Discharge Flashcards
What causes cottage cheese discharge?
vaginal candidiasis
how would vaginal candidiasis present?
itching
white, cottage cheese discharge
pruritus
tenderness and burning sensation
how does penile candidiasis present?
soreness, pruritus
redness
dull, dry and glazed plaques and papules
vulvitis: superficial dyspareunia, dysuria
what is the pathophysiology candidiasis?
- fungal: Candida albicans
- transmission non-sexual
- caused by overgrowth despite being part of normal commensal flora
what are some risk factors for candida?
immunosuppression, endogenous oestrogen, recent Abx, DM, mucosal breakdown, recurrent candidiasis
how is candida investigated?
microscopy - detection of blastospores, pseudohyphae and neutrophils
high vaginal swab - charcoal not routine if clinical strong
*recurrent investigate for immunosuppressive conditions
what is the management for candida?
- first line fluconazole
- second line clotrimazole pessary
- pregnancy → cream or pessaries
- recurrent → induction with fluconazole
- general skin care
*compliance for medication, abstinence till complete, no use of soaps, tight underwear and douching
what causes grey-white discharge?
Bacterial vaginosis
what is the pathophysiology of BV?
bacterial imbalance of the vagina caused by an overgrowth of anaerobic bacteria, such as Gardnerella vaginalis, and a loss of lactobacilli, the dominant bacterial species responsible for maintaining an acidic vaginal pH
what factors could cause a pH imbalance which leads to BV?
- Having multiple sexual partners or a new sexual partner
- Douching
- Lack of consistent condom use
- Hormonal changes, such as those that occur in pregnancy
what are some risk factors for BV?
douching, perfumed products, cunnilingus, black race, recent change in partner, smoking, presence of an STI
how does is BV diagnosed?
Amsel’s criteria for diagnosis of BV - 3 of the following 4
- thin, white homogenous discharge
- clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5 - positive whiff test (addition of potassium hydroxide results in fishy odour)
how is BV investigated?
- microscopy: no lactobacilli
- pH: alkali
- high vaginal swab
- whiff test
how is BV managed?
- Metronidazole or Clindamycin, which can be administered orally or intravaginally
- Sex partners do not typically require treatment
- can have a gel if cannot keep off alcohol
- washing advice - no douching, no use of soaps
when might BV cause life threatening complications?
*if pregnant
- results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
What causes Offensive, yellow/green, frothy discharge?
Trichomonas vaginalis
what is the pathophysiology of trichomonas?
- Flagellate protozoan
- transmission: sex
how might trichomonas present?
- Vaginal discharge (thin, frothy yellow coloured)
- Strawberry cervix on speculum examination
- Vulval pruritus
- Vulvovaginitis
- Dysuria
- Dyspareunia
how might trichomonas present in men?
- Urethral discharge
- Urethral irritation/itching
- Dysuria
- Balanitis
how is trichomonas investigated?
- pH >4.5
- microscopy of a wet mount shows motile trophozoites
how is trichomonas managed?
oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole
- avoid alcohol during tx and 72h afterwards
- - full sexual health screen
- contact tracing and partner notifications
- avoid sex until tx
- test of cure not routine
what are some complications of trichomonas?
- Pelvic inflammatory disease: increases the risk of ectopic pregnancy and infertility
- Altered vaginal flora
- Prostatitis
- In pregnancy, there is an increased risk of premature rupture of membranes and preterm birth
what presents as Copious, mucopurulent discharge, dysuria, sx 3 days after new sexual contact?
Gonorrhoea
what is the pathophysiology of gonorrhoea?
- Neisseria gonorrhoea - gram negative intra-cellular diplococci
- primary sites: columnar epithelium lines mucous membranes
- urethra, endocervix, rectum, pharynx, conjunctiva
- urethral - mucopurulent discharge
- transmitted through sexual contact + direct inoculation of infected secretions, vertical transmission can cause ophthalmia neonatorum
how does gonorrhoea present?
- rectal: proctitis leading to pain, bleeding and discharge
mucopurulent
dysuria
Upon examination in women, discharge from the cervical os, Skene’s gland or Bartholin’s gland may be observed
how is gonorrhoea investigated?
- Self-taken vulvovaginal swab in women or self-obtained first pass urine in men; self-obtained rectal swab; or clinician-obtained endocervical or penile swab
- Microscopy revealing monomorphic Gram-negative diplococci within polymorphonuclear leukocytes
- Nucleic acid amplification tests (NAAT)
- Culture
how is gonorrhoea managed?
Ceftriaxone as the first-line treatment. Following treatment, a test of cure after 14 days is essential to monitor disease clearance and assess the effectiveness of the chosen antibiotic regimen
- avoid sex
- partner notification
- treat them
how does gonorrhoea complicate?
- DIC: pustular lesions, joints, tendon involvement
*are complication of gonococcal infection leading to systemic features (including arthritis, skin lesions and arthralgia) - transluminal spread - PID, epidiymoorchitis, prostatitis
what presents as Colourless mucoid, watery urethral discharge, dysuria?
Chlamydia
what is the pathophysiology of chlamydia?
- Organism: chlamydia trachomatis, obligate intracellular bacteria
- transmission: sexual contact, peri-natal transmission in vaginal canal → neonatal conjunctivitis and pneumonia
how does chlamydia present in women?
- Vaginal discharge
- Proctitis
- Post-coital bleeding (may indicate cervicitis)
- Intermenstrual bleeding
- Cervicitis on vaginal exam
- PID
how does chlamydia present in men?
- Urethral discharge (usually clear)
- Dysuria
- Proctitis
- scrotal pain → epididymo-orchitis
how is chlamydia investigated?
For women: a vulvovaginal swab (either self-taken or clinician-taken) or an endocervical swab analysed using NAATs
For men: urine or urethral swab, analysed using the same method
For suspected anal infections: an anal swab, also analysed using NAATs
how is chlamydia managed?
Treatment involves a course of oral doxycycline, administered twice daily for 7 days
Following treatment of rectal infections, a test of cure is usually recommended
- contact tracing + partner notification
- abstinence until completed tx
- test of cure at 5w in case of rectal infection or pregnancy
what are some complications of chlamydia?
- Pelvic inflammatory disease (PID): increases the risk ofectopic pregnancyand infertility
- Epididmyo-orchitis (leading to scrotal pain and swelling)
- Prostatitis
- Reactive arthritis
what does vulvovaginal swabs test for?
- NAAT for gonorrhoea and trachomatis
- PCR for T.vaginalis
what does high vaginal swab test for?
- culture - t.vaginalis
- microscopy with wet mount or gram stain
what does endocervical swabs?
gonorrhoea
what are some differentials for physiological discharge?
- pregnancy
- sexual arousal
- cyclical
- hormonal contraception
what may cause pathological vaginal discharge?
- candidiasis
- TV
- BV
- foreign body
- post-menopausal vaginitis
what are some pathological cervical discharge?
- gonorrhoea
- chlamydia
- herpes
- non-specific genital infections
- cervical ectopy
