vaginalis causes a copious white, yellow, or green discharge that may be malodorous Bacterial vaginosis causes a gray, white, or yellow discharge with a malodorous “fishy” odor Carefully consider the need for a bimanual examination with or without a speculum examination in adolescents with vaginal symptoms if there is concern for upper genital tract disease, foreign body, mass, or nonmenstrual source of bleeding (see Chapter 92 Gynecology Emergencies ) Diagnostic Testing and Treatment Diagnostic Testing Bedside testing of the vaginal discharge for pH, wet mount microscopy with saline and 10% KOH may assist in identifying etiologies Vaginal pH (from the fornix) and wet mount microscopy for clue cells support the diagnosis of bacterial vaginosis Rapid antigen tests for trichomonas offer higher sensitivity than KOH wet mount and are available widely Urine for NAAT for gonorrhea and chlamydia can be obtained from the patient, specimens can also be obtained by endocervical collection or self-collected vaginal swabs Candidal vulvovaginitis is a clinical diagnosis; if tested pH is normal and KOH wet mount may reveal hyphae or pseudohyphae Rapid trichomonal antigen tests performed on vaginal discharge offer a higher sensitivity for diagnosis of infection so are replacing bedside testing Trichomonas vaginitis is associated with vaginal pH >4.5 and saline wet mount preparation slide may reveal flagellated motile trichomonads Bacterial vaginosis is characterized by vaginal pH >4.5, the presence of a fishy odor (enhanced by the addition of KOH wet mount), and the presence of clue cells on saline wet mount (epithelial cells present stippled with Gardnerella) (see Table 80.2 ) Presence of three of the four Amsel criteria are used to make the diagnosis