Syndromic Diagnosis in Evaluation of Women with Symptoms of Vaginitis
- 424 Downloads
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.
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.
KeywordsSyndromic 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.WHO. Management of patient with sexually transmitted diseases. Report of WHO Study Group. WHO Technical Report Series 810; 1991.Google Scholar
- 2.WHO. Guideline for management of sexually transmitted infections. Geneva: publisher WHO; 2003.Google Scholar
- 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
- 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. www.fba.org.ar/programas/prosar
- 10.Sherrard J, Donders Gilbet, White D. European (IUSTI/WHO) Guideline on management of vaginal discharge. 2011;1–23.Google Scholar
- 11.Hainer BL, Gibson MV. Vaginitis: Diagnosis and Treatment. Am Fam Physcician. 2011;83(7):807–15.Google Scholar
- 12.Gergen C, Wilkins V, Ragunathan P, Walsh J. When is syndromic management of sexually transmitted disease useful? An analysis of literature. https://www.hsph.harvard.edu/ihsg.
- 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.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. www.publichealth.gc.ca.
- 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.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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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