Management of Vaginal Discharge Flashcards
Vaginal physiology
7cm fibromuscular canal w/ stratified non-keratinising squamous epithelium. During reproductive life hormones thicken lining
Oestrogen (proliferative phase) –> epithelium thickens. Secretory phase –> intermediate layers fill with glycogen (split by lactobacillus –> lowers pH)
Physiological discharge
Normal exudate from vaginal skin & cervical discharge
Newborns are exposed to maternal estrogens so can have normal physiological discharge
Causes of Vaginal Discharge
Physiological –> the majority of discharge is not related to STI
STIs–> Trichomonas vaginalis (TV), Gonorrhoea, C trachomatis
Other infective–> Bacterial vaginosis, Candida, Aerobic Vaginitis
Other–> Foreign body, cervical ectropion, Allergy, Cervical carcinoma
Trichomonas vaginalis
10-50% asymptomatic, offensive discharge (70%) & can be yellow/frothy, 2% get ‘strawberry cervix, vulval itching, dysuria –> rarely, low abdominal discomfort. 100m new infections/yr globally.
Uncommon in UK–> sig. co-factor with HIV and Increases the likelihood of preterm birth
Prevalence of Vaginal discharge
10-12% of young women report having abnormal discharge but this does not strongly correlate with abnormal findings after investigation
Its really common and usually fine
Bacterial Vaginosis
50% asymptomatic
Offensive fishy smelling discharge
Commonest cause of abnormal vaginal discharge in women of childbearing age–> can occur postmenopause but rarer in children
Candidiasis
10-20% asymptomatic. Vulval itching or soreness. Non-offensive vaginal discharge and Superficial Dyspareunia
Very common and mostly self limiting –> overgrowth of a normal organism
Risk factors for Bacterial vaginosis
More common in women who: smoke, not using contraception, Douche more than twice a week
IUD and IDS do not increase risk of BV
Sig ethnic variation: Caucasian 5-15%, black 45-55%, asian 20-30%
Bacterial Vaginosis - Causes
Overgrowth of anaerobes (gardnerella, prevotella, mycoplasma etc) which replace lactobacillus and increase the pH–> not an infection and can happen to virgins
Bacterial Vaginosis - Diagnosis
Largely one of exclusion–> examine with speculum & microscopy–> busy with gram variable bacteria instead of just gram +ve lactobacillus
check for other causes (particularly trichomonas)
Can use the Amsel, Hay/Ison or Nugent scores
Amsel Score
3 or more the following in BV:
- Thin, white/yellow homgenous discharge
- Clue cells on microscopy
- pH of vagina >4.5 or Fishy odor on adding alkali solution
Hay/Ison criteria
Grade 1–> Normal, lactobacillus predominate
Grade 2–> Intermediate, mixed flora
Grade 3–> BV, mainly Gardnerella and Mobiluncus
Nugent Score
For research only
Composite score based on number and type of bacteria seen on microscopy
Treatment of BV - Indications
Treat people with symptoms who wish to be treated, or women who are pregnant with a Hx of problems in pregnancy or will be having surgery
BV treatment
Metronidazole/Tindazole 2g single dose (cheapest & easiest) OR Metronidazole 400mg BD for 5 days OR Clindamycin 300mg oral BD for 1wk OR clindamycin cream (2%) OD for 1wk (pregnancy safe)
Candidiasis -Signs and symptoms
Vulval erythema/fissuring
Satellite skin lesions
Vulval Oedema
Curdy, non-offensive discharge
Candidiasis - Risk factors
Pregnancy, Broad spec Abx, Immuno-suppression (HIV, drugs, etc), Endocrine disorders (diabetes, Cushing’s), possibly Iron Deficiency
Candidiasis - Diagnosis
Microscopy of discharge–> yeasts or pseudohyphe (40-65% sensitivity)
absence of smell is indicative, as candidiasis and BV will not usually co-exist. Exclude other STIs
Candidiasis - Treatments
If a patient asks for it, treat them: oral Fluconazole 150mg stat OR Itraconazole 200mg Twice
Pessaries –> Clotrimazole 500mg once/200mg OD for 3 days OR Miconazole 1200mg once/400mg OD for 3 days OR Econazole 150mg once
Topical creams are of no proven benefit
Cervical Ectropion
An erosion of the cervix where the normal squamo-columnar junction is extended outwards from the opening of the cervix
Can cause increased discharge
More common in pregnancy or if on the COC
Managed by reassurance
Diagnosis of Trichomonas Vaginalis (TV)
Direct observation under microscopy (40-70% sensitivity)
Culture –95% sensitivity
NAATs —> 100% sensitivity and specificity
Treatment of Trichomonas Vaginalis (TV)
Always treat if positive test
Metronidazole/Tindazole 2g oral stat dose OR metronidazole 500mg oral BD for 5-7 days
Offer full STI/HIV screen + Partner management
No sex till a week after partner has been treated
Treatment of BV in pregnancy
As it is a risk factor for a number of problems including preterm labour it should be treated with oral metronidazole or clindamycin cream
Vaginal pH above 4.5?
This could be both TV or Bacterial vaginosis
