Vaginal discharge

Vaginal Discharge

1. Approach to patient with vaginal discharge

2. Objectives Introduction Normal vaginal discharge Important history Symptoms and signs Diagnosis Treatment Case presentation

3. Introduction Vaginitis is the general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora . Around 90% of vaginitis is caused by infection, mainly bacterial vaginosis , vulvovaginal candidiasis, and trichomoniasis . These 3 diagnoses should be excluded in all patients before considering other less common causes.

4. Less common causes include: vaginal  atrophy/atrophic vaginitis, cervicitis, foreign body, irritants and allergens, and several rarer entities, including some systemic medical disorders.

5. Normal In reproductive aged women, normal vaginal discharge consists of 1 to 4 mL fluid (per 24 hours), which is white or transparent, thick or thin, and mostly odorless. This physiologic discharge is formed by mucoid endocervical secretions in combination with sloughing epithelial cells, normal vaginal flora, and vaginal transudate. The discharge may become more noticeable at times (“physiological leukorrhea ”), such as at midmenstrual cycle close to the time of ovulation or during pregnancy or use of estrogen-progestin contraceptives.

6. Diet, sexual activity, medication, and stress can also affect the volume and character of normal vaginal discharge.

7. History In a patient presenting with a complaint of ongoing vaginal discharge, the initial history should include: Any new sexual partners\partner symptomatic Use of new soaps or detergents Douching Contraceptive vaginal ring or IUD use Symptoms such as pelvic pain, itching, quality/quantity/ odour of discharge.

8. Symptoms Change in the volume, color, or odor of vaginal discharge Pruritus Burning Irritation Erythema Dyspareunia Spotting Dysuria Abdominal pain Fever

9. symptoms

10. Physical examination The vulva usually appears normal in bacterial vaginosis whereas erythema, edema, or fissures suggest candidiasis, trichomoniasis , or dermatitis. Atrophic changes are caused by hypoestrogenemia , and suggest the possibility of atrophic vaginitis. Changes in vulvovaginal architecture ( eg , scarring) may be caused by a chronic inflammatory process, such as erosive lichen planus , as well as lichen sclerosis, or mucous membrane pemphigoid , rather than vaginitis.

11. A foreign body ( eg , retained tampon) is easily detected and is often associated with vaginal discharge, intermittent bleeding or spotting, and/or an unpleasant odor due to inflammation and secondary infection. Removal of the foreign body is generally adequate treatment. Antibiotics are rarely indicated.

12. Vaginal warts are skin-colored or pink, and range from smooth flattened papules to a verrucous , papilliform appearance When extensive, they can be associated with vaginal discharge, pruritus, bleeding, burning, tenderness, and pain . Punctate hemorrhagic areas or the so-called "strawberry cervix" are pathognomonic for trichomoniasis

13. The presence of multifocal rounded macular erythematous lesions (like a spotted rash or bruise), purulent discharge, and tenderness suggests erosive vulvovaginitis , which can be caused by trichomoniasis or one of several noninfectious inflammatory etiologies

14. Necrotic or inflammatory changes associated with malignancy in the lower or upper genital tract can result in vaginal discharge; spotting is more common in this setting than in infectious vaginitis. Bimanual examination should be done to check for any cervical motion tenderness or adnexal tenderness which suggest PID.

15. Clinical signs

16. Clues for diagnosis A lack of itching makes diagnosis of vulvovaginal candidiasis unlikely . Presence of inflammatory signs is more commonly associated with vulvovaginal candidiasis. Lack of odor is associated with vulvovaginal candidiasis. Presence of a fishy odor on examination is predictive of bacterial vaginosis . A lack of perceived odor makes bacterial vaginosis unlikely.

17. Diagnosis Individual symptoms and signs, pH level, and microscopy results often do not lead to an accurate diagnosis of vaginitis . Laboratory tests perform better than standard office-based evaluation for diagnosing causes of vaginitis, but they do not add substantially to the treatment threshold and are justified only in patients with recurrent or difficult-to-diagnose from symptoms

18. Candidiasis Candida species are the most common cause of symptomatic vaginal discharge . Risk factors: glucosuria , diabetes mellitus, pregnancy, obesity, recent use of antibiotics, corticosteroids, or immunosuppressive agents.

19. Despite elimination of all predisposing factors, some women continue to experience episodes of recurrent, symptomatic vaginal candidiasis. Candidiasis is not a sexually transmitted disease.

20. Diagnosis microscopic examination of vaginal secretions with a 10% potassium hydroxide solution thus it is helpful for identifying hyphae and budding yeast for the diagnosis of candidal vaginitis pseudohyphae . Vaginal pH is usually normal (4.0 to 4.5 ). Vaginal culture should be considered in recurrently symptomatic women with negative microscopy and a normal pH.

21. Treatment C andidiasis can be classified as uncomplicated or complicated. Patients with uncomplicated vulvovaginal candidiasis: Mild to moderate disease Fewer than four episodes of candidiasis per year Pseudohyphae or hyphae visible on microscopy.

22. Treatment of uncomplicated vulvovaginal candidiasis: Clotrimazole 100 mg vaginally tab vaginally HSx7 days or HSx2 weeks ,, 200 mg vaginally HSx3 days or Clotrimazole 500 mg tab vaginally single dose Clotrimazole 2% cream 5 g intravaginally once daily for three days Nystatin 100,000 unit tab OD for 2 weeks.

23. Patients with complicated vulvovaginal candidiasis have one or more of the following: Moderate to severe disease Four or more episodes of candidiasis per year Only budding yeast visible on microscopy Adverse host factors (e.g., pregnancy, diabetes mellitus, immunocompromise ). Needs an intensive, longer course of antifungals

24. Initial regimen Any topical agent for seven to 14 days Fluconazole 100 , 150, or 200 mg orally once daily every third day for three doses Maintenance regimen Fluconazole 100 , 150, or 200 mg orally once weekly for six months Pregnancy: Any topical azole Intravaginally once daily for seven days

25. Bacterial vaginosis 37 %- 64% of women presenting to sexually transmitted disease clinics for treatment of other infections; two-thirds of these women were assymptomatic . Bacterial vaginosis is associated with late miscarriages, premature rupture of membranes, and preterm birth. Although there is an association with sexual activity, it is not a sexually transmitted infection.

26. DIAGNOSIS In clinical practice, bacterial vaginosis is diagnosed by the presence of three out of four Amsel criteria: Thin, homogenous vaginal discharge Vaginal pH greater than 4.5 Positive whiff test (fishy amine odor when 10 percent potassium hydroxide solution is added) At least 20 percent clue cells (vaginal epithelial cells with borders obscured by adherent coccobacilli on wet-mount preparation or Gram stain .

27. Treatment Metronidazole ( Flagyl ) 500 mg orally twice daily for seven days Clindamycin 300 mg orally twice daily for seven days Metronidazole gel ( Metrogel ) One full applicator (5 g) intravaginally once daily for five days Clindamycin 2% cream One full applicator (5 g) intravaginally at bedtime for seven days

28. Pregnancy Metronidazole 500 mg orally twice daily for seven days Metronidazole 250 mg orally three times daily for seven days Clindamycin 300 mg orally twice daily for seven days

29. Trichimoniasis T. vaginalis accounted for up to 25% of all clinically significant vaginal infections in the United States. Up to 50% of women with positive cultures for T. vaginalis are assymptomatic . The most consistently described risk factors associated with trichimoniasis are increased level of sexual activity and multiple sexual partners

30. Symptoms and signs of trichomoniasis are not specific, and diagnosis by microscopy is more reliable. Features suggestive of trichomoniasis are : trichomonads seen in wet mount test, leukocytes more numerous than epithelial cells positive whiff test vaginal pH greater than 5. purulent, foul-smelling, thin discharge

31. Treatment A single 2-g dose of metronidazole is adequate. Metronidazole in a dosage of 500 mg twice daily for seven days will treat bacterial vaginosis and trichomoniasis . Metronidazole in a dosage of 2 to 4 g daily for seven to 14 days is recommended for metronidazole-resistant strains

32. Sexual partners should be treated simultaneously. To reduce recurrence, partners should avoid resuming sexual intercourse until both have completed treatment and are asymptomatic.

33. Any women with new or multiple sexual partners, a symptomatic sexual partner, or an otherwise unexplained cervical or vaginal discharge ,should be tested for the presence of other sexual transmitted infections (chlamydia and gonorrhea) , by culture or an alternative sensitive test.

34. Chlamydia The most common bacterial STD in the United States. The prevalence of chlamydial infections has ranged from 3% in assymptomatic sexually active women to 40% in women screened in STD clinics. The most common symptom is a mucopurulent discharge associated with dysuria and lower abdominal discomfort

35. Diagnosis of the infection depends entirely on culture. screening cultures must include urethral and cervical specimens. Treatment: Azithromycin (Zithromax), 1 g (single dose) o r Doxycycline 100 mg orally BIDx7 days Other alternative , Tetracycline 500 mg orally QlDx7 days

36. In pregnancy: Azithromycin, 1 g (single dose) or Amoxicillin, 500 mg three times daily for seven days

37. Partners who had sexual contact with patient within 60 days before a diagnosis was made or at the onset of symptoms , should be treated. Patients should also be instructed to abstain from sexual intercourse until seven days after a single-dose regimen or after completion of a multiple-dose regimen, and after their partner has also completed treatment.

38. Gonorrhea In men, uncomplicated urethritis is the most common manifestation, whereas in women, less than one-half of cases produce symptoms (such as vaginal discharge and dyspareunia). Treatment: cephalosporin ( ceftriaxone , 125mg by intramuscular injection, as a single dose or cefixime , 400mg orally, as a single dose. plus either azithromycin or doxycycline Treat along with chlamydia as they coexist .

39. Case presentation 24-year-old single female who presented with complaints of a smelly, yellow vaginal discharge and slight dysuria for one week. ?History  

40. Denies vulvar itching, pelvic pain, or fever Has had 2 sex partners over the past 6 months—did not use condoms with these partners—on oral contraceptives for birth control

41. Physical Exam Vital signs: blood pressure 112/78, pulse 72, respiration 15, temperature 37.3° C Abdominal exam NAD. Normal external genitalia with a few excoriations near the introitus , but no other lesions Speculum exam reveals a moderate amount of frothy, yellowish, malodorous discharge, without visible cervical mucopus or easily induced cervical bleeding Bimanual examination was normal without uterine or adnexal tenderness

42. What do you think the cause? Do you want to do any thing more?

43. Vaginal pH—6.0 Saline wet mount of vaginal secretions—numerous motile trichomonads and no clue cells KOH wet mount—negative for budding yeast and pseudohyphae How are you going to treat her?

44. metronidazole 2 g orally, and she was instructed to abstain from sexual intercourse until her current partner was treated.

45. References Vaginal Discharge: An Approach to Diagnosis and Management , William J. Watson, MD, CCFP Gregory DeMarchi , MD, CCFP Vaginosis daignosis and treatment . AFP Chlamydia Trachomatis Infections: Screening, Diagnosis, and Management . AFP Approach to women with symptoms of vaginitis , Up-To-Date.

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