KEYWORDS: ..분비샘의 분비물, 질벽에서 나오는 여출액, 질과 자궁경부의 탈락세포들, 자 궁경부 점액, 상부 생식기관에서 나오는 액, 미생물과 그 대사물질로 구성된 다. (정상 질 분비물은 pH 3.5~4.5의 산도를 유지하며 소양증, 악취 및 통증이 없고 색깔은 맑거나 흰색을 띈다.) ..One of the most common presenting complaints in gynecologic practices. (적절한 에스트로젠 레벌과 4.5이하의 질내 산성환경은 lactobacilli의 성장에 좋은 환경이 되며, 이 균은 hydrogen peroxide와 lactic acid를 생산하여 다른 병인균의 성장을 제한한다.) < Differential diagnosis of Vaginal discharge> i. Bacterial vaginosis-50% : Gardnerella vaginalis, Haemophilus, Corynebacterium ii. Candida-20~25% : C.albicans, C.glabrata, C.tropicalis iii. Trichomoniasis-15~20% iv. Mycoplasma or Ureaplasma Infectious v. Herpes Simplex or human papillomavirus vi. Nonspecific vaginitis : Group A streptococcus, Staphylococcus, E.coli, Enterococci-more common in the prepubescent female vii. Neisseria gonorrhoeae, Chlamydia cervicitis viii.Pinworm vaginitis ix. Retained foreign body with secondary infection x. Idiopathic ulceration with HIV infection i. Allergy/Hypersensitivity/Contact dermatitis : Deodorant hygiene products-tampons, pads, toilet paper and soaps/Contraceptiveslatex condoms and spermicides/Medications, Treatment creamspovidone iodine douches, topical antimycotic creams ii. Desquamative inflammatory vaginitis Noninfectious iii. Atrophic vaginitis iv. Erosive lichen planus v. Collagen vascular disease, Bechet's syndrome, Pemphigus syndrome vi. Idiopathic vaginitis vii. Physiologic discharge Vaginal discharge 535 The Root of ambulatory care 1. Wet prep 2. pH : In the postmenopausal female, when the pH is neutral, consider atrophic vaginitis. 3. KOH application : A positive“ whiff”test (fishy, amine odor when KOH applied) can be found in bacterial vaginosis. This test can also be positive in trichomoniasis. 4. Culture : 각 세균마다 특정한 세균배지가 필요한 경우가 많아 가정의학 외래에서 시행하 기엔 제한점이 있다. 1. Identify etiology and begin treatment or remove offending agent. 2. Treat sexual partner in trichomoniasis, Chlamydia, and N.gonorrhoeae. 3. Evaluate for possible systemic cause of the vaginitis 4. In cases of recurrent Candida ( >4 times/year), consider screening for diabetes and HIV. ..Avoid sexual activity until patient and partner are cured. Key tests Treatment Bacterial Vaginosis Trichomoniasis Candidiasis Symptoms Malodorous, purulent Malodorus, purulen Pruritis, dyspareunia, discharge discharge : dyspreunia soreness Color of Gray/thin Discharge adherent Greenish or yellow/green, Thick, white, clumpy discharge in nondependent portions frothy/thin Erythema and edema Examination of vagina Erythema of labia of labia -”strawberry”cervix in 10% > 20% of squamous cells are Motile trichomonads Budding yeast forms and clue cells : absence of (60% of cases) may be pseudohyphae with KOH in lactobacilli : positive nonmotile if hypertonic 60~70% Wet prep “whiff”test with KOH saline used ▶ Clue cells of G. vaginalis ▶ Trichomonads in a ▶ Candida in a saline wet vaginitis on a saline wet saline wet mount mount mount pH > 4.5 5~7 < 4.5 < Characteristics of infectious vaginitis> Patient education Vaginal discharge 1. Avoid tight-fitting clothing : wear cotton garments. 2. Avoid chemical irritants. Use showers rather than tub baths. 3. Discourage douching and using perfumes in the vaginal area. 4. Reinforce importance of completing entire course of medication. 5. Change tampons and sanitary napkins frequently. 참고 문헌 Mari E. Egan, M.D., Martin S. Lipsky, M.D. : Diagnosis of Vaginitis. A journal of the American Family Physicains 2000 ; 62 : 1095-1104 Jennifer R. Kessmann : Vaginal discharge, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 518-520 고희정 : 질분비물, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1326-1328