Management of Vaginal Discharge

Question 1

Vaginal physiology

Answer 1

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)

Question 2

Physiological discharge

Answer 2

Normal exudate from vaginal skin & cervical discharge

Newborns are exposed to maternal estrogens so can have normal physiological discharge

Question 3

Causes of Vaginal Discharge

Answer 3

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

Question 4

Trichomonas vaginalis

Answer 4

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

Question 5

Prevalence of Vaginal discharge

Answer 5

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

Question 6

Bacterial Vaginosis

Answer 6

50% asymptomatic
Offensive fishy smelling discharge
Commonest cause of abnormal vaginal discharge in women of childbearing age–> can occur postmenopause but rarer in children

Question 7

Candidiasis

Answer 7

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

Question 8

Risk factors for Bacterial vaginosis

Answer 8

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%

Question 9

Bacterial Vaginosis - Causes

Answer 9

Overgrowth of anaerobes (gardnerella, prevotella, mycoplasma etc) which replace lactobacillus and increase the pH–> not an infection and can happen to virgins

Question 10

Bacterial Vaginosis - Diagnosis

Answer 10

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

Question 11

Amsel Score

Answer 11

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

Question 12

Hay/Ison criteria

Answer 12

Grade 1–> Normal, lactobacillus predominate
Grade 2–> Intermediate, mixed flora
Grade 3–> BV, mainly Gardnerella and Mobiluncus

Question 13

Nugent Score

Answer 13

For research only

Composite score based on number and type of bacteria seen on microscopy

Question 14

Treatment of BV - Indications

Answer 14

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

Question 15

BV treatment

Answer 15

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)

Question 16

Candidiasis -Signs and symptoms

Answer 16

Vulval erythema/fissuring
Satellite skin lesions
Vulval Oedema
Curdy, non-offensive discharge

Question 17

Candidiasis - Risk factors

Answer 17

Pregnancy, Broad spec Abx, Immuno-suppression (HIV, drugs, etc), Endocrine disorders (diabetes, Cushing’s), possibly Iron Deficiency

Question 18

Candidiasis - Diagnosis

Answer 18

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

Question 19

Candidiasis - Treatments

Answer 19

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

Question 20

Cervical Ectropion

Answer 20

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

Question 21

Diagnosis of Trichomonas Vaginalis (TV)

Answer 21

Direct observation under microscopy (40-70% sensitivity)
Culture –95% sensitivity
NAATs —> 100% sensitivity and specificity

Question 22

Treatment of Trichomonas Vaginalis (TV)

Answer 22

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

Question 23

Treatment of BV in pregnancy

Answer 23

As it is a risk factor for a number of problems including preterm labour it should be treated with oral metronidazole or clindamycin cream

Question 24

Vaginal pH above 4.5?

Answer 24

This could be both TV or Bacterial vaginosis