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Q In patients with vaginitis, how do individual symptoms, physical examination signs, and laboratory tests perform in diagnosing vaginal candidiasis (VC), bacterial vaginosis (BV), and vaginal trichomoniasis (VT)?
Clinical impact ratings GP/FP/Primary care ★★★★★★☆ Emergency medicine ★★★★★☆☆ Infectious diseases ★★★★☆☆☆
studies were identified by searching Medline (1966–April 2003), hand searching the most recent American College of Obstetricians and Gynecologists Technical Bulletin, and scanning bibliographies of relevant studies.
Study selection and assessment:
studies were selected if they included symptomatic patients in primary care or sexually transmitted disease clinics, compared a diagnostic test with a recognised gold standard, calculated sensitivity and specificity, and discussed tests that would provide diagnostic information during the office visit. Gold standard tests for VC, BV, and VT included a positive culture or identification of yeast by microscopy, the Amsel criteria (3 of a thin, homogeneous vaginal discharge, clue cells, positive whiff test, and vaginal pH level >4.5), and a positive culture, respectively. Studies were assessed for methodological quality using a 3 level scale (level 1 = highest quality).
sensitivity, specificity, and likelihood ratios.
18 articles met the selection criteria. The quality of the studies ranged from level 2 to 3. The test characteristics of individual symptoms and physical examination signs are in the table. Laboratory tests performed better than signs and symptoms in diagnosing VC, BV, and VT (table).
In patients with vaginitis, individual symptoms and physical examination signs do not perform well in diagnosing vaginal candidiasis, bacterial vaginosis, and vaginal trichomoniasis. Laboratory tests perform better for diagnosing these conditions.
Abstract and commentary appear in ACP Journal Club.
Common, non–life-threatening problems are often the least studied areas of medicine, despite the overall burden of disease that they cause. At last, we are beginning to accumulate evidence to guide diagnosis and management in these areas. The review by Anderson et al presents a summary of the available evidence on the accuracy of the symptoms, signs, and office laboratory tests for diagnosing vaginal complaints.
With the exception of white curdy discharge, which helps to rule in the diagnosis of VC; yellow discharge, which can indicate the presence of either BV or VT; and redness or oedema, which can also indicate VT, these symptoms and signs are only moderately helpful in determining whether a patient has any of these vaginal conditions. The absence of symptoms and signs is even less helpful in ruling out disease, with only the absence of odour or yellow discharge ruling out BV. Office laboratory tests perform better because they rule in the disease if they are positive, but they do not rule out the disease if they are negative. Furthermore, many clinicians do not have the skills, time, or equipment to use these tests.
Several questions remain after reading this review: Could there be combinations of symptoms and signs that might better rule in or rule out the diagnosis? How does this information combine with more definitive testing, such as culture of a high vaginal swab? What is the treatment threshold for these conditions? Might it be better to treat on clinical suspicion, and test only those patients who fail a course of treatment? Primary care gynaecology requires more research to guide clinical decision making in this area.
For correspondence: Dr M R Anderson, Albert Einstein College of Medicine, Bronx, NY, USA.
Source of funding: no external funding.