Abnormal vaginal discharge Flashcards
Normal vaginal discharge
Cervical and vaginal secretions are normal in women of the reproductive age group
- Clear or white discharge
- Consistency and amount of discharge varies throughout the menstrual cycle
- More stretchy peri-ovulation (akin to egg white)
- Thicker and slightly yellow during luteal phase
- No strong odour, no itch
What is pruritus vulvae?
Itch of the vulva that is persistent and causes distress
*Sx not a diagnosis
How to differentiate between normal vs abnormal vaginal discharge?
Amount or character of the discharge has altered significantly from the woman’s usual pattern
- Change in consistency or colour
- Unusually large amount
- A/w itch or foul smell
- A/w abdo-pelvic pain or abnormal vaginal bleeding
Causes of abnormal vaginal discharge
- Physiological
- Pregnancy
- OCP
- Cervical entropian
- Emotional stress - Infective
- Bacterial vaginosis ++
- Candidiasis +
- STI (Genital herpes, Chlamydia, Gonorrhea)
- Trichomonas - Pelvic inflammatory disease
- main p/c is lower abdo pain but can p/w discharge - Malignancy
- Vaginal cancer
- Cervical cancer
- Endometrial cancer
- Fallopian tube cancer
Common causative agent of candida vulvovaginosis (aka thrush infection)
Candida albicans
Risk factors of candida vulvovaginosis
- Chronic use of broad spectrum antibiotics
- Use of steroids
- Use of OCPs, HRT
- Immunosuppression (HIV, DM, pregnancy)
- Vaginal douching, tight-fitting undergarments
- Underlying dermatosis (eczema)
Symptoms of candida infection
- Discharge: curdy, thick and white (cottage cheese) with a yeast odour
- Vulvo-vaginal itching
- Soreness or burning sensation at itroitus -> Dyspareunia
- Scratching -> abrasions -> stinging sensation on micturition -> Dysuria
- Partner may complain of itching of glans penis and foreskin
PE findings for candida vulvovaginosis
- Speculum examination: white, curdy discharge that is adherent to vaginal walls and cervix
- Whole vulva area is red, swollen and fissured
Investigations for candida vulvovaginosis
High vaginal swab
- presence of more than 10 yeast colonies confirms the dx
Management of candida vulvovaginosis
PO Fluconazole OR Clotrimazole pessary if oral C/I
Avoid:
- contact with perfumed soap, shampoo, bubble baths
- vaginal douching
- sex until infection has cleared
Bacterial vaginosis
*commonest cause of abnormal vag discharge in women of childbearing age
- due to lesser lactobacilli in the vagina producing hydrogen peroxidase -> rise in vaginal pH -> overgrowth of predominantly anaerobic organisms
Risk factors of bacterial vaginosis
- Smoking
- IUCD
- Receptive oral sex
- Recent change in sex partner
- Vaginal douching, use of scented soap, bubble baths
Symptoms of BV
- fishy-smelling discharge, particularly after sexual intercourse
- whitish/greyish discharge, thin and homogenous watery consistency
- speculum examination: white thin, homogenous watery discharge coating the walls of the vagina
Complications of BV in pregnancy
Preterm labour
Low birth weight
Preterm pre-labour rupture of membranes
Post partum endometritis
Chorioamnionitis
Miscarriage
Investigations for BV
- Wet mount to look for Clue cells
- Whiff test: Addition of KOH releases fishy, amine-like odour
- Gram stain to look for clue cells (Epithelial cells of vagina)
What criteria to use to diagnose BV?
Ansel’s criteria (3 out 4):
1. Characteristic thin, white watery homogenous discharge on examination
2. Vaginal pH >4.5
3. Presence of “clue cells” on microscopy
- “Clue cells” are vaginal epithelial cells so heavily coated with bacteria that their borders are obscured
4. Release of a fishy smell on adding an alkali —usually 10% KOH
Management of BV
PO metronidazole or topical clindamycin cream
- Clindamycin use for pregnant women in 1st trimester
Avoid vaginal douching, bubble bath
Side effects of PO metronidazole
N/V
Metallic taste
Change breastmilk taste
Trichomoniasis
Sexually transmitted infection caused by trichomonas vaginalis, parasite found at vagina, urethra and paraurethral gland
Risk factor of trichomonas vaginalis (STI in general)
Unprotected sexual intercourse
Symptoms of trichomonas vaginalis
- Frothy yellowish-green vaginal discharge
- Vaginal soreness, itching
- Dyspareunia
- Dysuria
- Low abdo pain
Speculum examination: strawberry cervix due to punctate haemorrhages
Investigations for TV
Microscopy/High vaginal swab for culture nucleic acid amplification tests
Management of TV
- Metronidazole
- Treat sexual partner + trace & treat recent partners
- Avoid sex until tx period over to avoid re-infection
Genital herpes
STI caused by HSV 1 or 2
- HSV 1 mainly orolabial
- HSV 2 mainly genital
Clinical features of herpes simplex virus
Asymptomatic
Local symptoms:
- Painful ulceration
- Dysuria
- Vaginal or urethral discharge
Systemic symptoms:
- Fever
- Myalgia
Signs
- Blistering (vesicles) and ulceration of the external genitalia or perianal region
- Tender inguinal lymphadenitis, usually bilateral
Investigations for HSV
- Take swabs from base of lesions (vesicles should be unroofed first)
- HSV DNA detection by PCR
Management of HSV
- Symptoms: Saline bath, topical lignocaine
- 1st episode: acyclovir 400 mg orally three times a day for 7-10 days
- Recurrent: Aciclovir 800 mg three times daily for 2 days
- Suppressive (6 recurrances per annum): Aciclovir 400 mg twice daily
- IV therapy for immunocompromised patients
Why do genital herpes recur?
because after primary infection, virus lies dormant in the dorsal root ganglia and may be re-activated periodically to cause recurrent outbreaks
Complications of HSV
Meningism
Urinary retention
Causative agent of chlamydia
Bacterium chlamydia trachomatis
Symptoms of chlamydia trachomatis
70% are asymptomatic
- Abnormal vaginal discharge - Burning sensation when urinating
- Lower abdominal pain, low back pain
- Nausea, fever, pain during intercourse, or bleeding between menstrual periods
Investigations for chlamydia
Endocervical swab or urine sample
Management of chlamydia
Azithromycin 1g STAT followed by 500mg daily x2d (NOTE: azithro is SAFE in pregnancy)
OR
Doxycycline 100 mg orally twice a day for 7 days (C/I in pregnancy)
- in non-pregnancy: choose doxycycline first before azithromycin
Trace, screen all sex partners and treat
Neisseria gonorrhoea
Mostly asymptomatic
- Increased or abnormal vaginal discharge
- Painful or burning sensation when urinating
- Vaginal bleeding between periods
Investigations for gonorrhoea
Endocervical swab or urine sample
Management of gonorrhoea
IM Ceftriaxone 1g in a single dose or PO Cipro 500mg
once
Trace, screen all sex partners and treat
TOC REQUIRED
Avoid sexual intercourse till 7 days after treatment of both partners
Physical examination for STI
- Vitals, BMI
- General inspection
- Oral cavity, palms, skin
- Rashes, lump, ulcers, discharge - Abdominal Examination
- Speculum/Vaginal examination
- Inspection of external genitalia, perineum
- Speculum examination
- Bimanual pelvic examination (cervical excitation, adnexal tenderness)
General investigations for STI
- Clamydia, Gonorrhoea - endocervical swab or urine sample
- Candida, gardnerella, trichomonas - High vaginal swab
- HIV/Hep B/VDRL - blood
- HSV swab if vesicles present
- Cervical smear - PAP or HPV depending on age
General management of STI
- Identify the condition and recognise that it is an STD
- Inform of diagnosis, nature of treatment and expected outcome
- Reiterate need for compliance and completion of treatment
- Prevention of disease transmission
- Avoid further sexual contact until treatment completed
- Contact tracing & treatment of sexual partners - Some conditions may require test of cure
- Prevention of future infection
- Abstinence, reducing number of sexual partners and avoiding sexual contact
with persons with multiple sexual partners
- Correct and consistent use of condoms - Mandatory notification of chlamydia, gonorrhoea, syphilis within 72 hours to MOH
- Only demographic data is collected for these STIs: STI, age, gender, nationality,
ethnicity - Mandatory notification of HIV / AIDS within 72 hours to MOH
- Name, identity number and address as well as demographic data are collected
Conditions that require TOC
- Gonorrhoea (hard to treat, tends to linger after treatment)
- STIs in pregnancy
Note: Chlamydia and gonorrhoea symptoms are rather non-distinguishable (abt the same)
-
Long term complications of recurrent chlamydia infection
Chronic PID
- tubo-ovarian abscess
- hydrosalphinx
Tubal ectopic preg
Tubal infertility
Chronic pelvic pain
