Approach to Diagnosis of Vulvovaginitis
The main reasons for visiting a primary gynecologic clinic are vaginal discharge, pruritus, malodor, and dyspareunia. Using medical history, genital examination, measurements of vaginal pH, and wet mount (microscopy of vaginal secretion) can diagnose thes
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Orna Reichman and Shiri Weinberg-Hendel
23.1 Introduction Vaginal discharge, pruritus, malodor, and dyspareunia are the main reasons for visiting a primary gynecologic clinic [1]. Unfortunately, such symptoms are nonspecific and caused by various etiologies such as hormonal deficiency, several infections, idiopathic inflammation, and contact dermatitis to numerous substances. It is essential to understand that symptoms alone do not provide a sufficient basis for diagnosis [2]. However, by combining medical history with a thorough genital examination, measurements of vaginal pH, and wet mount (microscopy of vaginal secretion), most causes of vaginal discomfort can be diagnosed [2, 3]. Infectious causes that cannot be identified by the microscope can be diagnosed by cultures or molecular biology assays, such as polymerase chain reaction (PCR) [4]. This chapter presents a clinical approach for diagnosing vaginitis by combining point of care tests: pH test, potassium hydroxide (KOH), and wet mount.
23.1.1 Vaginal Epithelium The vaginal wall is a dynamic stratified squamous epithelium which undergoes maturation in response to estrogen. It is composed of three cell O. Reichman (*) · S. Weinberg-Hendel Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
types, all originating from the basal layer. Estrogen induces proliferation of the basal cell layer to form parabasal cells that further undergo cyto-differentiation to form the intermediate cells which are enriched with glycogen. The intermediate cells further differentiate to squamous cells that contain keratin that protects the tissue from the potential damage of friction. The three cell types differentiate in their functional activity and morphology. As the cell differentiates, the cytoplasm-nuclei ratio grows, a phenomenon that helps diagnosing the status of maturation by a microscope, to those women where estrogen is present to these without estrogen (Figs. 23.1 and 23.2) [5]. Lack of estrogen, as seen in premenarchal girls and postmenopausal women, results in an atrophic vaginal epithelium composed by a thin, 3–5-layer stratified epithelia, characterized predominantly by parabasal cells and lacking the intermediate cells and squamous layer. The distribution of the three-cell type (i.e., parabasal, intermediate, and squamous) reflects estrogen levels and could assist in estimating the level of estrogen in the vagina. Meisels developed a scoring system known as the vaginal maturation index (VMI) in which 100 exfoliated vaginal cells are characterized and scored according to their maturation; parabasal cells are scored 0.1, intermediate cells are scored 0.5, and squamous cells receive a score of 1. A score below 50 indicates lack of estrogen and vaginal atrophy where above 65 reflects a well-estrogenized vagina [6].
© Springer International Publishing AG, part of Springer Nature 2019 J. Bornstein (ed.), Vulvar Disease, https://doi.org/10.1007/978-3-319-61621-6_23
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Superficial cells
Intermediate cell
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