicts a poor agreement (k = 0.18)between the gynecologist’s clinical diagnosis ofcandidal infection and the definitive laboratorydiagnosis, as initially 115 of the enrolled women(75.2%) were diagnosed clinically as havingcandidal infection. The clinical diagnosis ofCandida was verified in only 53% of the women,while 37.4% were shown to have normal flora.

Of the 26 women diagnosed clinically as havingBV, the diagnosis was verified by Gram stainin only 6 (23.1%). The gynecologist correctlydiagnosed only one patient of the six whereTrichomonas grew in Diamond medium.

Diagnosis of vulvovaginitis Bornstein et al.

INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 107

Clinical diagnosis (n (%))

Laboratory diagnosis Candida Bacterial vaginosis Trichomoniasis Mixed infection Total

Normal floraCandida speciesBacterial vaginosisTrichomoniasisMixed infectionTotal

43 (37.4)61 (53) .6 (5.2)0 (37.4)5 (4.3)

115 (37.4)

9 (34.6)6 (23.1)6 (23.1)4 (15.4)1 (3.8)

26 (50.1)

0 (50)0 (50)1 (50)1 (50)0 (50)2 (50)

3 (30)1 (10)2 (20)1 (10)3 (30)

10 (30)

55681569

153

Table 2 Comparison of the clinical and laboratory diagnoses. k agreement = 18%; numbers in parentheses arepercentages of cases in the same column

There was a non-significant trend for womenwith a laboratory diagnosis of infectious vaginitisto be younger than those with normal flora andthere was no correlation between the marital statusof the patients and the specific causes of infection(Table 3).

Table 4 shows a non-significant trend of alower rate of pruritus in women with normalflora compared to women with infectious vulvo-vaginitis. The amount of vaginal discharge wasgreater (according to the physician’s estimate) inVVC than in BV or in the presence of normal flora,although not to a significant extent. There was alsoa trend to having a white-colored discharge in casesof Candida or mixed flora, while Trichomonas or BVwas characterized as being gray in color (data nottabulated).

Tables 5 and 6 depict a significant associationbetween pH of the discharge and the infectiousvaginal agent. Candida infection was associatedwith pH levels of lower than 4.5 (p < 0.0001,

odds ratio = 5.0, 95% CI: 2.46–10.16, positivepredictive value 68.4%), while only a few caseswith BV or Trichomonas were associated with a pHof 4.5 or lower. The whiff test was positive in onlya small percentage of BVcases, similar to the find-ings in Candida and normal flora (p = NS). Cluecells were documented by the gynecologist in53.3% of patients with a laboratory diagnosis of BV(p < 0.02, odds ratio = 6.02, 95% CI: 1.98–18.32,positive predictive value 26.7%), and in 66.7% ofsmears of those with a laboratory diagnosis ofTrichomonas infection. The physician had deter-mined that hyphae existed in 75% of women finallyshown to have Candida infection (p = 0.048, oddsratio = 1.99, 95% CI = 1.00–4.02), but also in60% of women with normal flora and in 60% ofthose with BV. In the KOH smear test only a fewmore hyphae were seen than in the saline smear(data not tabulated).

DISCUSSIONThe main finding of this study is that in only 66.1%of women with a clinical diagnosis of VV was alaboratory diagnosis of infection established. Mostinaccuracies occurred with BV, where only 23.1%of the clinical diagnoses were confirmed by Gramstain. VVC was confirmed by culture in only53.5% of those with clinical diagnoses of VVC.Hyphae were documented by the gynecologists incases that were later diagnosed by the laboratorywith normal flora or with BV. These unexpectedfindings cast doubt on the expertise of the gyneco-logists participating in the study, and we presumedthat their experience with the use of microscopyand the other bedside tests was inadequate. How-ever, the same rate of discrepancies between theclinical and laboratory diagnoses was found regard-less of the examiner. It should also be taken intoaccount that the same or an even higher rate ofmistakes in clinical diagnoses is possibly madeevery day by many gynecologists. Therefore, wesuggest that the common practice of relying on theclinical diagnosis for establishing the treatmentmay be unreliable, and needs to be re-evaluated.

Another possible explanation for the findings inthe present study of a poor correlation betweenclinical and laboratory diagnosis is that the labora-tory rather than the clinical diagnoses were

Diagnosis of vulvovaginitis Bornstein et al.

108 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY

Laboratorydiagnosis

No. ofwomen(n (%))

Age(mean (SD))

Age(range)

%married

Normal floraCandida speciesBacterial vaginosisTrichomoniasisMixed infectionTotal

55 (35.9)68 (44.4)15 (9.8)6 (3.9)9 (5.9)

153

32.8 (11)31.5 (8.3)30.7 (6.9)25.7 (7.4)29.8 (9.3)

18–5519–5322–4518–3718–46

56.461.860.466.766.7

Table 3 Demographic characteristics

Symptom (n (%))

Laboratorydiagnosis

Increaseddischarge

Increaseddischarge

and pruritusPruritusalone Total

Normal floraCandida speciesBacterial vaginosisTrichomoniasisMixed infectionTotal

23 (41.8)21 (30.9)2 (13.3)1 (16.7)2 (22.2)

49 (32.0)

32 (58.2)46 (67.6)13 (86.7)5 (83.3)7 (77.8)

103 (67.3)

–1 (1.5)

–––

1 (0.7)

55681569

153

Table 4 Correlation of symptoms with laboratorydiagnosis; p £ 0.1; numbers in parentheses are percent-ages of cases in the same row

inaccurate. Indeed, most patients with a positiveCandida culture had had a clinical diagnosis ofcandidiasis. Possibly, some of the infectiousmicro-organisms failed to grow in culture. A possi-ble inhibitor of culture growth may have been thepatient’s use of an anti-fungal or anti-trichomonalagent prior to obtaining the culture. Although inthe present study patients were enrolled only ifthey had not taken anti-fungal or anti-trichomonalmedications for a month, we suspect that some ofthe women had a supply of anti-fungal oranti-trichomonal cream or vaginal pessaries leftfrom previous VV episodes. They may haveinserted a vaginal suppository or applied a cream toease the symptoms, and then come to the doctor’soffice only when this self-treatment failed to com-pletely alleviate their symptoms. These treatmentscould have inhibited the growth in culture of theCandida.

In addition it is difficult to ascribe a ‘goldstandard’ in the laboratory diagnosis of theseinfections. It could be argued that the polymerasechain reaction (PCR) test may be more sensitivethan culture for identification of Candida speciesand Trichomonas. However, PCR has not yet been

introduced into routine clinical use in cases of VV.Delay in cultivating the specimens is anotherpossible cause of lack of culture growth of Candida.In the present study efforts were made to transferthe specimens to the laboratory immediately aftercollection. In addition, experienced personnelexamined the cultures and stained slides. Wetherefore argue that the laboratory diagnosis inthese cases could serve as the gold standard. Hence,based on bedside tests, the clinicians over-diagnosepatients with vaginal discharge as suffering frominfectious vulvovaginitis.

BV infection was detected in only 15 womenand Trichomonas vaginalis in six. These smallnumbers limit discussion of the findings. However,the discrepancy between the clinical and labora-tory diagnoses of BV is particularly disturbing, butcould have resulted from the clinical nature of thediagnosis. Clinical assessment is traditionally usedfor diagnosis7,8. However, in the present study,which based the diagnosis of BV on Amsel’scriteria (pH ³ 4.5, homogenous discharge, cluecells and a positive whiff test)7 – which mightsuffice for the diagnosis of BV – nevertheless at thesame time some of them could have represented a

Diagnosis of vulvovaginitis Bornstein et al.

INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 109

Laboratory diagnosis (n (%))

Sign/test Normal flora Candida Bacterial vaginosis Trichomoniasis Mixed infection

Excessive dischargepH < 4.5Positive whiff testClue cells > 20%Positive hyphae (10% KOH)Total

.12 (21.8)

.17 (30.9)

. 4 (7.3)0 (100)

33 (60)55

.25 (36.8)39 (57.4)*.4 (5.9)0 (100)

51 (75)68

. 1 (6.7)

. 1 (6.7)

. 1 (6.7)

. 8 (53.3)9 (60)

15

3 (90)0 (100)3 (50).4 (66.7).1 (16.7)6

.2 (22.2)0 (100)1 (11)0 (100).8 (88.9)9

*p < 0.0001 (positive predictive value: 68.4%)

Table 5 Correlation of signs with laboratory diagnosis; numbers in parentheses are percent of cases in the samecolumn. Some women had more than one sign/test

Test Diagnosis p value%

sensitivity%

specificityPositive predictive

value Odds ratio 95% CI

pH < 4.5Clue cells > 20%HyphaePositive whiff test

VVCBVVVCBV

< 0.0001< 0.02< 0.048

NS

57.453.375.3N/A

78.884.240.3N/A

68.426.750.37.7

5.006.021.99N/A

2.46–10.161.98–18.321.00–4.02

N/A

BV, bacterial vaginosis; CI, confidence interval; N/A, not applicable; NS, not significant; VVC, vulvovaginal candidiasis

Table 6 Reliability of diagnostic tests

candidal infection. In addition, a mixed infectionof VVC and BV might have been responsible foranother interesting finding, that of many womenwith a laboratory diagnosis of BV complaining ofpruritus – a symptom not generally associated withpure BV.

Based on the laboratory diagnosis, the mostcommon vaginitis was VVC, with a frequencyof 35.9%. The incidence of BV was only 9.8%,which is not in accord with the situation in othercountries, such as the USA, where BV is the mostcommon VV.

From Tables 4–6 it seems that the onlysymptom that might be considered reliable inestablishing the infectious etiology of VV is pruri-tus combined with discharge, which was associatedwith VVC in 67.6% of cases and with mixed infec-tion (containing VVC) in 77.8%. The only usefulbedside test was a pH lower than 4.5, which carrieda positive predictive value of 68.4% and oddsratio of 5.00 (95% CI: 2.46–10.16) of predictinga candidal infection. Nevertheless, a significantnumber of women with normal vaginal flora had apH of the vagina between 3.8 and 4.5. The otherclassic sign, hyphae representing VVC, had an oddsratio of 1.99 (95% CI: 1.00–4.02) for detectingcandidiasis. A positive whiff test failed as a sign ofBV, since it did not differentiate between VVC,BV, Trichomonas infection and normal flora.

There may be several causes for the low specifi-city and sensitivity of most of the bedside tests. Inpoint of fact, the reliability of these bedside tests tomake the diagnosis of infectious VV has never beenestablished. Early studies indicated that each

symptom and sign was associated with a range ofdiagnoses8,9. For example, some Candida infectionswere associated with a pH of 5–5.9 and also withpH of 6–7.2, while BV has been found to be associ-ated with pH lower than 4.18,9. Determination ofpH may be biased by the lack of uniformity inobtaining the test – for example, taking the samplefor pH from different locations in the vagina.

Although these tests are not reliable, theyappear in textbooks and review papers10, as aidsfor the practicing clinician to establish a clear-cutdiagnosis in each case of VV and to help him or herprescribe the proper treatment. Even in our study,in 60% of cases with a laboratory diagnosis ofnormal flora, Hyphae were documented in wetmount microscopy. Therefore, although mosttextbooks continue to emphasize the unequivocalsignificance of the bedside tests for the diagnosis ofVV, our study indicates that vaginal culturesshould be used for the diagnosis of VVC andtrichomoniasis.

CONCLUSIONSBased on these findings, the current approachto the diagnosis of VV should be reconsidered.The classical symptoms and signs were proven notto be reliable diagnostic measures, while beingtime-consuming. Obviously, to target treatmenta proper diagnosis has to be made. Thereforecultures and Gram stains by the laboratory shouldbe made in each case of VV, or, alternatively, astandard treatment for all VV, covering all possibleinfectious micro-organisms, should be developed.

REFERENCES1. Thomason JL, Gelbart SM, Broekhuizen FF.

Office and clinical laboratory diagnosis of vulvo-vaginal infections: an overview. In Horowitz B,Mardh PA, eds. Vaginitis and Vaginosis. New York:Wiley-Liss Inc., 1991:93–108

2. Sobel JD, Faro S, Force RW, et al. Vulvovaginalcandidiasis: epidemiologic, diagnostic and thera-peutic considerations. Am J Obstet Gynecol 1998;178:203–11

3. Kaufman RH. Establishing a correct diagnosis ofvulvovaginal infection. Am J Obstet Gynecol 1988;158:986–8

4. Nyirjesy P, Seeney SM, Terry Grody MH, et al.Chronic fungal vaginitis: the value of cultures. Am JObstet Gynecol 1995;173:820–3

5. Gelbart SM, Thomason JL, Osypowski PJ, et al.Culturing Trichomonas vaginalis. In Horowitz B,Mardh PA, eds. Vaginitis and Vaginosis. New York:Wiley-Liss Inc., 1991:109–14

6. Lossick JG. The diagnosis of vaginal tricho-moniasis. JAMA 1998;259:1230

7. Amsel R, Totten PA, Spiegel CA, et al. Non-specific vaginitis: diagnostic criteria and microbialand epidemiological association. Am J Med 1983;74:14–22

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8. Holst E. Bacterial vaginosis: clinical and micro-biological findings. In Horowitz B, Mardh PA, eds.Vaginitis and Vaginosis. New York: Wiley-Liss Inc.,1991; 115–20

9. Hilier SL. Laboratory diagnosis of yeast vaginitis.In Horowitz B, Mardh PA, eds. Vaginitis andVaginosis. New York: Wiley-Liss Inc., 1991;121–4

10. Friedrich EG. Vaginitis. Am J Obstet Gynecol 1985;152:247–51

RECEIVED 11/30/01; ACCEPTED 04/03/01

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