VAGINAL DISCHARGE: VAGINOSIS, CANDIDIASIS AND TRICHOMONIASIS

Question 1

What is the normal pH of the vagina of a woman of child-bearing age?

Answer 1

3.5 - 4.5

Question 2

What commensal organism in the vagina of a woman of child-bearing age leads to a slightly acidic environment?

Answer 2

Lactobacilli

Question 3

What might increase the amount of a physiological vaginal discharge in a woman of child bearing age?

Answer 3

Mid way through menstrual cycle

Pregnancy

Starting COCP

Question 4

What is the most common cause of abnormal vaginal discharge in women of childbearing age across the world?

Answer 4

Bacterial vaginosis

Question 5

What is the prevalence of bacterial vaginosis in the UK?

Answer 5

12%

Question 6

What organism allows for the development of bacterial vaginosis?

Answer 6

Gardnerella vaginalis creates a biofilm which allows other opportunistic bacteria to thrive

Question 7

Other than Gardnerella vaginalis, what microorganisms are classically associated with bacterial vaginosis?

Answer 7

Bacteroides spp - eg Prevotella

Mycoplasma hominis

Mobiluncus spp

Atopobium vaginae

They are all mostly anaerobes

Question 8

What are the risk factors for developing bacterial vaginosis?

Answer 8

Black race

IUD

Sexually active - however, not actually considered a STI as is also found in virgins

May be particularly common in lesbian women

Question 9

What point in menstrual are symptoms of bacterial vaginosis most prominent?

Answer 9

Menstruation

Question 10

What happens to the pH of the vagina during bacterial vaginosis?

Answer 10

Increases to between 4.5 and 7.0

Question 11

What are the clinical features of bacterial vaginosis?

Answer 11

Offensive, fishy smelling discharge

Particularly around menstruation and sexual intercourse

Question 12

What colour is the vaginal discharge associated with bacterial vaginosis?

Answer 12

White or yellow

Question 13

What is the consistency of the discharge associated with bacterial vaginosis?

Answer 13

Thin, homogenous

Question 14

What is the name of the criteria traditionally used to diagnose bacterial vaginosis? What are the criteria?

Answer 14

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

Question 15

What are clue cells?

Answer 15

Vaginal epithelial cells so heavily coated with bacteria that the border is obstructed.

Question 16

How do we diagnose bacterial vaginosis nowadays in GUM clinics?

Answer 16

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.

Question 17

How should someone with bacterial vaginosis be managed?

Answer 17

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

Question 18

What is the initial cure rate of bacterial vaginosis?

Answer 18

70-80%

Question 19

What percentage of patients with bacterial vaginosis will suffer relapse within 1 month? 3 months?

Answer 19

1 month - 30%

3 months - 50%

Question 20

What are the obstetric complications of bacterial vaginosis?

Answer 20

Increased risk of second trimester miscarriage.

Increased risk of premature delivery.

Increased risk of cerebral palsy

Question 21

How would the management of bacterial vaginosis differ in a pregnant lady from a non-pregnant woman?

Answer 21

It wouldn’t really, except that 2g dose should be avoided. Recent guidelines now say that metronidazole should be given throughout pregnancy.

Question 22

What are the side effects of metronidazole?

Answer 22

GI upset

Neuropathy at high doses

Metallic taste to breast milk.

Question 23

What are the side effects of clindamycin?

Answer 23

Pseudo-membranous colitis.

Question 24

How can we reduce the rate of recurrence of bacterial vaginosis?

Answer 24

Regular treatment with 0.75% metronidazole gel twice a week for 6 months

Question 25

What proportion of women will experience at least one episode of vaginal candidiasis in their lifetime?

Answer 25

75%

Question 26

What is the prevalence of vaginal candidiasis in the UK?

Answer 26

25% but only a minority will be symptomatic

Question 27

What is the organism that causes vaginal candidiasis in most cases?

Answer 27

Candida albicans (accounts for more than 80%). It is a fungus.

Question 28

Which age groups are most susceptible to vaginal candidiasis and why?

Answer 28

Women of child bearing age. This is because it is oestrogen dependent so rarely seen in pre-pubescent girls or post-menopausal women.

Question 29

What are the risk factors for developing vaginal candidiasis?

Answer 29

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

Question 30

What are the clinical features of candidiasis?

Answer 30

Itching of the vagina and vulva Soreness of the vagina and vulva Redness of the vagina and vulva Curdy white discharge Fissuring Excoriations

Question 31

What colour is the discharge associated with vaginal candidiasis?

Answer 31

White

Question 32

How is the smell of the discharge associated with vaginal candidiasis described?

Answer 32

May be 'yeasty' but not offensive

Question 33

What is the consistency of the discharge associated with vaginal candidiasis?

Answer 33

Curdy, like cottage cheese

Question 34

What happens to the pH of the vagina during vaginal candidiasis?

Answer 34

Increases to pH 4.5 - 7.0

Question 35

How is the diagnosis of vaginal candidiasis confirmed?

Answer 35

Microscopy and culture of vaginal fluid

Question 36

How do we manage someone found to have vaginal candidiasis?

Answer 36

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.

Question 37

Who should be given longer treatment courses for vaginal candidiasis?

Answer 37

Pregnant women Predisposing factors that cannot be eliminated such as steroid therapy.

Question 38

What are the complications associated with vaginal candidiasis?

Answer 38

Rare Women can become allergic to topical agents Severe episodes can trigger long term vulvodynia (pain)

Question 39

How do we treat genuine recurrent candida?

Answer 39

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.

Question 40

What type of organism is trichomonas vaginalis?

Answer 40

Flagellated protozoan parasite

Question 41

What is the route of transmission of trichomonas vaginalis?

Answer 41

Sexually transmitted

Question 42

What are the clinical features of trichomoniasis?

Answer 42

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

Question 43

What causes the cervix to appear like a strawberry in trichomoniasis?

Answer 43

Punctate haemorrhages

Question 44

What colour is the discharge associated with trichomoniasis?

Answer 44

Yellow or green

Question 45

How is the smell of the discharge associated with trichomoniasis described?

Answer 45

Can be offensive, but not always as in bacterial vaginosis

Question 46

What is the consistency of the discharge associated with trichomoniasis?

Answer 46

Thin, homogenous

Question 47

What happens to the pH of the vagina during trichomoniasis?

Answer 47

Increases to pH 4.5 - 7.0

Question 48

How is the diagnosis of trichomoniasis confirmed?

Answer 48

Microscopy of vaginal secretions mixed with saline and culture

Question 49

What medium should be used to culture trichomona vaginalis?

Answer 49

Fineberg-Whittington

Question 50

What is seen on microscopy of vaginal secretions of someone with trichomoniasis?

Answer 50

Numerous polymorphonuclear cells with moving flagellae

Question 51

How do we manage a patient with trichomoniasis?

Answer 51

Metronidazole 2g stat OR Metronidazole 400 mg BD for 5 days OR Tinidazole 2g stat Partner notification is needed

Question 52

What are the complications of trichomoniasis?

Answer 52

PID Risk factor for preterm birth

Question 53

How would you treat recurrent trichomoniasis?

Answer 53

Higher doses of metronidazole - 400mg TDS and then 1g PR or IV if still recurring Arsphenamine pessaries and clotrimazole can be used

Question 54

What are the side effects and contraindications of fluconazole?

Answer 54

Deranged LFTs at high doses Avoid in pregnancy

Question 55

What are the risk factors for presence of STIs?

Answer 55

Age under 25 No condom use Symptoms developed after recent change of sexual partner Multiple partners Recurrent or persistent symptoms

Question 56

What are the less common non-infective causes of vaginal discharge?

Answer 56

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

Question 57

What is toxic shock syndrome?

Answer 57

Rare condition associated with retention of tampons or foreign bodies in the vagina. Leads to overgrowth of staphylococci producing a toxin.

Question 58

What are the clinical features of toxic shock syndrome?

Answer 58

Fever Diarrhoea Vomiting Erythematous rash Vaginal discharge