Special Topics In Gynaecology

Question 1

Abnormal Vaginal Discharge and its causes?

Answer 1

ABNORMAL VAGINAL DISCHARGE

INTRODUCTION

Abnormal vaginal discharge is a frequent complaint of women seen in the gynecologic clinic. The discharge may be an excess of normal or it may pathological. It may be blood-stained or contaminated with urine or stool, all of which are however excluded from the discussion made below.

Characteristics of normal vaginal fluid: It is watery, white in color, nonodorous with pH around 4.0. Microscopically, it contains squamous epithelial cells and a few bacteria. Lactobacilli (Doderlein bacilli, page 5), few gram-negative bacteria and anaerobes are present without any white or red blood cells.

Causes of abnormal discharge are schematically presented in Flowchart 34.1, Tables 34.1 and 34.2.

Question 2

Leukorrhea:
1. Definition

Answer 2

Definition
Leukorrhea is strictly defined as an excessive normal vaginal discharge.
The term leukorrhea should fulfill the following

criteria:

■The excess secretion is evident from persistent vulvar moistness or staining of the undergarments (brownish- yellow on drying) or need to wear a vulvar pad.

■It is nonpurulent and nonoffensive. ■It is nonirritant and never causes pruritus.

Physiologic excess: The normal secretion is expected to increase in conditions when the estrogen levels become high. Such conditions are:

■During puberty: Increased levels of endogenous estrogen lead to marked overgrowth of the endocervical epithelium which may encroach onto the ectocervix producing congenital ectopy (erosion) increased secretion.

■During menstrual cycle:

• Around ovulation: Peak rise of estrogen increase in secretory activity of the cervical glands.

• Premenstrual pelvic congestion and increased mucus secretion from the hypertrophied end- ometrial glands.

■Pregnancy: There is hyperestrinism with increased vascularity. This leads to increased vaginal transudate and cervical gland secretion.
■During sexual excitement, when there is abundant secretion from the Bartholin’s glands.

Cervical cause: Noninfective cervical lesion may produce excessive secretion, which pours out at the vulva. Such lesions are-cervical ectopy, chronic cervicitis, mucous polyp and ectropion (cervical glands are exposed to the vagina).

Vaginal cause: Increased vaginal transudation occurs in conditions associated with increased pelvic congestion. The conditions are uterine prolapse, acquired retroverted uterus, chronic pelvic inflammation, ‘pill’ use and vaginal adenosis. Ill health is one of the important causes of excessive discharge. It produces excess exfoliation of the superficial cells.

Diagnosis

Evaluation of a patient with vaginal discharge needs detailed history, physical examination and the investiga- tions.

History should cover the symptoms, duration of discharge, any prior episodes, associated dysuria, dyspareunia, pelvic pain and use of contraception.

Physical examination to cover: General health assessment, abdominal examination for any mass or tenderness, Inspection of the vulva for the discharge any ulcer.

Speculum examination: To detect any pathology in the cervix, vagina.

Bimanual pelvic examination: For any foreign body, adnexal tenderness or mass.
Investigations to be organized for the discharge are: Microbiological study (p. 89) Pap smear, urine for RE and CS and tests for PCR/NAAT for the pathogens (p. 89).

Treatment

The following are the guidelines:

■ Improvement of general health.

■ Cervical factors require surgical treatment like electro- cautery, cryosurgery or trachelorrhaphy.

■Pelvic lesions producing vaginal leukorrhea require appropriate therapy for the pathology.

■Pill users may have to stop ‘pill’ temporarily, if the symptom is very much annoying.

■Above all, local hygiene has to be maintained meticulously.

■Treatment for specific infection.