Vaginal discharge

Question 1

What are the causes of vaginal discharge

Answer 1

Physiological: mucoid/opaque, increases with ovulation, pregnancy, and women taking the COCP

Pathological:
Candidiasis
Bacterial vaginosis
Atrophic vaginitis
Cervical eversion/ectropion
Gonococcal/chlamydial cervicitis
Trichomoniasis
Malignancy
Foreign body

Question 2

What investigations should be done for vaginal discharge

Answer 2

Endocervical swab (2 in 1 NAAT): chlamydia, gonorrhoea
High vaginal swab (Charcoal swab): candidiasis, BV, TV, GBS
Whiff test
Cervical smear
Litmus paper for pH (normal 3.5-4.5)
Slide
Bloods: HIV, syhpilis
+/- TVUSS

Question 3

What is suggested by the following:
Bloody discharge
Itch, cottage cheese discharge
Malodour, worse with intercours
Cherry red cervix
Frank vulvovaginitis with cervicitis ± ulceration
Anaerobic/malodourous
Vaginal bleeding and discharge

Answer 3

Blood discharge: cervicitis, cervical or endometrial malignancy
Itch, cottage cheese discharge: candidiasis
Malodour, worse with intercourse: BV
Cherry red cervix: Trichomoniasis
Frank vulvovaginitis with cervicitis ± ulceration: Herpes simplex
Anaerobic/malodourous: foreign body
Vaginal bleeding and discharge: cervical carcinoma

Question 4

Give the following features of cervical ectropion: discharge, itching, redness, odour, pH, treatment

Answer 4

Clear discharge
No itching
No redness
Normal odour
Normal pH
Tx: Cryotherapy

Question 5

Give the following features of bacterial vaginosis: discharge, itching, redness, odour, pH, treatment

Answer 5

Grey/white discharge
No itching
No redness
Fishy odour
Raised pH
Tx: Abx

Question 6

Give the following features of Trichomoniasis: discharge, itching, redness, odour, pH, treatment

Answer 6

Grey/green discharge
Itching
Redness
Foul odour
Raised pH
Tx: Abx

Question 7

Give the following features of malignancy: discharge, itching, redness, odour, pH, treatment

Answer 7

Red/brown discharge
No itching
No redness
foul odour
Variable pH
Tx: biopsy

Question 8

Give the following features of atrophic vaginitis: discharge, itching, redness, odour, pH, treatment

Answer 8

Clear discharge
No itching
Redness
No odour
Raised pH
Tx: oestrogen

Question 9

What is thrush and what are the causes

Answer 9

Vulvovaginal candidiasis
symptomatic inflammation of the vagina and/or vulva caused by a superficial fungal infection (usually yeasts that belong to the genus Candida)

Causes:
Candida yeasts are part of the normal flora of the mucous membranes of the female genital tract, but overgrowth can cause infection
Candida albicans (most common)
Candida glabrata
C. tropicalis, C. parapsilosis, C. Krusei etc.

Question 10

What defines recurrent candidiasis infection

Answer 10

Four or more symptomatic episodes in one year, with at least two episodes confirmed by microscopy or culture when symptomatic (at least one must be culture)

Question 11

What defines treatment failure for candidiasis

Answer 11

failure of symptoms to resolve within 7–14 days of treatment

Question 12

What are the risk factors for candidiasis

Answer 12

Recent antibiotic use (Causes a change in vaginal flora)
Local irritant use - soaps, shampoos, shower gels/douching
Persistent infection with Candida species elswhere
Uncontrolled diabetes mellitus
Immunosuppression: HIV, long-term corticosteroid use
Oestrogen e.g. COCP or HRT, pregnancy

Question 13

What are the symptoms and signs of genital candidiasis

Answer 13

Vulval itching
Soreness
Irritation
Discharge: ‘cottage cheese’, thick white
Vulvitis: superficial dyspareunia, dysuria

O/E
External genitalia may be normal
Erythema that is usually localised to the vagina and vulva
Vaginal fissuring and/or oedema
Satellite lesions

Question 14

What investigations should be done for genital candidiasis

Answer 14

Clinical diagnosis: Ix not routinely required, done if there is uncertainty or persistent or recurrent symptoms

Bedside: litmus pH testing (low/normal (<4.5)), high vaginal swab for MC&S (speckled gram +ve spores, pseudohyphae in C. albicans)
Bloods: HbA1c (RF), FBC, ferritin

Question 15

What is the management for genital candidiasis

Answer 15

First line: Fluconazole 150mg PO single dose
Second line: Clotrimazole 500 mg intravaginal pessary single dose

+ follow up IF symptoms have not resolved within 7-14 days
+ advice: Use simple emollients as soap, avoid contact with irritants (soap, shampoo, bubblebaths, wipes), avoid douching, wear loose-cotton clothing, avoid complementary therapies
+ if pregnant: only use topical treatment

Question 16

What is the treatment for genital candidiasis if they have vulva symptoms, if they have severe symptoms, or if they are breastfeeding

Answer 16

vulva symptoms → topical imidazole (clotrimazole 1% or 2% cream applied 2-3 times a day) - can be bought over the counter

severe symptoms → repeat antifungal drug treatment after 72 hours (Day 1 and 4)

breastfeeding → Oral antifungal is CI → topical imidazole

Note: topical imidazole can damage latex condoms and diaphragms

Question 17

What are the complications of candidiasis

Answer 17

Treatment failure in 10-20% of women receiving imidazole treatment for acute infection
Recurrent infection
Reduced quality of life and psychosexual difficulties e.g. embarrassment, reduced libido and arousal
Candidal balanitis may occur in male partners of women with vulvovaginal candidiasis