DGGG Review 355 Diagnostic Value of Vaginal Discharge, Wet Mount and Vaginal pH – An Update on the Basics of Gynecologic Infectiology Was Fluor, Nativpräparat und pH-Wert verraten – Ein Update zu den Grundlagen der gynäkologischen Infektiologie Authors W. Frobenius1, C. Bogdan 2 Affiliations 1 Frauenklinik, Universitätsklinikum Erlangen, Erlangen 2 Mikrobiologisches Institut, Universitätsklinikum Erlangen, Erlangen Key words Abstract Zusammenfassung l" bacterial vaginosis ! ! l" vulvovaginal candidiasis The majority of uncomplicated vulvovaginal com- Die überwiegende Zahl unkomplizierter vulvo- l" trichomoniasis plaints (e.g. bacterial vaginosis, vulvovaginal can- vaginaler Beschwerden (z.B. bakterielle Vaginose, l" pelvic inflammatory disease didiasis, trichomoniasis) can be detected with un- Vulvovaginalkandidose, Trichomoniasis) lässt sich l" vaginal pH complicated basic infectiological tests and can durch eine einfache, infektiologische Basisunter- Schlüsselwörter usually be treated effectively without requiring suchung abklären und ohne weitergehende Diag- l" bakterielle Vaginose further diagnostic procedures. Tests include mea- nostik meist auch effektiv behandeln. Zu dieser l" Vulvovaginalkandidose surement of vaginal pH, preparation and assess- Untersuchung gehören die Messung des vagina- l" Trichomoniasis ment of wet mount slides prepared from vaginal len pH-Wertes, die Anfertigung und Beurteilung l" Pelvic inflammatory Disease l" vaginaler pH‑Wert or cervical discharge, and the correct clinical and eines Nativpräparats aus vaginalem bzw. zervi- microbiological classification of findings. In Ger- kalem Fluor sowie die korrekte Einordnung der many, at least in recent years, this has not been erhobenen Befunde in das klinische Bild und den sufficiently taught or practiced. As new regula- mikrobiologischen Kontext. Zumindest in tions on specialist gynecologic training in Ger- Deutschland wird dies seit Jahren zu wenig ge- Deutschsprachige many are currently being drawn up, this overview lehrt und praktiziert. Die vorliegende Übersicht Zusatzinformationen provides basic information on gynecologic in- vermittelt deshalb auch im Hinblick auf die kom- online abrufbar unter: fectiology and summarizes clinically relevant as- mende neue Weiterbildungsordnung grund- www.thieme-connect.de/ pects of recent microbiological findings on the legende Kenntnisse dazu und fasst gleichzeitig ejournals/toc/gebfra physiology and pathology of vaginal flora. The den klinisch relevanten Teil der aktuellen mikro- clinical signs and symptoms of aerobic vaginitis, biologischen Erkenntnisse zur Physiologie und the pathogenesis of which is still not completely Pathologie der Vaginalflora zusammen. Ferner understood, are also reviewed. Finally, the symp- wird das pathogenetisch nach wie vor unvollstän- toms, indications and risk factors for pelvic in- dig verstandene Krankheitsbild der aeroben Vagi- flammatory disease (PID) are presented. In con- nitis diskutiert. Letztlich werden auch Symptome, trast to the above-listed infections, PID requires Zeichen und Risikofaktoren einer Entzündung des „ “ received 7.11.2014 immediate culture of the pathogen from samples kleinen Beckens ( Pelvic Inflammatory Disease , revised 22.12. 2014 (e.g. obtained by laparoscopy) with microbiologi- PID) vorgestellt, da diese Erkrankung im Gegen- accepted 9.1.2015 cal diagnostic procedures carried out by specialist satz zu den obengenannten einen unverzüglichen laboratories. A schematic summary of all patholo- kulturellen und/oder molekularen Erregernach- Bibliography DOI http://dx.doi.org/ gies discussed here is presented. weis durch entsprechende Materialgewinnung 10.1055/s-0035-1545909 (z.B. mittels Laparoskopie) und mikrobiologische Geburtsh Frauenheilk 2015; 75: Labordiagnostik erfordert. Für alle dargestellten – 355 366 © Georg Thieme Krankheitsbilder werden Schemata zum thera- Verlag KG Stuttgart · New York · ISSN 0016‑5751 peutischen Vorgehen präsentiert. Correspondence PD Dr. Wolfgang Frobenius Frauenklinik Introduction patient consultations. Infectiological diagnostics Universitätsklinikum Erlangen ! and treatment play a not unimportant role in hos- Universitätsstraße 21–23 The diagnosis and treatment of vulvovaginal pitals, although the focus there is primarily on in- 91054 Erlangen wolfgang.frobenius@ symptoms associated with genital infections ac- fections of the cervix (cervicitis), endometrium uk-erlangen.de counts for a large proportion of gynecologic out- (endometritis), fallopian tubes and ovaries (oo- Frobenius W and Bogdan C. Diagnostic Value of… Geburtsh Frauenheilk 2015; 75: 355–366 356 GebFra Science phoritis, salpingitis or adnexitis) as well as – in the worst case – dards (MiQ) of the German Society for Hygiene and Microbiology inflammations of the entire minor pelvis including generalized (DGHM) [6,7], and even a summary would far exceed the scope peritonitis and sepsis. The latter pathologies are grouped togeth- of the discussion possible here. er under the term pelvic inflammatory disease (PID). Despite its enormous practical importance, infectiological train- ing in gynecology still leaves much to be desired [1]. Attempts to Physiology and Pathology of Vaginal Flora detect the underlying causes of symptoms may be carried out on ! a “trial and error” basis, resulting in unnecessary or inadequate Important aspects of the knowledge of the physiology and pa- microbiologic diagnostic investigations and antibiotic treatment thology of vaginal flora, which for around a century was based which may not be indicated or may be insufficient or – in the on examinations of cultured specimens, are currently changing. worst case – have adverse consequences for patients [2]. According to a recent overview by Lamont et al. [8], molecular Experience has shown that the biggest problem lies in the basic techniques used to supplement the knowledge obtained over infectiological diagnostic procedures. For various reasons, spe- the past 100 years have shown that cialist knowledge of how to prepare and assess wet mount slides " the diversity of organisms in the vaginal milieu is much greater for microscopic investigation of vaginal discharge is the excep- than was initially thought, tion rather than the rule in outpatient clinics or hospitals. In con- " the role of Lactobacillus requires a more nuanced assessment, trast to the United States for example where regulations require " the range of what is “normal” is broader than was thought, and wet mount proficiency testing, gynecologists in Germany do not " bacterial vaginosis should probably be understood more as a currently need to prove their specialist knowledge in this area. symptom than as a uniform clinical picture. The subject will only now become part of mandatory specialist The principle that Lactobacillus predominates in the vaginal flora training in gynecology. In July 2014 the Professional Society for of healthy women of reproductive age still generally applies. Lac- Infections and Infection Immunology (AGII) in Germany drew tobacillus organisms metabolize the estrogen-dependent glyco- up and published the content requirements for this subject area gen stored in the squamous epithelium to lactic acid, which con- [3]. tributes to create a vaginal pH equal to or less than 4.5. Acidic pH This is an extremely welcome development, not least because the but also H2O2 production by many Lactobacillus species together overwhelming number of uncomplicated vulvovaginal symp- with a number of other factors are responsible for ensuring that toms can already be diagnosed using basic diagnostic proce- the numbers of other bacteria also found in the “commensal dures; the diagnosis of bacterial vaginosis (BV), vulvovaginal can- flora” of the vagina remain below a critical threshold. didiasis and the now rarely occurring (in Germany) trichomonia- However, an absence of Lactobacillus does not inevitably result in sis is usually fairly straightforward based on the patientʼs medical illness; molecular biological investigations have identified other history, clinical examination with measurement of vaginal pH, bacteria which produce lactic acid and thus contribute to main- whiff/KOH test and evaluation of wet mount slides. All of these taining a normal vaginal milieu (e.g. Atopobium vaginae, Mega- methods are usually also sufficient to differentiate between nor- sphaera and Leptotrichia) [9]. Nor is cultured proof of a limited mal vaginal findings and bacterial vaginitis not caused by proto- number of facultative pathogenic bacteria (e.g. Gardnerella vagi- zoa or fungal infection (for example aerobic vaginitis) with a rel- nalis, E. coli, Pseudomonas spp., Group B Streptococcus, or Pep- atively high degree of accuracy. Basic diagnostic procedures can tostreptococci) necessarily an indication for treatment [8]. Excep- also be used in the often difficult differential diagnosis of lower tions to the rule are specific pathogenic organisms such as the abdominal pain to exclude PID with a high level of negative pre- pathogens of sexually transmitted diseases or, in special cases, dictive certainty. The emphasis of this article is therefore on basic Group A Streptococcus (S. pyogenes). diagnostic procedures that can be carried in the practice of a reg- According to recent studies, colonization with two or more Lac- istered doctor or in hospital at limited cost. In addition to the tobacillus species is common in healthy women with Lactobacil- physiology and pathology of the vaginal flora in women of repro- lus flora. Colonization