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V SKILLS: Lots of white blood cells on the wet mount? What do they mean?

Many white blood cells (wbc) on the wet mount (more than one wbc/epithelial cell) mean that a variety of conditions need to be ruled out. If clinically relevant, consider upper tract disease: endometritis, PID, fistula. Culture for herpes and culture or do genprobe for GC and clamydia. Look on wet mount for Candida and trichomonas; if not seen (remember wet mount is negative ~50% of the time in the presence of disease) send a yeast culture and a trichomonas culture. Other causes of elevated wbc are low estrogen or atrophy, vaginal lichen planus and lichenoid vaginitis (desquamative inflammatory vaginitis).

V SKILLS: Suspect Yeast, But is Wet Mount Negative?

The diagnosis of Candida albicans is frequently missed because wet mount is only about 40% specific; the Candida is in the vagina but we do not see it on the wet mount. What to do? Always send a yeast culture, especially when there are many white blood cells but yeast is not seen. Also, be sure to ask the patient when she last used antifungals. If she took Diflucan in the past week or two, you may not see or grow Candida but it may recur. When trying to diagnose recurrent vulvovaginal irritative symptoms, be sure to evaluate the patient when she has full-blown symptoms and has not used any treatment. Give her materials for a yeast culture at home if necessary.