Abnormal Vaginal Discharge

Question 1

Abnormal Vaginal Discharge

Answer 1

Abnormal Vaginal Discharge
While a vaginal discharge is a notable clinical feature of a Sexually Transmitted Infection (STI), not all forms of vaginal discharge are abnormal or indicative of an STI. Vaginal discharge may be associated with normal physiological changes such as the menstrual cycle or pregnancy. Increased discharge may also occur with the presence or use of foreign substances such as the Intra Uterine Contraceptive Device (IUCD).
Careful history taking should reveal whether a vaginal discharge is abnormal and if it is associated with use of chemical substances e.g. topical self-medication, repeated douching with abrasive substances or indeed due to STI. Changes in the characteristics of a woman’s vaginal discharge either in colour, odour, amount and presence of additional symptoms and signs such as soreness and itchiness indicate a need for medical attention.
Abnormal vaginal discharge due to STIs may result in serious pelvic inflammation with sequelae such as ectopic pregnancy and infertility. Careful risk assessment is therefore required (see note below) of women presenting with a vaginal discharge in order to identify the possible causes and provide appropriate treatment regimens based on the most likely aetiology of the vaginal discharge. Factors that must also be considered when selecting treatment for patients include pregnancy status and patient discomfort.
Additionally, the syndromic approach must be used to assess the patient, identify risk factors and treat the likely cause of infection.

Question 2

Causes

Answer 2

Causes
y STI-related
y Neisseria gonorrhoea
y Chlamydia trachomatis
y Trichomonas vaginalis (green or yellow, smelly, bubbly or frothy
discharge associated with itching)
y Herpes simplex virus (following extensive first episode of infec-
tion)
y Non STI-related
y Candidiasis (white, lumpy or thick discharge associated with itching)
y Bacterial vaginosis (grey or white, fishy smelling discharge, es- pecially after sexual intercourse)
y Gardnerella vaginalis y Foreign bodies
y Herbal preparations

Answer 3

Vaginal discharge that is chunky, foamy or accompanied by itching and changes in color may mean you have an infection. Color: Vaginal discharge is healthy if it’s clear, milky white or off-white. Dark yellow, brown, green or grey discharge may indicate an infection or other issue.

Question 4

Risk Factors

Answer 4

Certain hygiene practices, such as douching or using scented sprays or soaps.
Cervical cancer.
Pregnancy.
Vaginal atrophy , also called genitourinary syndrome of menopause.
Vaginal cancer.
Vaginal fistula.

Question 5

Signs and symptoms

Answer 5

Symptoms
y Abnormal vaginal discharge - change in colour, odour, consistency or amount
y Vulval itching
y Vulval swelling
y Pain on urination
y Lower abdominal or back pain
Signs
y Abnormal vaginal discharge
y Vulval swelling
y Vulval erythema
y Lower abdominal tenderness
y Cervical excitation tenderness
y Cervical mucopus or erosions (on speculum examination)

Question 6

Investigations

Answer 6

Investigations
y Highvaginalswabformicroscopy,cultureandsensitivity(ifavailable)

Question 7

Treatment

Answer 7

Treatment
Treatment objectives
y To identify and treat non-STI vaginitis
y To assess STI risk and treat STI-related infections appropriately y To prevent complications and sequelae
y To treat both partners simultaneously as much as possible
Non-pharmacological treatment
y Promote good peri-anal and genital hygiene y Encourage use of loose cotton underwear
y Dry underwear out in the sun
y Keep underwear dry
y Avoid douching with herbal or chemical preparations y Avoid use of medicated soaps
Pharmacological treatment
Box 14-1: Risk assessment
Parameters used in the risk assessment for cervicitis are:
i. Patient’s partner is symptomatic (i.e. partner has a urethral discharge)
ii. Patient is less than 21 years old
iii. Patient is single
iv. Patient has more than one sexual partner
v. Patient has had a new sexual partner in the last 3 months
The risk assessment is said to be positive and treatment for cervicitis is recom- mended if
The answer to (i) is yes or
The answer to any 2 of items (ii) - (v) is yes.
If a woman has a vaginal discharge with no positive risk factor, treat for vaginitis alone.
If she has a vaginal discharge, and a positive risk factor, treat for both vaginitis and cervicitis.
A. Treatment for Vaginitis due to trichomoniasis and bacterial vaginosis
y Metronidazole, oral, 400 mg 8 hourly for 5 days (contraindicated during the 1st trimester of pregnancy)
Or
Or
y Secnidazole, oral, 2 g stat. (contraindicated during the 1st trimester of pregnancy)
Evidence Rating: [B]
y Metronidazole, oral, 2 g stat. (contraindicated during the 1st trimes- ter of pregnancy)
B. Treatment for Vaginitis due to trichomoniasis and bacterial vaginosis for pregnant women in the 1st trimester
y Clindamycin cream, 2%, vaginal, One applicator full at bedtime for

Question 8

Treatment for Vaginitis due to Candidiasis

Answer 8

Treatment for Vaginitis due to Candidiasis

Fluconazole, oral,
Uncomplicated: 150 mg stat. as a single dose
Complicated: 150 mg 72 hourly for 3 doses
Recurrent: 150 mg daily for 10 to 14 days followed by 150 mg once weekly for 6 months
Or

Clotrimazole, vaginal tablets, 200 mg inserted into vagina at night for 3 days
Or

Miconazole vaginal tablets, 200 mg inserted into vagina at night for 3 days
And
y Clotrimazole cream, vaginal, 1% or 2%, Apply twice daily for 3 to 7 days (for vulval irritation)

Question 9

Treatment for Cervicitis due to gonorrhoea

Answer 9

Treatment for Cervicitis due to gonorrhoea

1st Line Treatment

Evidence Rating: [B]
y Cefixime, oral, 400 mg stat. And
y Azithromycin, oral, 1 g stat.
2nd Line Treatment Evidence Rating: [B]
y Ceftriaxone, IM, 250 mg stat. And
y Azithromycin, oral, 1 g stat.

Question 10

E. Treatment for Cervicitis due to Chlamydia

Referral Criteria

Answer 10

E. Treatment for Cervicitis due to Chlamydia
1st Line Treatment
y Doxycycline,oral,100mg12hourlyfor7days(avoidinpregnantand nursing mothers)
Or
Evidence Rating: [A]
y Erythromycin, oral, 500 mg 6 hourly for 7 days Or
y Azithromycin, oral, 1 g stat. (recommended in pregnancy)
Referral Criteria
Refer all cases of recurrent vaginal discharge and/or treatment failures to a health facility where speculum examination can be carried out and microbiological culture and antimicrobial sensitivity tests can be done on the vaginal discharge.

Question 11

Flowchart: Abnormal Vaginal Discharge (Without Speculum)

Answer 11

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