Diagnosis of mixed vaginitis
A vaginitis diagnosis is made
according to the presence of symptoms, clinical findings and microscopy
examination (Gram-staining and wet-mount smears)(30).
The key points in diagnosing mixed
vaginitis are as follows(1):①the
simultaneous presence of at least two vaginal pathogens; ②an abnormal
vaginal milieu due to the pathogens and, hence, symptoms and signs of
vaginitis; and ③the requirement of specific therapies for both
pathogens.
Since
the diagnosis of mixed vaginitis is largely dependent on the diagnostic
criteria for single vaginitis, the criteria to facilitate recognition of
the coexistence of multiple pathogens are as follows.
TV: at least one of the
following must be present: ①positivity on wet-mount smear, although the
sensitivity has been reported to be as low as 45–60%(31);
②positivity on culture, which has a
higher sensitivity than microscopy but is not widely available in
clinical settings; or ③positivity on a nucleic acid amplification test
(NAAT), which has the highest sensitivity for the detection of TV in
comparison to both microscopy and culture. The Guidelines Group
recommends that the most effective tests to diagnose TV in women are
NAATs(32). However, examination of wet-mount preparations is still
commonly used in clinical practice.
VVC: at least one of the following must be present:
①the presence of yeast or
pseudohyphae in vaginal discharge on wet-mount microscopy with either
saline or 10–20% KOH solution (40–60% sensitivity); ②the presence of
yeasts or
pseudohyphae
on gram staining (up to 65% sensitivity) of vaginal discharge;
or ③positivity on
culture, which is helpful in
diagnosing recurrent or complicated vulvovaginal candidiasis because
species other than C. albicans (e.g., Candida glabrata ,Candida tropicalis ) may be present.
Moreover, drug sensitivity testing
should also be conducted. The Guidelines Group recommends that the
current best test to diagnose Candida in women is microscopy(32)
because positivity on microscopy
indicates a large number of Candida, and hyphal formation is
infrequently observed with only colonization.
BV: at least one of the following must be present: ①a Nugent
score(33) >6; the
Nugent score is considered the gold
standard for studies and relies upon estimating the relative proportions
of bacterial morphotypes on a Gram-stained vaginal smear to assign a
score between 0 and 10. A score of <4 represents normal
conditions, 4–6 represents intermediate infection, and >6
represents BV. ②The presence of three of four
Amsel’s criteria, including
homogeneous, thin, white discharge
that smoothly coats the vaginal wall;
clue-cells on microscopic
examination (prerequisite); pH of vaginal fluid >4.5; or
vaginal discharge with a fishy odor before or after the addition of 10%
KOH (whiff test). Amsel’s criteria have a sensitivity of 60–72% for
the diagnosis of BV compared to the Nugent score(32).
AV: The diagnosis of AV should be based on a combination of
clinical features and microscopic findings(32).
①The clinical features are as
follows: vulvar erythema;
vulvar swelling;
thinning of the vaginal mucosa;
vaginal congestion;
scattered
bleeding points; and yellow-colored vaginal secretion, increased
discharge or pruritus. ②The microscopic features are as follows: wet
mount smears with a AV score ≥3(30).
Accordingly,
three main characteristics form the basis of an AV diagnosis:
a
variable amount of inflammation;
thinning of the vaginal
epithelium;
and a disturbed bacterial community
lacking
the commonly observed high abundance of lactobacilli(34).
Amalgamative infection of the
cervical and vagina should be recognized.
Some cervical infections caused by
pathogens, such as HSV-2, CT, NG, mycoplasma, and HPV(35), might occur
concurrently with vaginitis, and
symptoms of cervical cancer are generally obscured,
increasing the complexity of
diagnosis. Thus, coinfection with
the pathogens mentioned above should be excluded in the diagnosis of
mixed vaginitis.