Urethral discharge diagnosis and management

Question 1

Causes of urethral discharge

Answer 1

- Bacterial
Gonorrhea - purulent discharg
Chlamydia trachomatis
T. pallidum
Mycoplasma genitilium
Ureaplasma urealyticum
UTIs - E. coli, S. saprophyticus, Klebseilla pneumoniae, P. aeruginosa
Reiter's syndrome - Syphllis, Salmonella, Shigella, Campylobacter. 

• Protozoal
  Trichomonas vaginalis
• Viral
  HSV 1 and 2 (mostly 2)
  HPV
• Physical or chemical trauma to the urethra, urinary tract.

Question 2

Causes of Diagnosing urethral discharge

Answer 2

Urethral smears, patient should not have urinated in 4 hours.

Gram stain,

• neutrophils confirms urethritis
• can reveal g.neg. gonococcus, E. coli, C. trachomatis intracellular reticular body inclusions.
• Trichomonas vaginalis

Methylene blue stain - C. albicans

Urease test for ureaplasma urealyticum

Cultures of the swab for gonococcus and chlamydia

Two-glass urine test - can suggest whether the infection is localized to the anterior urethra or higher in the urinary tract.

Serology for HIV, Syphillis

HSV, HPV, Syhpillis, H. Ducryei - lesion scrapings,
Tzank smear - HSV
Koilocytes - HPV
Dark field Syphillis and RPR VDRL tests and TPPA and TPHA tests

PCR formycoplasma or ureaplasma

Question 3

What does the RPR test test for

Answer 3

The term reagin means that this test does not look for antibodies against the bacterium itself, Treponema pallidum, but rather for antibodies against substances released by cells when they are damaged by T. pallidum (cardiolipin and lecithin).

False positives:
SLE
HIV
Lyme disease
Some pneumonias

Question 4

Causes of Vaginal discharge

Answer 4

Candida albicans - Thick, white, lumpy

Bacterial vaginosis- Gardenerella, Prevotella - Thin, white, fishy odor

Gonococcus - viscous, purulent discharge

Chlamydia - thin, watery, leady discharge

Trichomonas - Frothy, yellow-green, smelly discharge

HSV 2 - From vaginal vesicles, erosions, ulcers

HPV - bloody/brown discharge from bleeding of vaginal/cervical warts.

Non-infective causes:
Cervical polyps or neoplasia
Prolonged tampon use or chemical irriation
Physiological discharge - clear and odorless.

Question 5

Diagnosis of vaginal discharge

Answer 5

Smears obtained from inside the vagina on the lateral vaginal wall

Gram stain

• gonorrhea g neg diplococci
• chlamydia intracellular reticular bodies
• gardenerella, gram variable rod, heavily coating epithelial cells, forming clue cells.
• pelvic inflamatory disease E coli.

Wet mount for trichomonas from the posterior fornix - Motile trophozoites - trichomonas
Clue cells - gardenerella
Pseudohyphae of budding yeast - Candida

KOH whiff test for bacterial vaginosis

Methylene blue stain for candida or other fungi.
Rectal and throat swabs for gonococci and chlamydia

Test vaginal secretion pH.

HIV and syphilis serology (common coinfections of gonococcus and STDs)

Pap smear for HPV infection, abnormal cells, koilocytes or dysplasia.

Vaginal inspection for polyps, erosions, ulcers.

Question 6

What is the normal major bacteria of healthy vaginal flora

Answer 6

Lactobacillus species - long gram positive rods. (normal vag has a long g+ rods in it)
with a minor population of anaerobic gram negatives.

Question 7

Normal vaginal pH?

Answer 7

4-4.5

or 3.8-4.5

Question 8

How does vaginal pH change in:
Bacterial vaginosis

Trichomonas vaginitis

Candidal vaginitis

Answer 8

Bacterial: Alkalinized above 4.5 often between 5.0-6.5

Trichomonas: Above 4.5

Candida: Normal, 4.0-4.5