Vaginal Discharge Flashcards
Give 4 common causes of vaginal discharge
Physiological
Bacterial vaginosis
Trichomonas vaginalis
Candida
What is physiological vaginal discharge?
Clear/ white, mucoid.
No odour or itching.
Related to cycle (↑mid cycle + premenstrual)
A/w oestrogen (puberty, pregnancy, COCP) or sexual excitement
“Leucohorroea”
What is bacterial vaginosis? Describe the discharge.
Elevated vaginal pH (>4.5) with Clue cells
White-grey watery offensive discharge but NO itching
Non-STI but increased risk with more sexual partners.
Unclear triggers
What is the cause of bacterial vaginosis?
Overgrowth of anaerobic bacteria, esp Gardnerella or Bacteroides, replacing usually dominant vaginal lactobacilli
Describe the epidemiology of BV
Most common cause of abnormal discharge in childbearing age.
Much more prevalent in black populations (~50% vs ~10% white)
What criteria is used to diagnose BV?
Amsel criteria for Dx (3/4):
- white-grey homogeneous discharge
- pH >5.5
- fishy smell when KOH added
- Clue cells on microscopy wet mount
What are Clue cells?
Squamous epithelial cells with bacteria adherent on their walls
What should be advised in BV?
Avoid vaginal douching, use of shower gel, + use of antiseptic agents or shampoo in the bath
What investigations should be performed for bacterial vaginosis?
Examination + Ix can be omitted if clear dx + empirical Tx started
High vaginal swab + gram stain (ddx, recurrence)
Vaginal pH
What is the management for bacterial vaginosis?
Metronidazole 400mg BD 5-7d
or single oral dose 2g
or
PV Clindamycin/ metronidazole
What is the management of BV in pregnancy?
Metronidazole 400mg BD 5-7d
What complications are associated with bacterial vaginosis?
BV can (rarely) cause problems in pregnancy:
Miscarriage
Preterm labour
LBW
Describe the discharge and symptoms in candidiasis
White curd-like discharge “cottage cheese”
Vulval itching++
Soreness
No odour.
May have excoriations + erythema +/- satellite lesions
What is the epidemiology of candidiasis?
Non-sexually transmitted.
75% lifetime risk
Very common in pregnancy
Unlikely in post-menopausal patients unless diabetic, immunosuppressed, or have recently had Abx.
What is the oral management for candidiasis?
Itraconazole 200mg PO BD for 1 day
or
Fluconazole 150mg PO stat
What is the local management of candidiasis? For which patients is this the only option?
Clotrimazole pessary/ cream
Topical for 12-15y
Intravaginal Pregnant women
What should be prescribed if vulval symptoms are present in candidiasis?
Topical imidazole
What treatment can be bought OTC for candidiasis?
Intravaginal clotrimazole (Canesten)
Topical clotrimazole
Oral fluconazole
What advice should be given in candidiasis?
Return if not resolved in 7-14d
Don’t over-clean, use soaps/ feminine hygiene products, douche, wear tight fitting underwear
When is candidiasis considered to be recurrent? How is this managed?
> ,4x per year
Induction: Fluconazole every 3/7 x 3
Maintenance: Fluconazole weekly 6/12
Give 7 risk factors for candidiasis
Pregnancy
OCPs
Diabetes
Immunosuppression
Recent Abx use
Steroids
Excessive washing
What are 6 signs and symptoms of Trichomonas vaginalis?
Green/grey frothy fishy-smelling discharge
Itching
Soreness
Dysuria
Dyspareunia/ bleeding after SI
2% also have ‘strawberry cervix’ (petechiae)
What causes TV?
Sexually transmitted flagellated protozoan
some evidence it may enhance HIV transmission
What investigations are performed for TV?
Refer to GUM
Microscopy of wet mount: motile trophozoites
High vaginal swab + NAAT
STI screen
What is the management of TV?
Metronidazole 2g PO STAT
OR
Metronidazole 400–500mg BD 5–7d
What is the management of TV in pregnant or breastfeeding women?
Metronidazole 400–500mg BD 5–7d
What are 4 signs and symptoms of cervicitis?
Greenish mucopurulent watery discharge
No odour
No itch
Cervix inflamed + may bleed easily
Can also have PCB, IMB, dysuria, deep dyspareunia, deep pelvic pain (PID)
What is cervicitis most commonly caused by?
STI - most commonly chlamydia or gonorrhoea
(70% chlamydia = asymptomatic + most gonorrhoea is asymptomatic too)
How should cervicitis be managed?
Treat as for chlamydia whilst awaiting swab results:
Azithromycin PO STAT
or
Doxycycline BD 7d
Azithromycin 1g PO stat if pregnant
Refer for contact tracing
Give 3 signs/ symptoms of discharge caused by foreign body
Grey/ bloody purulent discharge
Offensive smell
Not itchy
What is management for foreign body?
Remove
Give 3 signs/ symptoms of discharge caused by malignancy
Bloody watery discharge
Offensive smell
No itch
How should discharge caused by possible malignancy be managed?
High index of suspicion in any post-menopausal with ↑PV discharge
Urgent ref 2ww + imaging
Give 3 signs/ symptoms of atrophic vaginitis
Clear/ blood stained watery discharge
No odour.
Can have itching, soreness, dyspareunia
Give 3 risk factors for atrophic vaginitis
Post-menopausal
Hormone blockers e.g. Tamoxifen
Lactating
What is management of atrophic vaginitis?
topical oestrogen
Give 4 signs/ symptoms of cervical ectropion
Clear watery discharge
No odour
No itch
+/- PCB, PMB, IMB
How else may cervical ectropion present?
asymptomatic + picked up on routine smear test
Which 2 groups are more likely to develop cervical ectropion?
OCP
Pregnancy
What is management of cervical ectropion?
N/A if asymptomatic
If symptomatic stop COCP or
Cryotherapy
What is cervical ectropion?
presence of everted endocervical columnar epithelium on the ectocervix
What is the most common cause of vaginal discharge and soreness in childhood?
Vulvovagintis
often occurring when starts being responsible for toileting
What is the management of vulvovaginitis?
Often no organism isolated
Wipe front to back
Avoid bubble bath + bio washing powder
Loose cotton underwear.
Can consider simple emollient or short course oestrogen cream
What signs and symptoms could indicate fistula is causing PV discharge?
Hx of recurrent infections, faecal / urinary incontinence
Often secondary to obstructed/ prolonged delivery
How should a patient be investigated for fistulae? What is the management?
Sims speculum
(unlikely to see on Cusco)
Surgical repair
What investigations should be used for PV discharge?
Vaginal pH
Endocervical/ self-taken vulvovaginal swab for NAAT
High vaginal swab
Urine pregnancy test
Urine dip
What is indicated by vaginal pH < 4.5?
Candidiasis
What is normal vaginal pH?
3.5-4.5
What is indicated by vaginal pH > 4.5?
BV
TV
What is a endocervical/ self taken vulvovaginal swab used to screen for?
Chlamydia
Gonorrhoea
What is a high vaginal swab used to screen for?
BV
Candida
TV
Which causes of PV discharge should be referred to GUM?
Chlamydia
Gonorrhoea
TV
If testing for gonorrhoea or chlamydia, what else should be offered?
blood tests for HIV + syphilis
