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m4 obgyn > Abnormal vaginal discharge > Flashcards

Abnormal vaginal discharge Flashcards

1
Q

Normal vaginal discharge

A

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

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2
Q

What is pruritus vulvae?

A

Itch of the vulva that is persistent and causes distress
*Sx not a diagnosis

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3
Q

How to differentiate between normal vs abnormal vaginal discharge?

A

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

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4
Q

Causes of abnormal vaginal discharge

A
  1. Physiological
    - Pregnancy
    - OCP
    - Cervical entropian
    - Emotional stress
  2. Infective
    - Bacterial vaginosis ++
    - Candidiasis +
    - STI (Genital herpes, Chlamydia, Gonorrhea)
    - Trichomonas
  3. Pelvic inflammatory disease
    - main p/c is lower abdo pain but can p/w discharge
  4. Malignancy
    - Vaginal cancer
    - Cervical cancer
    - Endometrial cancer
    - Fallopian tube cancer
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5
Q

Common causative agent of candida vulvovaginosis (aka thrush infection)

A

Candida albicans

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6
Q

Risk factors of candida vulvovaginosis

A
  • 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)
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7
Q

Symptoms of candida infection

A
  • 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
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8
Q

PE findings for candida vulvovaginosis

A
  • Speculum examination: white, curdy discharge that is adherent to vaginal walls and cervix
  • Whole vulva area is red, swollen and fissured
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9
Q

Investigations for candida vulvovaginosis

A

High vaginal swab
- presence of more than 10 yeast colonies confirms the dx

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10
Q

Management of candida vulvovaginosis

A

PO Fluconazole OR Clotrimazole pessary if oral C/I
Avoid:
- contact with perfumed soap, shampoo, bubble baths
- vaginal douching
- sex until infection has cleared

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11
Q

Bacterial vaginosis

A

*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
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12
Q

Risk factors of bacterial vaginosis

A
  • Smoking
  • IUCD
  • Receptive oral sex
  • Recent change in sex partner
  • Vaginal douching, use of scented soap, bubble baths
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13
Q

Symptoms of BV

A
  • 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
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14
Q

Complications of BV in pregnancy

A

Preterm labour
Low birth weight
Preterm pre-labour rupture of membranes
Post partum endometritis
Chorioamnionitis

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15
Q

Investigations for BV

A
  • 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)
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16
Q

What criteria to use to diagnose BV?

A

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

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17
Q

Management of BV

A

PO metronidazole or topical clindamycin cream
- Clindamycin use for pregnant women in 1st trimester
Avoid vaginal douching, bubble bath

18
Q

Side effects of PO metronidazole

A

N/V
Metallic taste
Change breastmilk taste

19
Q

Trichomoniasis

A

Sexually transmitted infection caused by trichomonas vaginalis, parasite found at vagina, urethra and paraurethral gland

20
Q

Risk factor of trichomonas vaginalis (STI in general)

A

Unprotected sexual intercourse

21
Q

Symptoms of trichomonas vaginalis

A
  • Frothy yellowish-green vaginal discharge
  • Vaginal soreness, itching
  • Dyspareunia
  • Dysuria
  • Low abdo pain

Speculum examination: strawberry cervix due to punctate haemorrhages

22
Q

Investigations for TV

A

Microscopy/High vaginal swab for culture nucleic acid amplification tests

23
Q

Management of TV

A
  • Metronidazole
  • Treat sexual partner + trace & treat recent partners
  • Avoid sex until tx period over to avoid re-infection
24
Q

Genital herpes

A

STI caused by HSV 1 or 2
- HSV 1 mainly orolabial
- HSV 2 mainly genital

25
Q

Clinical features of herpes simplex virus

A

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

26
Q

Investigations for HSV

A
  • Take swabs from base of lesions (vesicles should be unroofed first)
  • HSV DNA detection by PCR
27
Q

Management of HSV

A
  • 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
28
Q

Why do genital herpes recur?

A

because after primary infection, virus lies dormant in the dorsal root ganglia and may be re-activated periodically to cause recurrent outbreaks

29
Q

Complications of HSV

A

Meningism
Urinary retention

30
Q

Causative agent of chlamydia

A

Bacterium chlamydia trachomatis

31
Q

Symptoms of chlamydia trachomatis

A

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

32
Q

Investigations for chlamydia

A

Endocervical swab or urine sample

33
Q

Management of chlamydia

A

Azithromycin 1g STAT followed by 500mg daily x2d OR
Doxycycline 100 mg orally twice a day for 7 days (C/I in pregnancy)

Trace, screen all sex partners and treat

34
Q

Neisseria gonorrhoea

A

Mostly asymptomatic
- Increased or abnormal vaginal
discharge
- Painful or burning sensation when urinating
- Vaginal bleeding between periods

35
Q

Investigations for gonorrhoea

A

Endocervical swab or urine sample

36
Q

Management of gonorrhoea

A

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

37
Q

Physical examination for STI

A
  1. Vitals, BMI
  2. General inspection
    - Oral cavity, palms, skin
    - Rashes, lump, ulcers, discharge
  3. Abdominal Examination
  4. Speculum/Vaginal examination
    - Inspection of external genitalia, perineum
    - Speculum examination
    - Bimanual pelvic examination (cervical excitation, adnexal tenderness)
38
Q

General investigations for STI

A
  1. Clamydia, Gonorrhoea - endocervical swab or urine sample
  2. Candida, gardnerella, trichomonas - High vaginal swab
  3. HIV/Hep B/VDRL - blood
  4. HSV swab if vesicles present
  5. Cervical smear - PAP or HPV depending on age
39
Q

General management of STI

A
  1. Identify the condition and recognise that it is an STD
  2. Inform of diagnosis, nature of treatment and expected outcome
  3. Reiterate need for compliance and completion of treatment
  4. Prevention of disease transmission
    - Avoid further sexual contact until treatment completed
    - Contact tracing & treatment of sexual partners
  5. Some conditions may require test of cure
  6. 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
  7. Mandatory notification of chlamydia, gonorrhoea, syphilis within 72 hours to MOH
    - Only demographic data is collected for these STIs: STI, age, gender, nationality,
    ethnicity
  8. Mandatory notification of HIV / AIDS within 72 hours to MOH
    - Name, identity number and address as well as demographic data are collected
40
Q

Conditions that require TOC

A
  1. Gonorrhoea (hard to treat, tends to linger after treatment)
  2. STIs in pregnancy
41
Q

Note: Chlamydia and gonorrhoea symptoms are rather non-distinguishable (abt the same)

A

-

m4 obgyn (37 decks)

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