Vaginal Discharge Flashcards
VAGINAL DISCHARGE
physiological causes
- Oestrogen related -puberty, pregnancy, COCP
- Cycle related – maximal midcycle and premenstrual
- Sexual excitement and intercourse
VAGINAL DISCHARGE
pathological causes
Infection – non STI (BV, candida) / sexually transmitted (TV, chalmydia, gonorrhea)
VAGINAL DISCHARGE
history
- Characteristics – onset, duration, odour, colour
- Associated symptoms – itching, burning, dysuria, superficial dyspareunia
- Relationship of discharge to menstrual cycle
- Precipitating factors – pregnancy contraceptive pill, sexual excitement
- Sexual history – risk factors for STI
- Medical history -diabetes immunocopromised
- Non infectious causes (foreign body, ectopy, malignancy, dermatological conditions)
- Hygiene practices – douches, bath products, talcum powder
- Allergies
VAGINAL DISCHARGE
examination
- External genital inspection for vulvitis, obvious discharge, ulcers, other lesiosn
- Speculum – appearance of vagina, cervic, foreign bodies, amount, coour, consistency
- Bimanual examination – masses, adrenal tenderness, cervical motion tenderness
VAGINAL DISCHARGE
investigations
Endocervical or vulvovaginal swabs for gonorrhoea and chlamydia
VAGINAL DISCHARGE physiological 1. colour 2. consistency 3. odour 4. vulval itching 5. treatment
- clear/white
- mucoid
- none
- none
- reassure
VAGINAL DISCHARGE candida infection 1. colour 2. consistency 3. odour 4. vulval itching 5. treatment
- white
- curd-like
- none
- itching
- antifungal
VAGINAL DISCHARGE Trichomonal infection 1. colour 2. consistency 3. odour 4. vulval itching 5. treatment
- green/grey
- frothy
- offensive
- itching
- metronidazole
VAGINAL DISCHARGE gonococcal infection 1. colour 2. consistency 3. odour 4. vulval itching 5. treatment
- greenish
- watery
- none
- none
- antibiotics
VAGINAL DISCHARGE bacterial vaginosis 1. colour 2. consistency 3. odour 4. vulval itching 5. treatment
- white/grey
- watery
- offensive
- none
- metronidazole
VAGINAL DISCHARGE malignancy 1. colour 2. consistency 3. odour 4. vulval itching 5. treatment
- bloody
- watery
- offensive
- none
- according to disease
VAGINAL DISCHARGE foreign body 1. colour 2. consistency 3. odour 4. vulval itching 5. treatment
- grey or bloody
- purulent
- offensive
- none
- remove object
VAGINAL DISCHARGE atrophic vaginitis 1. colour 2. consistency 3. odour 4. vulval itching 5. treatment
- clear/blood stained
- watery
- none
- none
- topical oestrogen
VAGINAL DISCHARGE cervical ectropion 1. colour 2. consistency 3. odour 4. vulval itching 5. treatment
- clear
- watery
- none
- none
- cryotherapy
JOCK ITCH (TINEA CRURIS) what is it causative organisms contagious? risk factors
- Superficial fungal infection or groin
- Trichophyton rubran, Epidermophyton floccosum
- Contagious – transmitted by fomites eg contaminated towels of hotel bedroom sheets
- Risk factors – tight fitting/wet clothing
- More common in men
- Recent visit to tropical climate, tight clothing, shared clothing, sports, coexisting diabetes, obesity
- Symmetric erythematous rash in groin
CANDIDIASIS
THRUSH
- Yeast like fungus – candida albicans
- 75% women experience at least one episode
- 10-20% asymptomaic chronic carriers (40% in pregnancy)
- Predisposing factors: immunosuppression, antibiotics, pregnancy, diabetes mellitus, anaemia
- Symptoms – vulval itchng, soreness, thick, curd like, white vaginal discharge, dysuria, superficial dyspareunia
- Diagnosis: appearance of erythema, vulval fissuring, typical white plaques adherent to vaginal wall, culture from HVS or LVS, microscopic detection of spores and pseudohypae onwet slides
- Treatment: only treat if symptomatic, clotrimazole 500mg psseary +/- topical clotrimazole cream OR flyconazole 150mg (single dose)
- Prevention – wear cotton underwear, avoid chemical irritants eg soap and bath salts
- In pregnancy is common – topical imidazoles aren’t systemically absorbed so are safe
MOLLUSCUM CONTAGIOSUM
- Benign viral infection
* Poxviridae family
GENITAL HERPES/HERPES SIMPLEX
what is it
- DNA virus – herpes simplex (orolabial/genital) and type 2 (genital only)
- 3rd most common STI in England
GENITAL HERPES/HERPES SIMPLEX
symptoms
primary infection – most severe and results in..
• prodrome (tingling/itching)
• flu like illness +/- inguinal lymphadenopathy
• vulvitis and pain (urinary retention)
• small charactereistic vesicles on vulva – can be atypical with fissues, erosions, erythema of skin
recurrent attacks
• result from reactivation of latent virus in sacral ganglia
• shorter and less severe
• triggered by – stress, sexual intercourse, menstruation
GENITAL HERPES/HERPES SIMPLEX
- complications
- diagnosis
- meningitis, sacral radiculopathy, transverse myelitis, disseminated infection
- appearance of typical rash, PCR testing of vesicular fluid (gold standard), culture of vesicular fluid
GENITAL HERPES/HERPES SIMPLEX
treatment
- no cure
- symptomatic relief with simple analgesia, saline bathing, topical anaesthetic
- oral acyclovir not beneficial
- condoms/abstinence whilst prodromal/symptomatic to reduce transmission
- suppressive antiviral treatment if >6 recurrences/year
SYPHILIS
- causative organisms
- prevalence
- treponema pallidum – spirochaete
2. rare, increasing prevelance
SYPHILIS
primary syphilis
- 10-90 days postinfection
* Painless, genital ulcer, inguinal lymphadenopathy
SYPHILIS
secondary syphilis
- Occurs within 2yrs of infection
- Generalised polymorphic rash affecting palms and soles
- Generalised lymphadenopathy
- Genital condyloma lata
- Anterior uveitis
SYPHILIS
tertiary syphilis
- Presents in upto 40% infected for at least 2yrs but may take 40+yrs to develop
- Neurosyphilis – tabes dorsalis and dementia
- Cardiovascular syphilis – commonly affecting aortic root
- Gummata – inflammatory plaques or nodules
SYPHILIS
diagnosis
- Specific treponemal enzyme immunoassay for screening (IgG +IgM)
- Primary lesion smear may show spirochaetes on dark field microscopy
- Quantitative cardioipin tests ie rapid plasma regain useful in assessing need for and response to treatment
SYPHILIS
treatment
- Depends on penicillin allergy
- Benzathine benzylpenicillin 2.4MU single dose IM
- Doxycycline 100mg bd PO 14 days
- Erythromycin 500mg qds PO 14 days
- Longer treatment in tertirary syphilis
- Contract trace
GONORRHEA
organism, prevelance, symptoms, complications
- Neisseria gonorrhoea – intracellular gram -ve diplococcus
- 4th most common STI in UK
- 33% strains are resistant to ciprofloxacin, 70% to tetracyclines
- Usually asymptomatic
- Can present with vaginal discharge, low abdo pain, IMB, PCB
- Diagnosis: endocervical or vulvovaginal swab with NAAT
- If diagnosed with NAAT, culture for sensitivity testing taken before antibiotic treatment
- Complications: PID, Bartholins or skenes abscess, disseminated gonorrhoea can cause fever, pustular rash, migratory polyarthralgia, septic arthritis / tubal infertility / ectopic pregnancy
GONORRHEA
treatment
- Ceftriaxone 500mg IM stat plus azithromycin 1g PO stat
- Spectinomycin 2mg IM plus azithromycin 1g PO stat (if penicillin allergy)
- Contact tracing
CHLAMYDIA
- Chlamydia trachomatis – obligate intracellular parasite
- Commonest bacterial STI in UK
- Cause of tubal infertility
- Symptoms: dysuria, vaginal discharge, irregular bleeding, 70% asymptomatic
- Complications: PID, perihepatitis (fitz-high-curtis syndrome), reiters syndrome (arthritis, urethritis, conjunctivitis), tubal infertility, risk of ectopic pregnancy
- Diagnosis – vulvovaginal or endocervical swab – NAAT
- Treatment – azithromycin 1g single dose OR doxycycline 100mg bd 7 days. Contact tracing and treat partners
- Screening – national chlamydia screening programme
- Implications in pregnancy – association with preterm rupture of membranes and premature delivery. Risks to baby are; neonatal conjunctivitis, neonatal pneumonia. Treat pregnant women with erythromycin 500mg bd for 10-14 days
HPV clinical features
- DNA virus
- Subtypes 6 and 11 cause genital warts
- ¼ presenting wih warts have concurrent sti
- Commonest viral STI
- Subtypes 16 and 18 associated with CIN and cervical neoplasia
- Asymptomatic
- Painless lumps in genitoanal area
HPV investigations
- Usually identified by clinical appearance
* Non wart HPV diagnosed by characteristic appearance on cervical cytology or colposcopy
HPV management
- Cryotherapy
- Trichloroacetic acid
- Electrosurgery/scissors excision/curettage/laser
- Podophyllotoxin cream 4-6 weeks
- Imiquimod cream – upto 16 weeks
- Routine vaccination – 16,18, 6, 11
TRICHOMONIASIS
clinical features
- Trichomonal vaginalis – flagellated protozoan
- Found in vaginal, urethrl and para-urethral glands
- Cervix may have strawberry appearance from puncture haemorrhages
- Asymptoatic in 10-50%
- May present with frothy, greenish, offensive smelling vaginal discharge, vulval itching and soreness, dysuria
- May enhance HIV transmission
TRICHOMONIASIS
investigations
- Observation of organism by wet smear or acridine orange stained slide from posterior vaginal fornix
- Culture media
- NAATS
TRICHOMONIASIS
management
- Metronidazole 2g oral single dose
- Metronidazole 400-500mg bd 5-7 days
- Contact tracing
BACTERIAL VAGINOSIS
clinical features
- Due to overgrowth of mixed anaerobes including Gardnerella and mycoplasma hominis
- Commonest cause of abnormal vaginal discharge in women of childbearing age
- Not sexually transmitted
- 12% women experience BV at some point in lives
- May be asymptomatic
- Profuse, whitish grey, offensive smelling vaginal discharge, fishy smell
BACTERIAL VAGINOSIS
investions
Amsel criteria – 3 out of 4 needed for diagnosis • Homogenous grey-white discharge • Vaginal pH >5.5 • Fishy smell • ‘clue cells’ on microscopy
BACTERIAL VAGINOSIS
management
- May resolve spontaneuously
- High recurrence rate
- Metronidazole 400mg oral bd 5 days
- Metronidazole 2g single dose
- Clindamycin 2% cream vaginally at night for 7 days
- Lifestyle – avoid vaginal douching/overwashing which can destroy natural vaginal flora