VAGINAL DISCHARGE: VAGINOSIS, CANDIDIASIS AND TRICHOMONIASIS Flashcards
What is the normal pH of the vagina of a woman of child-bearing age?
3.5 - 4.5
What commensal organism in the vagina of a woman of child-bearing age leads to a slightly acidic environment?
Lactobacilli
What might increase the amount of a physiological vaginal discharge in a woman of child bearing age?
Mid way through menstrual cycle
Pregnancy
Starting COCP
What is the most common cause of abnormal vaginal discharge in women of childbearing age across the world?
Bacterial vaginosis
What is the prevalence of bacterial vaginosis in the UK?
12%
What organism allows for the development of bacterial vaginosis?
Gardnerella vaginalis creates a biofilm which allows other opportunistic bacteria to thrive
Other than Gardnerella vaginalis, what microorganisms are classically associated with bacterial vaginosis?
Bacteroides spp - eg Prevotella
Mycoplasma hominis
Mobiluncus spp
Atopobium vaginae
They are all mostly anaerobes
What are the risk factors for developing bacterial vaginosis?
Black race
IUD
Sexually active - however, not actually considered a STI as is also found in virgins
May be particularly common in lesbian women
What point in menstrual are symptoms of bacterial vaginosis most prominent?
Menstruation
What happens to the pH of the vagina during bacterial vaginosis?
Increases to between 4.5 and 7.0
What are the clinical features of bacterial vaginosis?
Offensive, fishy smelling discharge
Particularly around menstruation and sexual intercourse
What colour is the vaginal discharge associated with bacterial vaginosis?
White or yellow
What is the consistency of the discharge associated with bacterial vaginosis?
Thin, homogenous
What is the name of the criteria traditionally used to diagnose bacterial vaginosis? What are the criteria?
Amstel’s criteria
3 of the following:
Thin, white, homogenous discharge
Vaginal pH of more than 4.5
Positive whiff test (addition of potassium hydroxide results in fishy odour)
Clue cells on microscopy: stippled vaginal epithelial cells
What are clue cells?
Vaginal epithelial cells so heavily coated with bacteria that the border is obstructed.
How do we diagnose bacterial vaginosis nowadays in GUM clinics?
Gram stained vaginal smear will show large numbers of gram-positive and gram-negative cocci and rods, with a reduced or absent large gram-positive bacilli (lactobacilli). Culture is not useful.
How should someone with bacterial vaginosis be managed?
Antibiotics need to have good anti-anaerobic properties:
Metronidazole 400 mg BD for 5 days is preferred treatment
Other options:
Metronidazole 2g stat
Metronidazole gel 0.75% for 5 days
Clindamycin cream 2% for 5-7 nights
What is the initial cure rate of bacterial vaginosis?
70-80%
What percentage of patients with bacterial vaginosis will suffer relapse within 1 month? 3 months?
1 month - 30%
3 months - 50%
What are the obstetric complications of bacterial vaginosis?
Increased risk of second trimester miscarriage.
Increased risk of premature delivery.
Increased risk of cerebral palsy
How would the management of bacterial vaginosis differ in a pregnant lady from a non-pregnant woman?
It wouldn’t really, except that 2g dose should be avoided. Recent guidelines now say that metronidazole should be given throughout pregnancy.
What are the side effects of metronidazole?
GI upset
Neuropathy at high doses
Metallic taste to breast milk.
What are the side effects of clindamycin?
Pseudo-membranous colitis.
How can we reduce the rate of recurrence of bacterial vaginosis?
Regular treatment with 0.75% metronidazole gel twice a week for 6 months
What proportion of women will experience at least one episode of vaginal candidiasis in their lifetime?
75%
What is the prevalence of vaginal candidiasis in the UK?
25% but only a minority will be symptomatic
What is the organism that causes vaginal candidiasis in most cases?
Candida albicans (accounts for more than 80%). It is a fungus.
Which age groups are most susceptible to vaginal candidiasis and why?
Women of child bearing age. This is because it is oestrogen dependent so rarely seen in pre-pubescent girls or post-menopausal women.
What are the risk factors for developing vaginal candidiasis?
Broad spectrum antibiotic therapy
Increased oestrogen - eg pregnancy, high dose COCP
Diabetes mellitus
Underlying dermatosis - eg eczema
Immunosuppression - eg HIV, steroids
Vaginal douching, bubble bath, shower gel
Tight clothing
What are the clinical features of candidiasis?
Itching of the vagina and vulva
Soreness of the vagina and vulva
Redness of the vagina and vulva
Curdy white discharge
Fissuring
Excoriations
What colour is the discharge associated with vaginal candidiasis?
White
How is the smell of the discharge associated with vaginal candidiasis described?
May be ‘yeasty’ but not offensive
What is the consistency of the discharge associated with vaginal candidiasis?
Curdy, like cottage cheese
What happens to the pH of the vagina during vaginal candidiasis?
Increases to pH 4.5 - 7.0
How is the diagnosis of vaginal candidiasis confirmed?
Microscopy and culture of vaginal fluid
How do we manage someone found to have vaginal candidiasis?
One off treatments:
Topical: Clotrimazole pessary 500mg stat
Oral: Fluconazole 150 mg stat
Longer courses:
Topical: Clotrimazole 100 mg OD for 6-7 days
Patients should only be treated if they are symptomatic.
Who should be given longer treatment courses for vaginal candidiasis?
Pregnant women
Predisposing factors that cannot be eliminated such as steroid therapy.
What are the complications associated with vaginal candidiasis?
Rare
Women can become allergic to topical agents
Severe episodes can trigger long term vulvodynia (pain)
How do we treat genuine recurrent candida?
This is uncommon and alternative diagnoses (eg herpes) should be explored.
Can be suppressed by weekly fluconazole 150 mg for 6 months.
If continues beyond this, then referral and voriconazole may be used.
What type of organism is trichomonas vaginalis?
Flagellated protozoan parasite
What is the route of transmission of trichomonas vaginalis?
Sexually transmitted
What are the clinical features of trichomoniasis?
Redness and swelling of vulva and vagina (vulvovaginitis)
Redness sometimes extends out onto labia majora and adjacent skin
Purulent green or yellow discharge
Strawberry cervix
What causes the cervix to appear like a strawberry in trichomoniasis?
Punctate haemorrhages
What colour is the discharge associated with trichomoniasis?
Yellow or green
How is the smell of the discharge associated with trichomoniasis described?
Can be offensive, but not always as in bacterial vaginosis
What is the consistency of the discharge associated with trichomoniasis?
Thin, homogenous
What happens to the pH of the vagina during trichomoniasis?
Increases to pH 4.5 - 7.0
How is the diagnosis of trichomoniasis confirmed?
Microscopy of vaginal secretions mixed with saline and culture
What medium should be used to culture trichomona vaginalis?
Fineberg-Whittington
What is seen on microscopy of vaginal secretions of someone with trichomoniasis?
Numerous polymorphonuclear cells with moving flagellae
How do we manage a patient with trichomoniasis?
Metronidazole 2g stat
OR
Metronidazole 400 mg BD for 5 days
OR
Tinidazole 2g stat
Partner notification is needed
What are the complications of trichomoniasis?
PID
Risk factor for preterm birth
How would you treat recurrent trichomoniasis?
Higher doses of metronidazole - 400mg TDS and then 1g PR or IV if still recurring
Arsphenamine pessaries and clotrimazole can be used
What are the side effects and contraindications of fluconazole?
Deranged LFTs at high doses
Avoid in pregnancy
What are the risk factors for presence of STIs?
Age under 25
No condom use
Symptoms developed after recent change of sexual partner
Multiple partners
Recurrent or persistent symptoms
What are the less common non-infective causes of vaginal discharge?
Retained tampon or condom
Cervical ectropion or endocervical polyp
Chemical irritation
IUD
Allergic vaginitis
Desquamative exudative vaginitis
Atrophic vaginitis
Trauma
Fistula: recto-vaginal or vesico-vaginal
Vault granulation tissue
Neoplasia
What is toxic shock syndrome?
Rare condition associated with retention of tampons or foreign bodies in the vagina. Leads to overgrowth of staphylococci producing a toxin.
What are the clinical features of toxic shock syndrome?
Fever
Diarrhoea
Vomiting
Erythematous rash
Vaginal discharge
