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While it is often possible to correctly guess the cause of a vaginal discharge,
based on history and/or physical exam, it is sometimes useful to use laboratory
skills to confirm a clinical impression. A wet mount is the suspension of a small amount of vaginal discharge in a
liquid medium. Two liquids are commonly used, normal saline and potassium
hydroxide. Each has it's own unique properties that make it useful in this
setting:
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Normal saline is a physiologic solution, so cell membranes are preserved
and vital activites (movement of protozoa, sperm, etc.) are undisturbed.
Saline is the best solution for visualizing trichomonas, and the bacterial
studding of vaginal epithelial cells known as clue cells.
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Potassium hydroxide (KOH) dissolves cell membranes and other biologic
materials, but not the cellulose found in the cell walls of fungi. This
property makes it particularly useful in identifying candida in vaginal
discharge. The KOH dissolves everything except the candida.
Obtain a Specimen
Use a spatula or cotton-tipped applicator to obtain a sample of the discharge.
You can usually find abundant discharge on the inside curve of the speculum
after you remove it. You can also obtain the specimen directly from the vagina
as you are looking at it.
I prefer to use a non-wooden collector because I avoid the tiny
wood fragments that contaminate the microscopic field.
The discharge need not be processed immediately, but can wait
until you have completed the rest of your exam. You can't wait indefinitely,
though. If the discharge dries completely before you can process it, the
information you obtain will be of less value.
Put a Tiny Amount of Discharge on a
Microscope Slide
Make this as small as possible.
Later, when you view it under the microscope, it will be spread
as thin as a single cell. If you start off with too much discharge, it will make
it harder for you to see the individual structures you need to evaluate.
Since you will actually be making two wet mounts (one of normal
saline and one of KOH), you can put some discharge on each of two slides.
Others prefer to use just a single slide, and they put a bit of
discharge at each end of the glass slide, to keep them separate. In this case,
it is important to keep them far enough apart that when you add the solutions
later, there will be no mixing of the NaCl and KOH.
Add NaCl
Add one drop of Normal Saline (0.9 percent NaCl) to the drop of discharge. Mix
well on the slide. This is the slide you will use for identifying Trichomonas
and bacterial vaginosis (BV).
The drop of NaCl should fall freely to the slide. Avoid touching the dropper
to the slide, or touching the drop to the slide before the drop is released from
the dropper. Either of these can result in your contaminating the NaCl bottle
with material from the discharge.
Prepare a second slide in the same way, using 10 percent Potassium Hydroxide
(KOH). This is the slide you will use to identify yeast.
As you are mixing the KOH with the discharge, you may notice an unpleasant
amine smell. This is called a positive "whiff test" (you caught a whiff of bad
smell), and indicates the presence of bacterial vaginosis.
Add Coverslips
Place glass coverslips over the glass slides. Remove any excess fluid with
tissue paper.
In order for the KOH to be effective in dissolving the cell
membranes of everything except yeast, you need to allow some time. A minute or
two may be enough. If you are in a hurry, you can speed the process by heating
the KOH slide with a match or lighter. The elevated temperatures will speed the
dissolving process and the glass slide cools quickly enough that you can place
it under the microscope as soon as you've finished heating it.
Do not warm the saline slide as you will stop flagella movement and coagulate
the proteins of the structures you are trying to identify.
Microscopic Evaluation
Examine the prepared slides under a microscope.
Experienced practitioners often find the lowest power (about 40X) works the
best. Others will start at low power and then move to slightly higher power
(about 100X).
The magnification is determined by multiplying the power of the eyepiece
(typically 10X) by the power of the objective lens (4X, 10X, 40X, 80X) to get
the various possible total magnifications (40X, 100X, 400X, and 800X in this
example.)
Yeast
Yeast (Candida, Monilia) is best identified with the KOH slide.
After the cell
membranes are dissolved, the typical branching and budding yeast cells can be
seen. Sometimes, it has the appearance of a tangled web of threads. At other
times, only small branches will be seen.
Yeast are normal inhabitants of the vagina, but only in very small numbers.
If you visualize any yeast in your sample, it is considered significant.
Read more
about yeast
Trichomonas
Trichomonas is best seen on the Normal Saline slide.
These protozoans are about the same size as a white blood cell (a little
smaller than a vaginal epithelial cell), but their violent motion is striking
and unmistakable.
Read
more about trichomonads
Bacterial Vaginosis
Bacterial vaginosis (also known as Gardnerella, hemophilus, or non-specific
vaginitis) is characterized by the presence of "clue cells" visible at both low
and medium power.
These clue cells are vaginal epithelial cells studded with bacteria. It
resembles a pancake that has fallen into a bowl of poppy seeds, but on a
microscopic level.
A normal vaginal epithelial cell is clear, with recognizable contents, and
sharp, distinct cell borders.
A clue cell appears smudged, with indistinct contents and fuzzy, poorly
defined borders.
Read
more about Bacterial Vaginosis
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