We have been doing wet preps a plenty in resident clinic lately, and I find myself reviewing the same info. That’s sounds like a good reason for a blog post! I’ve organized by diagnosis below, with history, PE, and wet prep clinical pearls.
Bacterial Vaginosis (40-45% of vagnitis)
- HX: profuse discharge, thin, watery. Worse after menses or after intercourse. May be foul-smelling. Usually not painful, pruritic.
- PE: Cup of milk
- Wet Prep: Clue cells. Which is one of those things that is easy to say, but hard to describe. Here’s a picture of normal squamous epithelial cells, followed by clue cells.
Cell borders are smooth, cytoplasm is clear, except for the nucleus.
Cells look “dirty”- cytoplasm is not so clear and the borders are irregular. In reality, the cytoplasm is the same, but bacteria are all around the outside of the cell.
- HX: Thick, white, clumpy, “cottage cheese” discharge, but may be thin and watery. Pruritus, irritation, vaginal soreness
- PE: White adherent discharge. Really don’t need the wet prep to diagnose this.
- Wet Prep: This is where the KOH prep is helpful. KOH breaks down the normal squamous cell walls, so hyphae are left.
- HX: Kind of a mix between the above two. Lots of discharge, foul-smelling, thin (like BV), but pain, pruritus, dysuria (like Candida).
- PE: Strawberry cervix is the board question, but it is rare. More often you see the discharge (it’s thin and yellowish), and the cervical mucosa is red, friable.
- Wet Prep: Trichomonads. Best way to see these is to look at the edges of the sample, and just leave the slide in one place for a while. Trich cells are more round/oval and smaller than the irregular shaped squamous cells. If you are patient, you can often see something moving – might just be the flagella moving, or you might notice the whole cell slowly moving against the flow of the rest of the liquid on the slide.
Cervicitis (GC, Chlamydia)
- HX: discharge is similar to Trichomonas, thin and watery but with associated symptoms of pain/pruritus/dysuria. If systemic sx: nausea, fever, abdominal pain- think PID.
- PE: friable, irritated cervix. Cervical motion tenderness or uterine tenderness on bimanual exam.
- Wet Prep: Normal looking squamous cells, may see lots of white cells (smaller, less clear cytoplasm) in the background.
If you are more of a table person, here’s most of the info above in handy chart form.
|Bacterial Vaginosis||Profuse Discharge, not painful/pruritic||Clue Cells||Women live with this for months before presenting. Worse after menses, intercourse|
|Candidiasis||Thick, white adherent discharge||Normal cells, but use KOH to identify Hyphae||If you see this, can skip the wet prep|
|Trichomonas||Combo of above- thin watery discharge, also painful/pruritic||Normal, but with white cells/trichomonads||Foul smelling discharge (even without the KOH)|
|Cervicitis||Similar to Trich, friable and painful cervix||Lots of white cells||May be GC, Chlamydia, Trich, HSV, others. (always test for other STIs)|
Did you know that we have a dropbox for pocket cards? This is so that you can keep them all in your pocket (on your phone). I’ll put the chart below there. If you want a link to the dropbox, send me an email or comment below and I’ll hook you up. Another benefit to reading I Hate Rashes!