Is a clitoral culture to evaluate for bacteria or fungus appropriate in the diagnosis of chronic vaginitis?

From the Guidelines

No, a clitoral culture is not appropriate for evaluating chronic vaginitis, as the standard approach includes obtaining vaginal cultures or swabs from the vaginal walls to assess for bacterial vaginosis, candidiasis, or trichomoniasis. The diagnosis of vulvovaginal candidiasis, a common cause of chronic vaginitis, relies on methods such as microscopy and clinical suspicion, but culture has remained the gold standard for diagnosis of vaginal fungal infections 1. However, the clitoris is not the site of infection in vaginitis, and sampling this area would not provide relevant diagnostic information.

Diagnostic Approaches

• Microscopic examination of vaginal discharge with saline and KOH preparations
• pH testing
• Specific cultures or nucleic acid amplification tests when indicated
• For bacterial vaginosis, Amsel's criteria or Nugent scoring of a Gram stain are typically used
• For fungal infections, a KOH preparation or fungal culture from vaginal secretions is appropriate, as seen in the treatment guidelines for vulvovaginal candidiasis which include over-the-counter intravaginal agents like clotrimazole and prescription intravaginal agents like terconazole 1

Treatment Options

• Antibiotics for bacterial vaginosis, such as metronidazole 500 mg twice daily for 7 days
• Antifungals for candidiasis, such as fluconazole 150 mg oral single dose, as recommended by the Centers for Disease Control and Prevention 1
• Antiprotozoal medications for trichomoniasis

Proper specimen collection from the vaginal walls is essential for accurate diagnosis and subsequent treatment of chronic vaginitis. The use of molecular tests, such as polymerase chain reaction (PCR) for the Candida group, has been found to have high clinical accuracy and may be considered in certain cases 1.

From the Research

Evaluation of Clitoral Culture in Chronic Vaginitis

• The use of clitoral culture to evaluate for bacteria or fungus in chronic vaginitis is not a standard diagnostic approach, as the primary focus is on vaginal discharge, odor, irritation, itching, or burning 2.
• However, in the diagnosis of vulvovaginal candidiasis, culture can be helpful in identifying non-albicans strains of Candida, which may be more resistant to treatment 3.
• The diagnosis of bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis typically involves a combination of symptoms, physical examination findings, and office-based or laboratory testing, such as Amsel criteria, Gram stain, or DNA probe testing 2, 4.
• In cases of recurrent bacterial vaginosis, an extended course of metronidazole treatment or alternative regimens may be recommended, but the use of clitoral culture is not specifically mentioned 5.
• A comprehensive approach to diagnosis and management of noncandidal vaginitis involves considering various etiologies, including trichomonas, bacterial vaginosis, and atrophic vaginitis, but clitoral culture is not a primary diagnostic tool 6.

Diagnostic Approaches for Chronic Vaginitis

• The diagnosis of chronic vaginitis typically involves:
  • Symptoms: abnormal vaginal discharge, odor, irritation, itching, or burning
  • Physical examination findings
  • Office-based or laboratory testing, such as:
    • Amsel criteria for bacterial vaginosis
    • Gram stain for bacterial vaginosis
    • DNA probe testing for vulvovaginal candidiasis
    • Potassium hydroxide microscopy for vulvovaginal candidiasis
    • Nucleic acid amplification testing for trichomoniasis 2, 4
• Clitoral culture may not be a necessary or standard diagnostic approach for chronic vaginitis, but culture can be helpful in identifying non-albicans strains of Candida in vulvovaginal candidiasis 3.