Abnormal vaginal discharge

Question 1

Normal vaginal discharge

Answer 1

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

Question 2

What is pruritus vulvae?

Answer 2

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

Question 3

How to differentiate between normal vs abnormal vaginal discharge?

Answer 3

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

Question 4

Causes of abnormal vaginal discharge

Answer 4

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

Question 5

Common causative agent of candida vulvovaginosis (aka thrush infection)

Answer 5

Candida albicans

Question 6

Risk factors of candida vulvovaginosis

Answer 6

• 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)

Question 7

Symptoms of candida infection

Answer 7

• 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

Question 8

PE findings for candida vulvovaginosis

Answer 8

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

Question 9

Investigations for candida vulvovaginosis

Answer 9

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

Question 10

Management of candida vulvovaginosis

Answer 10

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

Question 11

Bacterial vaginosis

Answer 11

*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

Question 12

Risk factors of bacterial vaginosis

Answer 12

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

Question 13

Symptoms of BV

Answer 13

• 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

Question 14

Complications of BV in pregnancy

Answer 14

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

Question 15

Investigations for BV

Answer 15

• 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)

Question 16

What criteria to use to diagnose BV?

Answer 16

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

Question 17

Management of BV

Answer 17

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

Question 18

Side effects of PO metronidazole

Answer 18

N/V
Metallic taste
Change breastmilk taste

Question 19

Trichomoniasis

Answer 19

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

Question 20

Risk factor of trichomonas vaginalis (STI in general)

Answer 20

Unprotected sexual intercourse

Question 21

Symptoms of trichomonas vaginalis

Answer 21

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

Speculum examination: strawberry cervix due to punctate haemorrhages

Question 22

Investigations for TV

Answer 22

Microscopy/High vaginal swab for culture nucleic acid amplification tests

Question 23

Management of TV

Answer 23

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

Question 24

Genital herpes

Answer 24

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

Question 25

Clinical features of herpes simplex virus

Answer 25

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

Question 26

Investigations for HSV

Answer 26

- Take swabs from base of lesions (vesicles should be unroofed first) - HSV DNA detection by PCR

Question 27

Management of HSV

Answer 27

* 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

Question 28

Why do genital herpes recur?

Answer 28

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

Question 29

Complications of HSV

Answer 29

Meningism Urinary retention

Question 30

Causative agent of chlamydia

Answer 30

Bacterium chlamydia trachomatis

Question 31

Symptoms of chlamydia trachomatis

Answer 31

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

Question 32

Investigations for chlamydia

Answer 32

Endocervical swab or urine sample

Question 33

Management of chlamydia

Answer 33

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

Question 34

Neisseria gonorrhoea

Answer 34

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

Question 35

Investigations for gonorrhoea

Answer 35

Endocervical swab or urine sample

Question 36

Management of gonorrhoea

Answer 36

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

Question 37

Physical examination for STI

Answer 37

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)

Question 38

General investigations for STI

Answer 38

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

Question 39

General management of STI

Answer 39

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

Question 40

Conditions that require TOC

Answer 40

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

Question 41

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

Answer 41

-

Question 42

Long term complications of recurrent chlamydia infection

Answer 42

Chronic PID - tubo-ovarian abscess - hydrosalphinx Tubal ectopic preg Tubal infertility Chronic pelvic pain