Urinalysis and Body Fluids CRg Unit 56 Vaginal Secretions Vaginal Fluids - objectives1. Define and list at least three (3) symptoms of vaginitis. 2. Identify at least two (2) sources of error that can occur during the collection and processing of vaginal wet prep specimens. 3. List three (3) common causes of infectious vaginitis. 4. Describe "clue cells" and explain the significance of finding them in a vaginal wet prep. 5. Evaluate the test for estrogenic activity including the appearance of positive and negative results.Vaginal Secretions• Normal secretions• Clear mucus• May turn slightly white or pale yellow when exposed to air• Healthy vagina -Lactobacillus species predominates• pH< 4.5 (3.8-4.5)• Amount / volume varies through menstrual cycle• Normal microscopic exam • Abnormal changes• Color• Consistency• AmountNormal Wet prep• No symptoms• Lactobacillus (normal)• Normal discharge4Vaginitis • Vaginitis• - inflammation or infection of the vulva and vagina • NOT a specific disease, but is a very common reason women seek medical attention• Estimated 1/3 to ½ outpatient visits by women • Can occur in all age groups, sexually active as well as sexually non-active.• Common symptoms• Vaginal discharge• Foul smell• Itching• Spotting• Pain5Vaginitis - evaluation• Patient history • Marital or relationship status• Timeline of when symptoms began, etc.• Symptoms / complaint(s)• Physical examination• Tests• Physical properties• Vaginal pH • Microscopic exam / Wet Prep• Amine (Whiff) test• Cultures, if warranted 6Vaginitis • Two (major) types• Non- infectious• May be caused by soaps ( no bubble baths ladies !), chemicals, foreign objects, allergies to condoms / lubricants etc. • Infectious (makes up 90% of all cases) • Fungal / yeast• Parasitic – Trichomonas vaginalis • Bacterial7Vaginitis • Specimen – Vaginal Wet Prep• Sterile swab (moistened with normal saline)• Must process these immediately, ie within 5 minutes• Swab in tube with @ ½ mL normal saline, or Ringer‟s lactate• Keeps organisms from drying out if delay is expected• Special collection procedures: Microbiology cultures for gonorrhea (GC) must be placed in special transport media immediately. • This microbiology testing being replaced by molecular diagnostics • Collection / processing errors • Insufficient specimen / poor collection• Swabs / slide drying out8Vaginitis - testing• vaginal pH• Most important preliminary test• Normal (childbearing age) < 4.5• pH paper9Vaginitis - testing• Microscopic exam / Saline Wet Prep• Sample mixed with saline examined microscopically to look for• Budding yeast with elongated pseudohyphae• Motile trichomonads & increased segmented neutrophils• PMNs & Clue cells10Vaginitis - testing• Microscopic exam / Saline Wet Prep• Limitations • Skill of collection• Transport time• Trichomonas organisms die / become immotile • Skill of technician • New wave in laboratory testing• Immunologic• Molecular diagnostic / pcr11Vaginitis - testing• Amine (Whiff) test• Also called potassium hydroxide or KOH preparation • Vaginal fluid & 10% KOH placed on a slide• Fumes from the slide are smelled to detect presence of „fishy odor‟ (trimethylamine) .• Presumptive for bacterial vaginosis, though can also be positive for trichomonal vaginosis12Vaginitis - suspect yeast (candidiasis)•Candida albicans • Commonly causes a majority of cases• Alteration of normal vaginal flora o antibiotic regimenso immunocompromised patients• Thick white, clumpy or “curd-like” discharge.• Laboratory findings• Normal vaginal pH• Identification of yeast cells and elongated pseudohyphae (mycelia forms) • saline wet mounts• 10% KOH wet preps• Gram stain13Vaginitis - suspect:Trichomonas vaginalis•Trichomonas vaginalis -Free- living organism• Parasitic vaginitis• Swimming / bathing in contaminated water• Sexually transmitted• Symptomatic - Yellow-Green frothy discharge; or may be asymptomatic• Organism seen in urine or on wet-prep• In males – sexually transmitted urogenital infection• Usually asymptomatic• Organism may be detected in urine microscopicT. vaginalis - testing / detection• Laboratory findings• Wet-prep microscopic• Single celled flagellate demonstrating jerky movements • @ size of WBC, but no nucleus and actively motile - unless specimen is old, dry or cold.• May demonstrate WBCs• DNA and immunological tests • Elevated vaginal pH • Positive amine / “whiff” testVaginosis – suspect bacteria• Healthy vagina -Lactobacillus species predominates• Bacterial vaginosis •Gardnerella vaginalis•Mobiluncus species•Prevotella species (anaerobes) • Characteristics (*Amsel criteria)• *Homogenous vaginal discharge• Amount & Color may vary, but often gray / off-white• Usually thin in consistency and malodorous.• Lack of WBCs, but increased epithelial cell exfoliation • *“Clue cells” (make up 20+%) – most reliable finding• *Vaginal pH > 4.5• *Positive amine test in the KOH prep“Clue cells”17Normal examplesClue cells Vaginitis – testing summaryObservation / testCandidiavaginatis yeastTrichomonasvaginalisBacterialAppearanceThick white, clumpy / curd-likeGreen-yellow &frothyThin, gray homogenouspH< 4.5>4.5> 4.5Wet Prep microscopicBudding yeast and pseudohyphaeMotiletrichomonads & PMNs> 20% Clue cells identifiedAmine (Whiff) test with 10% KOHNegativeNegative, or PositivePositive: fishy odorMiscellaneousDNA &immunological tests availableAmsel criteria: at least 3 of 4 must be positive. 18Summary• From the lab‟s perspective – 3 main causes for vaginitis• Yeast infection / candidiasis• Candidia albicans / other species possible• Trichomonas vaginalis• Bacterial • From disturbance of normal flora (ie decreased lactobacillus) that allows overgrowth of mixed flora, ie Gardnerella vaginalis and others• Gardnerella – results in „clue cells‟• Known pathogens, ie gonorrhea 19Fern test • Test for estrogenic activity• Cervical mucous smeared on glass slide and allowed to dry• Examine under the microscope – look for fern-like appearance / pattern• Seen during times of increased estrogen – as occurs at time of ovulation.• Also done to see if there has been pre-mature leakage of amniotic fluid - as it will also make a fern pattern due to its protein