Syndromic Diagnosis in Evaluation of Women with Symptoms of Vaginitis

  • Theophilus Ogochukwu NwankwoEmail author
  • Uzochukwu Uzoma Aniebue
  • Uchenna Anthony Umeh
Female Genital Tract Infections (J Sobel, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Female Genital Tract Infections


Purpose of review

This review aims to determine the effectiveness of the use of syndrome diagnosis in the evaluation of vaginitis and to make suggestions based on the review findings.

Recent findings

Vaginal discharge as the main symptom of vaginitis is unspecific. A randomized study of symptom-based diagnosis and treatment of vaginitis in the USA favored symptoms used for treatment; however, this was only a pilot study. Hence, a population-based study is necessary to validate these findings. Most of the study that assessed treatment of vaginitis in pregnancy reported low diagnostic sensitivity and specificity for bacterial vaginosis and vaginal candidiasis and a wide range for trichomonas vaginalis reflecting ineffectiveness of syndrome-based treatment in pregnancy.


A systematic review of the web for relevant literature was made, and appropriate articles were extracted and reviewed. Sensitivity, specificity, and positive values were used, where applicable to determine effectiveness. Forty-three full articles and abstracts were reviewed. Studies that validated or applied WHO algorithm for treatment of vaginitis reported high sensitivity (91.5–100%) but moderate to low specificity (0–27.5%) among women with vaginal symptoms. Studies that focused on symptoms for diagnosis of the three main etiologic agents of vaginitis reported low sensitivity and specificity, while such studies in pregnancy reported sensitivity and specificity ranging from 35.4 to 54% for TV, 11 to 100% for BV, and 0 to 56.2% for trichomonas vaginalis, bacterial vaginosis, and vaginal candidiasis, respectively. Studies that added point of care test reported higher sensitivity and specificity and positive predictive value. The use of WHO syndrome-based algorithm or its modification for treatment of vaginitis though moderately effective has the potential for overtreatment and physician error. Point of care testing and laboratory investigation are essential for productive intervention especially in pregnancy.


Syndromic evaluation Vaginitis Bacteria vaginosis Trichomonas vaginalis Vaginal candidiasis 


Compliance with Ethical Standards

Conflict of Interest

Drs. Nwankwo, Aniebue, and Anthony declare no conflict of interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    WHO. Management of patient with sexually transmitted diseases. Report of WHO Study Group. WHO Technical Report Series 810; 1991.Google Scholar
  2. 2.
    WHO. Guideline for management of sexually transmitted infections. Geneva: publisher WHO; 2003.Google Scholar
  3. 3.
    Egan ME, Lipsky MS. Diagnosis of Vaginitis. Am Fam Physician. 2000;62(5):1095–104.PubMedGoogle Scholar
  4. 4.
    Ahmeda HM, Rosolb VH, Tawilc NG. Prevalence of abnormal vaginal signs and symptoms among attendees of obstetrics and gynaecology department of shaglawa hospital. Med J Babylon. 2014.Google Scholar
  5. 5.
    Jaquuiery A, Stylianopoulos A, Hogg G, Glover S. Vulvo-vaginitis clinical features, aetiology and microbiology of genital tract. Arch Dis Child. 1999;81:64–7.CrossRefGoogle Scholar
  6. 6.
    Johnson D, Chanot E, Lhak P, Broker TRM, Shrestha S. Prevalence and correlates of cervico-vaginal clinical syndrome among women attending a health camp in Lalitpur District Napel. Kathmandu Univ Med J. 2013;11(4):268–73.CrossRefGoogle Scholar
  7. 7.
    Lien PT, Elias C, Loi NT, Chi BT, Phac NH, Gardner M. The prevalence of reproductive tract infection in Hue, Vietnam. Stud Fam Plan. 2002;33(3):217–26.CrossRefGoogle Scholar
  8. 8.
    Guideline for the Diagnosis of Vaginosis-Vaginitis in Primary care of Women in fertile age or menopause. Federacion Argentina de Sociedades de Gincologia y Obstetricia. 2012.
  9. 9.
    Romoren M, Sundby J, Velauthapilai M, Rahman M, Klouman E, Hjortdahi P. Chlamydia and gonorrhea in pregnant Botswana women: time to discard the syndromic approach? BMC Infect Dis. 2007;7:27. doi: 10.1186/1471-2334-7-27.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Sherrard J, Donders Gilbet, White D. European (IUSTI/WHO) Guideline on management of vaginal discharge. 2011;1–23.Google Scholar
  11. 11.
    Hainer BL, Gibson MV. Vaginitis: Diagnosis and Treatment. Am Fam Physcician. 2011;83(7):807–15.Google Scholar
  12. 12.
    Gergen C, Wilkins V, Ragunathan P, Walsh J. When is syndromic management of sexually transmitted disease useful? An analysis of literature.
  13. 13.
    Anderson MR, Klink K, Cohressen A. Evaluation of Vaginal Complaints. JAMA. 2004;291(11):1368–79.CrossRefPubMedGoogle Scholar
  14. 14.
    Carr PL, Felsenten D, Friedman RH. Evaluation and Management of Vaginitis. J Gen Intern Med. 1998;13(5):335–46.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Pettifor A, Walsh J, Wilkins V, Raghunathan P. How effective is syndromic management of STDs. A review of current studies. Sex Transm Dis. 2000;27(7):371–85.CrossRefPubMedGoogle Scholar
  16. 16.
    Landers DY, Wiessenfield HC, Heine RP, Krohn MA, Hiller SL. Predictive value of the clinical diagnosis of lower genital tract infection in women. Am J Obstet Gynecol. 2004;190(4):1004–10.CrossRefPubMedGoogle Scholar
  17. 17.
    Manshoori A, Mirzaei S, Valadkhani Z, Arababadi MK, Rezaeian M, Zainodini M, et al. A Diagnostic and symptomatological study on trichomoniasis in symptomatic pregnant women in Rafsanjan, South Central Iran in 2012–13. Iran J Parasitol. 2015;10(3):490–7.PubMedPubMedCentralGoogle Scholar
  18. 18.
    • Madhivanan P, Krupp K, Hardin J, Karat C, Klausner JD, Reingold AL. Simple and inexpensive point of care teat improve diagnosis of vaginal infections in resource constrained setting. Trop Med Int Health. 2009;14(6):703–8. They conducted a cohort study of 898 sexually active women attending reproductive health clinics in Mysors India and reported that point of care testing in symptomatic women diagnosed 83.0% as against 43.0% correctly diagnosed and managed by syndrome based approach. They recommended the use of point of care testing for diagnosis of vaginitis in regions where laboratory test are not available. It is important in the final recommendations for in employment of point of care test for the evaluation and treatment of vaginitis in symptomatic non-pregnant women.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Canadian guideline on sexually transmitted infections; Section 4-management and treatment of specific syndromes of vaginal discharge (bacterial Vaginosis, vulvovaginal Candidiasis, Trichomoniasis) public health agency of Canada.
  20. 20.
    Hawkes S, Morison L, Foster S, Gausia K, Charkraborty J, Peeling RW, et al. Reproductive tract infection in women in low income, low prevalence situations: assessment of syndromic management in Matlab. Bangladesh Lancet. 1999;354(9192):1776–81.CrossRefPubMedGoogle Scholar
  21. 21.
    Vishwanath S, Talwar V, Prasad R, Coyagi K, de Elias CJ, Zoysa I. Syndromic management of vaginal discharge among women in a reproductive health clinic in India. Sex Transm Infect. 2000;76:303–6.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Kisa S, Taskin L. Validity of the symptomatic approach used by nurses in diagnosing vaginal infections. J Clin Nurs. 2009;18(7):1059–68. ISSN: 1365–2702.CrossRefPubMedGoogle Scholar
  23. 23.
    Ranjan R, Sharma AK, Mehta G. Evaluation of WHO diagnostic algorithm for reproductive tract infections among married women. Indian J Community Med. 2003;28(2):81–4.Google Scholar
  24. 24.
    Ryan CA, Courtois BN, Hawes SE, Steven CE, Eschenbach DA, Holmes KK. Risk assessement, symptoms, and signs as predictors of vulvo-vaginal and cervical infections in an urban US STD clinic: Implications for use of STD algorithms. Sex Trannsm Infect. 1998;74(suppl):S59–76.Google Scholar
  25. 25.
    Onyekonwu CL, Olumide YM, Oresanya FA, Onyekonwu GC. Vaginal discharge: etiological agents and evaluation of syndromic management in Lagos. Niger J Med. 2011;20(1):155–62.PubMedGoogle Scholar
  26. 26.
    Kapiga SH, Vuylsteke B, Lyamuya EF, Dallabetta G, Laga M. Evaluation of sexually transmitted diseases diagnostic algorithms among family planning clients in Dar es Salaam, Tanzania. Sex Transm Infect. 1998;74 suppl 1:S132–8.PubMedGoogle Scholar
  27. 27.
    •• Anderson M, Cohrssen A, Klink K, Brahver D. Are a speculum examination and wet mount always necessary for patients with vaginal symptoms? A pilot randomized controlled trial. J Am Board Fam Med. 2009;22:617–24. This as a randomised study is high level evidence. It reported effectiveness of symptom-based initiated treatment compared to addition of speculum and Gram stain. It is however a pilot study and evaluated small number of participants. Large trial is hence needed to confirm these findings before it can influence practice.CrossRefPubMedGoogle Scholar
  28. 28.
    Sharma JB, Mittal S, Raina U, Chanana C. Comparative efficacy of two regimens in syndromic management of lower genital infections. Arch Gynecol Obstet. 2006;273(4):232–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Rathod SD, Li T, Madhivanan P. Logic regression-derived algorithms for syndromic management of vaginal infections. BMC Med Inform Decis Mak. 2015;15:106.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    • Msuya SE, Uriyo J, Stray-Pedersen B, Sam NE, Mbizvo EM. The effectiveness of syndromic approach in managing vaginal infection among pregnant women in northern Tanzania. East Afr J Public Health. 2009;6(3):263–7. Studied 2654 pregnant women at primary health care clinic and noted that 70% of cases of bacterial vaginitis and trichomonas vaginalis were asymptomatic. Self reported vaginal discharge or presence of discharge on vaginal examination had low sensitivity (29–54%) and (25–50%) for diagnosis of BV and TV, respectively. They suggested the introduction of simple point of care laboratory screening for vaginal infection at primary care clinic. The study is important in the conclusion and recommendations of syndromes evaluation and treatment of vaginitis in pregnancy. PubMedGoogle Scholar
  31. 31.
    Romoren M, Velauthapillai M, Rahman M, Sundby J, Kloumane E, Hjortdahld P. Trichomoniasis and bacterial vaginosis in pregnancy: inadequately managed with the syndromic approach. Bull World Health Organ. 2007;85:297–304.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Hylto-Kong T, Braithewaite AR, Del Rosario GR, Kristensen S, Kamara P, Jolly PE, et al. Marginal validity of syndromic management for reproductive tract infections among pregnant women in Jamaica. Int J STD AIDS. 2004;15(6):371–5.CrossRefGoogle Scholar
  33. 33.
    Tans CJ, Mpairive H, Morison L, Nassimu K, Hughes P, Omara M, et al. Lack of effectiveness of syndromic management in targeting vaginal infections in pregnancy in Entebbe, Uganda. Sex Transm Infect. 2006;82:285–9. doi: 10.1136/sti.2005.014845.CrossRefGoogle Scholar
  34. 34.
    Lima TM, Teles LR, de Oliveira A, Campos FC, Barbosa RD, Pinheiro AK, et al. Vaginal discharge in pregnant women: comparison between syndromic approach and examination of clinical nursing practice. Rev Esc Enferm USP. 2013;47(6):1265–71.CrossRefPubMedGoogle Scholar
  35. 35.
    Heine RP, MCGregor JA, Patterson E, Draper D, French J, Jones W. Trichomona vaginalis: diagnosis and clinical characteristics in pregnancy. Infect Dis Obsetet Gynaecol. 1994;1(5):228–34. ISSN: 1064–7449.CrossRefGoogle Scholar
  36. 36.
    Karaer A, Boylu M, Avsar AF. Vaginitis in Turkish women: symptoms, epidemiologic-Microbiologic association. Eur J Obstet Gynaecol Reprod Biol. 2005;121(2):211–5.CrossRefGoogle Scholar
  37. 37.
    Zribim M, Mansour KB, Masmoudi A, Fendri C. Syndromic approach to sexually transmitted infections in Tunisian women: bacteriological validation. Int J STD AIDS. 2008;19(2):112–4.CrossRefGoogle Scholar
  38. 38.
    Ferris DG, Hendrich J, Payne PM, Getts A, Rassekh R, Mathis D, et al. Office laboaratory diagnosis of vaginitis. Clinician-performed tests compared with a rapid nucleic acid hybridization test. J Fam Pract. 1995;41(6):575–81.PubMedGoogle Scholar
  39. 39.
    Karaca M, Bayram A, Kocoglu ME, Gocmen A, Eksi F. Comparison of clinical diagnosis and microbiological test results in vaginal infections. Clin Exp Obstet Gynecol. 2005;32(3):172–4.PubMedGoogle Scholar
  40. 40.
    Sowjanya R, Prathyusha V, Sai Sree Sudha R. Comparative study of visual, clinical and microbiological diagnosis of white discharge. J Dent Med Sci. 2015;14(11):24–7. e-ISSN: 2279–0853, p-ISSN: 2279–0861.Google Scholar
  41. 41.
    Esim B, Kars B, Karsidag AY, Karadeniz BI, Kaymaz O, Gencer S, et al. Diagnosis of vulvovaginitis: comparison of clinical and microbiological diagnosis. Arch Gynecol Obstet. 2010;282(5):515–9. doi: 10.1007/s00404-010-1498-x.CrossRefGoogle Scholar
  42. 42.
    Rajurkar SP, Sapkal PS, Raut MM, Joge US, Malkar VR, Wagh SV. Study of syndromic management among the women with leucorrhoea attending Malwani Urbon health centre Mumbai. Int J Med Health Sci. 2014;3(1):14–7.Google Scholar
  43. 43.
    Schwiertz A, Taras D, Rusch K, Rusch V. Throwing a dice for diagnosis of vaginal complaints. Ann Clin Microbiol Antimicrob. 2006;5:1. doi: 10.1186/1476-0711-5-4.CrossRefGoogle Scholar
  44. 44.
    Lowe NK, Neal JL, Ryan-Wenger NA. Accuracy of the Clinical Diagnosis of Vaginitis Compared With a DNA Probe Laboratory Standard. Obstet Gynecol. 2009;113(1):89–95.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Rekha S, Jyothi S. Comparison of visual, clinical and microbiological diagnosis of symptomatic vaginal discharge in the reproductive age group. Int J Pharm Biomed Res. 2010;1(4):144–8.Google Scholar
  46. 46.
    Mengistie Z, Woldeamanuel Y, Asrat D, Yigeremu M. Comparison of clinical and gram stain diagnosis methods of Bacterial vaginosis among pregnant women in Ethiopia. J Clin Diagn Res. 2013;7(12):2701–3.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Bradshaw CS, Morton AN, Garland SM, Horvath LB, Kuzevska I, Fairley CK. Evaluation of a point-of-care test, BVBlue, and clinical and laboratory criteria for diagnosis of bacterial vaginosis. J Clin Microbiol. 2005;43(3):1304. doi: 10.1128/JCM.43.3.1304-1308.2005.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Hemalatha R, Ramalaxmi BA, Swetha E, Balakrishna N, Mastromariono P. Evaluation of pH for detection of bacterial vaginosis. Indian J Med Res. 2013;138(3):354–9.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Malaguti N, Bahls LD, Uchimura NS, Gimenes F, Consolaro MDL. Sensitive detection of thirteen bacterial vaginosis-associated agents using multiple polymerase chain reactions. BioMed Res Int. 2015. doi: 10.1155/2015/645853
  50. 50.
    DeMeo LR, Draper DL, McGregor JA, Moore DF, Kapernick PS, McCormack WM. Evaluation of a deoxyribonucleic acid probe for detection of tichomonas vaginalis in vaginal secretions. Am J Obstetn Gynecol. 1996;174(4):1339–42. ISSN: 0002–9378.CrossRefGoogle Scholar
  51. 51.
    Carr PI, Rothberg MB, Friedman RH, Felsenstein D, Pliskin JS. “Shotgun” versus sequential testing cost-effectiveness of diagnostic strategies for vaginitis. J Gen Intern Med. 2005;20:793–9.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Nelso DB, Bellamy S, Odibo A, Nachamkin I, Ness RB, Allen-Taylor L. Vaginal symptoms and bacteria vaginosis (BV): how useful is self report? Development of screening tool for predicting BV status. Epidemiol Infect. 2007;135:1369–75.Google Scholar
  53. 53.
    Ryan-Wenger NA, Neal JL, Jones AS, Lowe NK. Accuracy of vaginal symptom self-diagnosis algorithms for deployed military women. Nurs Res. 2010;59(1):2–10. ISSN: 1538–9847.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Theophilus Ogochukwu Nwankwo
    • 1
    Email author
  • Uzochukwu Uzoma Aniebue
    • 1
  • Uchenna Anthony Umeh
    • 1
  1. 1.Department of Obstetrics and GynaecologyUniversity of Nigeria NsukkaNsukkaNigeria

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