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Clinical And Microscopic Correlation of Vaginal Discharge

Vijayalakshmi D1, Patil Sunil S.2, Sambarey Pradip W3

stant combination of symptoms and signs (syndrome) and on

ABSTRACT the knowledge of the most common causative organisms of
Introduction: Vaginal discharge in the reproductive age these syndromes and their antimicrobial susceptibility. The
group is the most common complaint encountered everyday main disadvantage of this management is, the cost of over
both by gynecologists and general practitioners. diagnosis and over treatment when multiple antimicrobials
Among the cases of symptomatic vaginal discharge Bacterial are given to patient where infection is caused by none or
vaginosis is commonest cause followed by Candidiasis and only one organism. Also to be considered are the risks of
Trichomoniasis. Multiple infections can also coexist but these adverse drug reactions, alteration of normal vaginal flora and
three conditions account for majority of all etiologies of ab-
also the potential for developing antibiotic resistance in the
normal vaginal discharge.
Material and methods: It is a cross sectional study. The
community. The addition of a simple microscopic evaluation
study reported here attempts to present the clinico-cytological by Gram stain of the vaginal smear has evolved as a sensitive
evaluation of vaginal discharge in a survey of two hundred pa- noncultural diagnostic technique for Bacterial vaginosis and
tients suffering from vaginal discharge complaint. The study Candidiasis.1 Direct microscopy (wet smear) of the vaginal
included the examination of the vaginal status of all women discharge to visualize the motile Trichomonas vaginalis has
with gross characteristics of vaginal discharge and discharge been determined to be as accurate as culture for the diagnosis
material was obtained from the posterior fornix with a ster- of Trichomoniasis. The present study was conducted to de-
ile swab stick for wet mount with normal saline and 10% of termine that symptomatic vaginal discharge can not only be
KOH, Whiff test and Gram stain. Papinaculaou smear taken in diagnosed by clinical examination but simple microscopic
all the cases of the patients in reproductive age group. techniques such as wet smear and Gram stain can aid in the
Results: Bacterial vaginosis constitutes the most common
accurate diagnosis of this common condition and to know
cause of vaginal discharge, followed by Candidiasis and then
Trichomoniasis in our set up. Pap smears revealed that 7 pa-
the most common cause of vaginal discharge in our set up.
tients out of 200 were having various grades of cervical dys- Aims and objectives of the study were to evaluation of pa-
plasia.For the etiological diagnosis of symptomatic vaginal tients complaining of abnormal vaginal discharge by clinical
discharge the microbiological diagnostic approach is best. and microscopic methods, to correlate the clinical and mi-
Conclusion: In low resource setting, primary clinical diagno- croscopic methods of vaginal discharge, to find out the most
sis based on simple microscopy, pH and amine test with WHO common cause of vaginal discharge in our set up and finally
algorithms should be made prior to treatment. to detect Carcinoma cervix in early stages.
Keywords: Vaginal discharge, Bacterial vaginosis, Candidia- MATERIAL AND METHODS
sis, Trichomoniasis. This cross sectional study was conducted in patients attend-
ing Gynecology OPD, Government hospital, Pune from Sep-
tember 2009 to September 2011. 200 non pregnant patients
INTRODUCTION of 20-70 years age group complained of vaginal discharge
The most common complaint in the reproductive age group is as their main or subsidiary symptom, which they either
vaginal discharge. Symptomatic vaginal discharge is caused complained of by themselves or on questioning. The study
by inflammation due to infection of the vaginal mucosa. It reported here attempts to present the clinico-cytological
occurs in 1-14% of all women in the reproductive age group evaluation of vaginal discharge in a survey of two hundred
and the prevalence of vaginal discharge in India is estimat- patients (200) suffering from the above complaint.
ed to be 30%.1 Inflammation of vagina leads to vaginitis.If Inclusion Criteria
untreated, it predisposes to pelvic inflammatory diseases, in- Age group of 20-70 years
fertility, endometriosis, urethral syndrome, pregnancy loss,
preterm labour. Among the cases of symptomatic vaginal 1
Assistant Professor, Department of Obstetrics and Gynecology,
discharge Bacterial vaginosis is commonest cause followed Vishwabharathi Medical College, Kurnool, Andhra Pradesh, 2As-
by Candidiasis and Trichomoniasis. Multiple infections can sistant Professor, 3Professor and Head, Department of obstetrics
also coexist but these three conditions account for majority and gynecology, B J Government Medical College and Sassoon
of all etiologies of abnormal vaginal discharge.2 Most of the Hospital, Pune, Maharashtra, India
time a presumptive diagnosis is made based on the nature of
the discharge (clinical diagnosis), which is often inaccurate Corresponding author: Dr Sunil Somnath Patil, Assistant Profes-
sor, Department of Obstetrics and Gynecology, B J Government
and incomplete. This eliminates the laboratory component
Medical College and Sassoon Hospital, Pune, India
(Microbiological diagnosis) leading to treatment misman-
agement. To address the limitations of clinical diagnosis, the How to cite this article: Vijaya D, Patil Sunil S., Sambarey
World Health Organisation (WHO) developed and advocated Pradip W. Clinical And Microscopic Correlation of Vaginal Dis-
the syndromic management approach. Syndromic approach charge. International Journal of Contemporary Medical Research
of WHO is based on the identification of a relatively con- 2016;3(5):1328-1331.

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International Journal of Contemporary Medical Research
Volume 3 | Issue 5 | May 2016 | ICV: 50.43 | ISSN (Online): 2393-915X; (Print): 2454-7379
Vijayalakshmi D, et al. Clinical and Microscopic Correlation of Vaginal Discharge

Complaining of vaginal discharge The diagnostic criteria used for microbiological diagnosis
Non pregnant women are:
Exclusion Criteria 1) Bacterial vaginosis – A Gram stain score of seven or
Age group< 20years and >70years more based on the scoring system by Nugent et al.
Pregnant women 2) Candidiasis – If gram positive budding yeasts and pseu-
Menstruation at the time of presentation dohyphae are seen on Gram stain.
Recently biopsied or operated cervix
Clinically obvious carcinoma- ulcer, cauliflower growth. 3) Trichomoniasis – If wet smear microscopy is positive for
motile Trichomonas vaginalis.
Methods of the study Haemoglobin estimation, peripheral blood smear examina-
A detailed clinical history- the age of the women, socio eco- tion, urine routine examination and microscopic examina-
nomic condition, religion and marital status are noted. The tion carried out for each patient in OPD.
complaints of white discharge per vagina was elaborated to Pap (papinaculaou) smear taken in all the cases of the pa-
include the tients in reproductive age group.
quantity, colour, consistency, odour, relationship to men- This gave a cytological diagnosis and provided for the cor-
struation and other associated symptoms like itching vulva, relation between cytological changes, and vaginal infection
burning sensation of vulva, urinary complaints, dyspareunia
are enquired.In obstetric history a careful note was made RESULTS
regarding married life, number of pregnancies, number of The study was conducted to determine the correlation be-
abortions. In menstrual history relationship of leucorrhea to tween the clinical and microscopic diagnosis of white dis-
menstrual cycle and date of last menstrual period is noted. charge per vaginum. White discharge per vaginum was the
Past history for having taken treatment for similar com- chief complaint in 200 cases attending Gynaecological OPD.
plaints. Personal history in regard to use of contraception, The mean age of the study cases were 34.3 years. More than
recent use of antibiotics, steroid therapy was obtained. Vul- 42% were in their 30.It shows parity of women in the study.
vovaginal, per speculum and bimanual examination carried Majority (39%) of the cases were of parity 2, followed by
out in all patients. parity 3 in 25%.The most common complaint was itching
Clinical observation seen in 33.3% cases, followed by backache seen in 29%.
The study included the examination of the vaginal status of Less common complaint was prolapse seen in 1% of cases.
all women in conjunction with gross characteristics of vagi- This table shows the duration of white discharge per vagi-
nal discharge. All 200 patients were classified into four cate- num. Maximum cases are seen within first month of infetion.
gories on the basis of vaginal discharge characteristics. Ten- In this study, 200 women presented with vaginal discharge.
derness of vaginal walls with inflammation of vulva and a A diagnosis was obtained for 161(80%) of them and in
green or yellow offensive irritating discharge associated with 39(20%) the etiological diagnosis could not be found.
or without multiple small punctate strawberry spots on the This table shows prevalence of bacterial vaginosis by clini-
vaginal vault and portio vaginalis of the cervix Trichomonal cal diagnostic approach was more than microbiological ap-
infection. Cases revealing redness of vaginal wall with white proach, while prevalence of candida and trichomoniasis by
patches or plaques of cheesy material adherent to the vagina microbiological approach was more than clinical approach.
with profuse irritating curdy type of vaginal discharge con- Out of 200 cases, clinically Bacterial vaginosis was found to
stituting monilial infections. Cases revealing thin, frothy, be positive in 108 cases and microscopically in 106 cases. 96
homogenous, irritating discharge which was malodorous but cases were both clinically and microscopically positive for
showed no gross pathological changes of the vagina and of Bacterial vaginosis. While clinically Candidiasis was found
vulva was suggestive of Bacterial vaginosis. The remaining to be positive in 45 cases and microscopically in 51 cases.
were assigned to unclassified category since the discharge 40 cases were both clinically and microscopically positive
presented mixed characteristics. for Candidiasis. Clinically Trichomoniasis was found to be
Cusco’s speculum was introduced per vaginally and then positive in 8 cases and microscopically in 6 cases. 5 cases
vaginal material was obtained from the posterior fornix with were both clinically and microscopically positive for Trich-
a sterile swab stick for 1) Wet mount-with normal saline and omoniasis.
10% of KOH 2) Whiff test 3) Gram stain Clinical diagnosis has higher sensitivity (90.6%) for diag-
Gram stain slide is interpreted by using Nugent score. nosing bacterial vaginosis and moderate sensitivity (83.3%)
for Trichomoniasis and (78.4%) for Candidiasis. Clinical

Age(years) No of patients (%) Parity No. of cases % Associated Morbidity No. of cases %
20-29 61 30.5 0 14 7.0 Back ache 58 29.0
30-39 84 42 1 27 13.5 Prolapse 2 1.0
40-49 40 20 2 77 38.5 Itching 67 33.5
>50 15 7.5 3 49 24.5 Dyspareunia 31 15.5
4 12 6.0 Urinary Complaints 22 11.0
5+ 21 10.5 Pain abdomen 20 10.0
Table-1: Age and Parity distribution with Associated Morbidity

International Journal of Contemporary Medical Research 1329

ISSN (Online): 2393-915X; (Print): 2454-7379 | ICV: 50.43 | Volume 3 | Issue 5 | May 2016
Vijayalakshmi D, et al. Clinical and Microscopic Correlation of Vaginal Discharge

Duration Number of cases % diagnosis has higher specificity (98.4%) for Trichomonia-
<1 month 65 32.5 sis and(96.6%) for Candidiasis, and moderate specificity for
1-3months 64 32.0 Bacterial vaginosis. Trichomoniasis has got the negative pre-
4-7months 36 18.0 dictive value of 99.5%
8-11 months 8 4.0 Pap smears revealed that 7 (3.5%) patients were having
>12 months 27 13.5 various grades of cervical dysplasia. Cytology reports were
Total 200 100 found to be normal in 25% of cases and 57.5% had inflam-
Table-2: Duration of vaginal discharge matory smears, and 14% had Bacterial vaginosis.
DISCUSSION
Diagnosis Clinical diagno- Microscopic diag- This cross sectional study of 200 patients was conducted
sis n=200(%) nosis n=200(%)
in women attending gynaecology outpatient department at
Bacterial vaginosis 108(54) 106(53)
a Government Medical College Hospital, from September
Candidiasis 45(22.5) 51(25.5)
2009 to September 2011. Two hundred women were includ-
Trichomoniasis 8(4) 6(3)
ed in the study. The etiological diagnosis was reached in 161
Undiagosed 39(19.5) 37(18.5)
(80.5%) of the patients included. In the remaining 19.5% of
Table-3: Prevalence of various infection based on two diagnos-
the patients, diagnosis could not be made with the microbio-
tic approaches
logical diagnostic approach. Similarly other studies showed
that in10 to 58% of the patients complaining of vaginal
Clinical Findings Microscopic Findings Total discharge, diagnosis could not be reached using any of the
Bacterial vagi- Positive Negative diagnostic approaches under consideration.3 This group of
nosis patients probably may have normal physiological discharge
Positive 96(88.9%) 12(11.1%) 108(54%) or less frequently viral vaginitis, aerobic vaginitis or vagi-
Negative 10(10.9%) 82(89.1%) 92(46%) nal lactobacillosis which are not routinely detected. Vaginal
Total 106 94 200 infections commonly occur in women of reproductive age
Candidiasis i.e between 25-35 years as noted in several other studies. In
Positive 40(88.9%) 5(11.1%) 45(22.5%) Rekha et al4 age group was 26-30years while in Jyothi et al1
Negative 11(7.1%) 144(92.9%) 155(77.5%) it was 27-31years.In our study we found most common in
Total 51 149 200 30-35years age group.
Trichomoniasis In present study patients sought medical help within
Positive 5(62.5%) 3(37.5%) 8(4%) 1-3months, when compared to Rekha et al4, where they
Negative 1(0.5%) 191(99.5%) 192(96%) sought medical help at least 1-6 months after the onset of
Total 6 194 200 symptoms. This showed a tendency towards decreased se-
Table-4: Comparison of clinical and microscopy Findings in quelae or complications associated with the infections.
each infection
White discharge per vaginum was the chief complaint of all

Clinical diagnosis Bacterialvaginosis (%) Candidiasis (%) Trichomoniasis(%)

Sensitivity 90.6 78.4 83.3
Specificity 87.2 96.6 98.4
Positive Predictive 88.9 88.9 62.5
Negative Predictive 89.1 92.9 99.5
Table-5: Validation of clinical diagnosis with microbiological diagnosis as the gold standard

Microscopic PAP Smear diagnosis

diagnosis Normal study Inflammatory smear ASCUS LSIL HSIL Bacterial Vaginosis Total
Bacterial vaginosis 20 57 2 2 1 24 106
Candidiasis 15 36 - - - - 51
Trichomoniasis 3 2 - 1 - - 6
Undiagnosed 12 20 - 1 - 4 37
Total 50(25%) 115(57.5%) 2(1%) 4(2%) 1(0.5%) 28(14%) 200
Table-6: PAP smear results

Clinical Rekha et al (%)4 Present study (%)

Diagnosis Sensitivity Specificity PPV NPV Sensitivity Specificity PPV NPV
Bacterial vaginosis 97.1 36.8 44.7 96.1 90.6 87.2 88.9 89.1
Candidiasis 58.3 82.0 41.2 90.1 78.4 96.6 88.9 92.9
Trichomoniasis 99.9 99.9 99.9 99.9 83.3 98.4 62.5 99.5
Table-7: Efficacy of clinical diagnosis of vaginal Efficacy of clinical diagnosis of vaginal

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International Journal of Contemporary Medical Research
Volume 3 | Issue 5 | May 2016 | ICV: 50.43 | ISSN (Online): 2393-915X; (Print): 2454-7379
Vijayalakshmi D, et al. Clinical and Microscopic Correlation of Vaginal Discharge

the patients included in the study. In this study, itching was cervix cannot be denied. And it was concluded that cervical
the commonest symptom. Similar findings were noted by intra epithelial neoplasia is common in our set up and can be
other authors. diagnosed early by Pap smears.
Prevalence of bacterial vaginosis, candidiasis, trichomonia- When the Clinical diagnostic approaches were compared
sis in the present study of 2011 was 54%, 22%, 4% respec- with the microbiological diagnosis, clinical diagnosis was
tively. noted to have moderate sensitivity for Bacterial vaginosis
In the study of 2010 by Rekha et al4 the prevalence of bac- and Trichomonisis, moderate specificity for Trichomoni-
terial vaginosis, candidiasis and trichomoniasis was 47%, asis; lower sensitivity for Candidasis and lower specificity
10%and 3% respectively.Studies conducted by Rao et al2 in for Bacterial vaginosis. This implies that if the clinical ap-
2004 showed 26%, 38% and 1.2% prevalence respectively proach is used to diagnose the infections, Bacterial vaginosis
while Khan et al5 in 2009 showed 28%,12% and 5% respec- and Trichomoniasis would be over treated while Candidiasis
tively. Ryan et al6 in 1998 showed 30% prevalence of bacte- would be under treated.
rial vaginosis an 30% of candidiasis. Similarly Snehalata et CONCLUSION
al7 in 2000 showed 26% and10% prevalence and Sanchez et
al8 in 1998 showed 30% and 7.3% prevalence respectively. Pap smears revealed that 7 (3.5%) patients out of 200 were
Efficacy of clinical diagnosis of vaginal infections in two having various grades of cervical dysplasia as compared to
different studies: another study11 in which 8(2.67%) patients out of 300 cases
Bacterial vaginosis was the commonest diagnosis by the were having cervical intraepithelial neoplasia. However it is
Clinical approaches in this study. When the Clinical diagnos- not significant enough to prove their causation in carcino-
tic approaches were compared with the microbiological di- ma cervix, but still their assosciation with carcinoma cervix
agnosis, clinical diagnosis was noted to have moderate sen- cannot be denied. Hence, regular follow up with Pap smear
sitivity for Bacterial vaginosis and Trichomonisis, moderate is mandatory.
specificity for Trichomoniasis; lower sensitivity for Can- It is concluded that cervical intra epithelial neoplasia is
didasis and lower specificity for Bacterial vaginosis. This common in our set up and it can be diagnosed early by Pap
implies that if the clinical approach is used to diagnose the smears. In a low resource setting, primary clinical diagnosis
infections, Bacterial vaginosis and Trichomoniasis would be based on simple microscopy, pH and amine test with WHO
over treated while Candidiasis would be under treated. Also algorithms should be made prior to treatment. Further stud-
the positive predictive value is low for Trichomoniasis with ies are needed to know the utility of the various diagnostic
moderate negative predictive values for all infections. approaches and the best approach that could be implemented
in the rapid and accurate diagnosis of symptomatic vaginal
Our analysis of the clinical approach showed that it does not
discharge.
deal adequately with the management of abnormal vaginal
discharge. By adding simple tests as recommended by WHO, REFERNCES
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Pap smears revealed that 7 (3.5%) patients out of 200 were
having various grades of cervical dysplasia as compared to Source of Support: Nil; Conflict of Interest: None
another study in which 8 (2.67%) patients out of 300 cases Submitted: 19-03-2016; Published online: 18-04-2016
were having cervical intraepithelial neoplasia.11 However it
was not significant enough to prove their causation in car-
cinoma cervix, but still their assosciation with carcinoma

International Journal of Contemporary Medical Research 1331

ISSN (Online): 2393-915X; (Print): 2454-7379 | ICV: 50.43 | Volume 3 | Issue 5 | May 2016