GUM - Presenting problems in women

Question 1

What features distinguish infective from normal vaginal discharge?

Answer 1

Vaginal discharge is normal and varies considerably with puberty, pregnancy or contraceptive medication. A sudden or recent change in discharge, especially if associated with alteration of colour and/or smell or vulval itch/ irritation is more likely to indicate an infective cause than a gradual long standing change.

Question 2

What is the most common cause of vaginal discharge?

Answer 2

In the UK, most cases of vaginal discharge are not sexually transmitted, being due to candida infection or BV. Worldwide, the most common cause of vaginal discharge is trichomoniasis (caused by the protozoa trichomonas vaginalis). Other possibilities include gonorrhoea and chlamydia. HSV may cause increased discharge although vulval pain and dysuria are usually predominant symptoms.

Question 3

What infections cause vaginal discharge and what are there distinguishing features?

Answer 3

1) BV - discharge is homogeneous and off white colour, vaginal pH >4.5, gram stain reveals scant or absent lactobacilli with significant numbers of gram variable organisms some of which may be coating vaginal squamous cells (“clue” cells)
2) Candidiasis - vulval and vaginal inflammation, curdy white discharge adherent to the walls of the vagina, low vaginal pH
3) Trichomoniasis - vulval and vaginal inflammation, frothy green discharge
4) Strep/ staph infection - purulent vaginal discharge

Cervical involvement increases the likelihood of chlamydial or gonococcal infection. Swabs should be taken.

Question 4

How are the infective causes of vaginal discharge treated?

Answer 4

BV = oral metronidazole 2g STAT or 400mg BD (5-7 days)
Candidiasis = clotrimazole (local) itraconazole (oral)
Trichomoniasis = metronidazole

Question 5

What features increase the likelihood of PID?

Answer 5

PID (= infection/ inflammation of the fallopian tubes and surrounding structures) should be considered as the differential in sexually active women with lower abdo pain. PID is increased if alongside acute/ subacute pain there is dyspareunia, abnormal vaginal discharge and/or bleeding. There may also be systemic features such as fever. Bimanual examination shows adenexal tenderness. Perform pregnancy test and STI workup. Rx is oral metronidazole + ofloxacin. Treatment delay increases likelihood of negative complications.

Question 6

What is the most common cause of genital ulceration in women?

Answer 6

Genital herpes is the most common. Classically, multiple painful ulcers affect labia and perineum. Inguinal lymphadenopathy and systemic features are more common than in men. Most labs with also test for syphilis. Inflammatory and tropical causes are as for men.

Question 7

What causes genital lumps?

Answer 7

Genital warts are the most common cause (caused by HPV). They are classically found in areas of friction during sex, such as fourchette and perineum. Differential diagnoses is molloscum contagiosum, skin tags and normal papillae or sebaceous glands.

Question 8

Name some causes of chronic vulval pain and/ or itch in women?

Answer 8

Candidiasis (itch but no pain) - oral antifungal
Lichen planus (+/- itch, but no pain) - papules
Lichen sclerosis (+/- itch, no pain) - strong steroid
Vestibulitis (no itch, painful)
Vulvodynia (no itch, painful)
Dermatoses (itch, no pain)
Genital herpes (+/- itch, painful) - oral aciclovir