Leukorrhea

Leukorrhea

1. Leukorrhea ชัยพงศ์ ตั้งสิทธิธรรม ทอแสง ชโยวรรณ

2. Leukorrhea Increased vaginal discharge Physiologic/Pathologic

3. Normal Vaginal Discharge Creamy white discharge Vulvar secretion Bartholin glands Sweat glands Sebaceous glands Skene glands Vagina Cervix Endometrial glands Fallopian tubes

4. Normal Vaginal Discharge Increased when Ovulation— endocervical glands Premenstrual phase Pregnancy Sexual excitement— Bartholin’s glands pH < 4.5

5. Physiological Vaginal Discharge Newborns Puberty Congestion of pelvic organs Cervical ectopian Contraceptives Vaginal douche

6. Pathological Vaginal Discharge Vaginitis in infancy and childhood Senile vaginitis ( Atrophic vaginitis ) Candidiasis Bacterial vaginosis Trichomonas vaginitis Mucopurulent cervicitis Foreign bodies Neoplasm Urinary and fecal discharge

7. Vaginitis in infancy and childhood Low immunity Age 1-5 years Infection/Foreign body/Tumor Wet smear, Gram stain, culture, speculum Treatment Rest antibiotics estrogen

8. Atrophic vaginitis Postmenopause Decreased estrogen Vaginal wall thining Decreased acidic environment Yellow/Green/Bloody Pruritic /Painful Dysuria Dyspareunia / Postcoital bleeding Vaginal wall thining , colpitis macularis , patchy ulceration, adhesive vaginitis

9. Atrophic vaginitis PAP smear, Gram stain, culture +- Cervical biopsy, Fractional curettage Treatment: Antibiotics estrogen (local/systemic)

10. Candidiasis Yeast cells/ Pseudohyphae Inflammation and curd-like discharge Predisposing factors Diabetes Obesity Pregnancy Antibiotics Contraceptives Low immunity Premenstrual period

11. Candidiasis KOH preparation, Gram stain (positive) Subouraud’s / Nicerson’s media culture Treatment: Uncomplicated Clotrimazole V.P. (100) Vg suppo OD 6days Clotrimazole V.P. (200) Vg suppo OD 3days Itraconazole (400) PO stat Fluconazole (150) PO stat Complicated Clotrimazole V.P. (100) Vg suppo OD 14 days then Clotrimazole V.P. (500) Vg suppo weekly for 6 months Repeat Fluconazole 3 days after then weekly for 6 months Partner?

12. Bacterial vaginosis Decreased amount of Lactobacilli  Increased amount of anaerobes Low immunity, fatigue, frequent sexual intercourse, vaginal douche Mostly asymptomatic Increased (foul-smelling) discharge

13. Bacterial vaginosis Amsel criteria (3/4) Gray-white discharge pH > 4.5 Clue cells Whiff test Treatment: Metronidazole (500) 1 tab PO bid pc 7 days Clindamycin (300) 1 tab PO bid pc 7 days

14. Trichomonas vaginitis Anaerobic flagellated protozoa Mainly sexually transmitted Yellowish green/white discharge Itchy Dysuria , dyspareunia Vaginal mucosa inflammation colpitis macularis , strawberry cervix

15. Trichomonas vaginitis Wet smear, Gram stain to rule out gonococcal infection Treatment Metronidazole (500) 1 tab PO bid pc 7 days Clotrimazole V.P. (100) Vg suppo OD 6days Must also treat partners, no intercourse until resolved

16. Mucopurulent cervicitis Mucopurulent discharge Dysuria Vulval inflammation N. gonorrhoeae , C. trachomatis , HSV Gram stain  intracellular gram negative diplococci

17. Mucopurulent cervicitis Dual therapy Gonococcal infection Ceftriaxone 125 mg IM stat Chlamydial infection Doxycycline (100) 1 tab PO bid pc 7 days Azithromycin (1g) 1 tab PO stat Must also treat partners, no intercourse until resolved

18. Foreign Bodies Children Adults—contraceptive devices, pessary , swabs, tampons Purulent vaginal discharge; foul-smelling, bloody Speculum; may use nasal or aural speculum Removal then antiseptics

19. Neoplasm Benign/Malignant Leukorrhea purulent, foul-smelling, bloody if infected/malignant

20. Urinary and fecal discharge Urinary discharge Urethro -vaginal fistula Vesico -vaginal fistula Uretero -vaginal fistula Fecal discharge Recto-vaginal fistula

21. Summary Physiologic Pathologic Vaginitis in infancy and childhood Senile vaginitis ( Atropic vaginitis ) Candidiasis Bacterial vaginosis Trichomonas vaginitis Mucopurulent cervicitis Foreign bodies Neoplasm Urinary and fecal discharge

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