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Vaginal discharge
- 1. Vaginal Discharge By Maira Shahid & Syed Sami Haider Roll # 234 & 239 Clinical Group G3
- 2. References – Obstetrics and Gynecology, Elmar Skala. BRS. Lippincot Williams and Wilkins. – www.emedicine.com
- 3. Out Line • Background & Terminology • Normal Vaginal Ecosystem • Clinical approach • Common Causes 1. Bacterial vaginosis 2. Candida vaginitis 3. Trichomonas vaginitis • Uncommon Causes
- 5. Background & Terminology Vaginal discharge s the most common gynaecologic condition encountered by physicians in the office . I. Pathophysiology : Disturbance of the normal vaginal pH and estrogen levels can alter the vaginal flora, leading to overgrowth of pathogens. Factors that alter vaginal environment include feminine hygiene products, contraceptives, vaginal medications, antibiotics, STDs, sexual intercourse, and stress. II. Frequency : Difficult to determine. 5-15% of visits. III. Mortality/Morbidity : o chronic irritation, excoriation, and scarring. o STD o PID o increased risk of premature rupture of the membranes, preterm labour, and preterm delivery.
- 6. Background & Terminology IV. Terminology i. Vaginitis : significant inflammatory response in vaginal wall. Accompanied by high number of leukocytes in vaginal fluid. Found with candida and trichomonas infections. ii. Vaginosis : minimal inflammatory response with few leukocytes in vaginal wall. Associated with increase in bacterial concentrations. iii. Leukorrhoea : a non-infective, non-bloodstained physiological vaginal discharge.
- 8. Normal Vaginal Ecosystem I. Characteristics : A dynamic equilibrium exist between the intact stratified epithilium, normal colonizing microorganisms, and local secretory ( hormonal) and cellular immune factors. Vaginal pH is low ( 3.8- 4.2) i. Estrogen increases vaginal epithilial glycogen. ii. Glycogen is metabolized by lactobacilli into lactic acid iii. pH is acidic and is unfavorable for pathogens
- 9. Normal Vaginal Ecosystem II. Normal Flora : i. Lactobacilli : • Found in 96% of women • Concentrations 105 to 108 / ml. • Protective effect by interfering with adherence to epithilial cells i. Facultative organisms : • Diphtheroids – streptococci – E.coli – ureapalasma urealyticum – mycoplasma hominis i. Anaerobic organisms : • Peptostreptococci – bacteroid - fusobacterium
- 10. Normal Vaginal Ecosystem III. Normal secretions i. Composition and Derivation : o water as transudate from vaginal wall o desquamated epithelial cells o cervical mucus this is 90% water o uterine and tubal secretions (e.g. incl. blood when menstruating) o a few leucocytes / polymorphs i. Variable dependent on multiple factors : o Age o Timing of Menstrual Cycle o Sexual arousal o Contraceptive use o Douching
- 12. Clinical approach I. History: o Source of discharge must be determined. Perineal discharge could originate from vagina, cervix, urinary tract and rectum o Ascertain the following attributes of the discharge: quantity, duration, colour, consistency and odour. o Symptoms include : itching or burning . External Dysuria, Dyspareunia o Obtain history of the following: • Prior similar episodes • Sexually transmitted infection • Sexual activities • Birth control method • Last menstrual period • Douching practice • Antibiotic use • General medical history • Systemic symptoms such as lower abdominal pain, fever, chills, nausea, and vomiting.
- 13. Clinical approach II. Physical Exam : o Appearance of discharge. o Erythema and edema of vaginal mucosa o pH levels II. Diagnostic Tools: o pH : Nitrazine paper o Wet prep: microscopic examination of discharge ( clue cells of BV) o KOH prep: dissolves cellular debris leaving pseudohyphae of candida. o Whiff test: Fishy odor of BV o Culture
- 14. Common Causes
- 15. Common Causes I. Normal discharge (30%) II. Bacterial Vaginosis (23-50%) III. Candida Vulvovaginitis (20-25%) IV. Trichomonas vaginitis (5-15%) V. Mixed infection or Sexually Transmitted Disease (20%)
- 16. Common Causes I. Bacterial Vaginosis i. Most common cause of vaginal complain. Up to 50% are asymptomatic. ii. Increase in anaerobic organisms. iii. Diagnosis: Amsel's criteria • Gray, homogeneous discharge adherent to walls • pH > 4.5 • Fishy odor with KOH • Clue cells on wet prep i. Treatment: • Symptomatic gynecologic and obstetric patients. • Selected asymptomatic gynecologic patients ( e.g. undergoing surgery) • Selected asymptomatic obstetric patient (e.g. SROM or preterm labor)
- 17. Common Causes I. Bacterial Vaginosis v. Medication: CDC 1998 1. Oral: metronidazole 500mg bid for 7 days, or clindamycine 300mg bid for 7 days. 2. Vaginal: metronidazole gel 0.75% bid for 5 days, or clindamycine cream 2% for 7 days. NO TREATMENT OF SEXUAL PARTNER IS NEEDED
- 18. • Homogeneous discharge adhering to vaginal walls. • Discharge in cervix
- 19. • Clue cell on wet prep
- 20. WWhhiiffff TTeesstt The vaginal discharge of patients with BV has a characteristic fishy odor due to increased activity of anaerobic species. Addition of KOH will augment this odor.
- 21. Common Causes II. Candida Vaginitis: i. 2nd most common. C. albicans, C. tropicalis, C. glabrata are all causative agents. ii. Risk factors include: 1. Altered immune status 2. Increased glucose levels 3. Decreased lactobacilli concentrations. i. Diagnosis : 1. Itching and burning. vulvar burning, dyspareunia, and vulvar dysuria 2. Clinically, vulvar erythema and edema with satellite lesions (discrete pustulopapular lesions) 3. Whitish discharge varying from thin to crud consistency. cottage cheese–like . 4. Vaginal pH is usually normal. 5. KOH prep : psudohyphea ( 100% specific)
- 22. Common Causes II. Candida Vaginitis: 1. Management : CDC, 1998. 1. Vaginal antifungal creams : butaconazole, clotrimazole, miconazole for 7- 14 d. 2. Oral antifungal : fluconazole in a single 150 mg dose. NO TREATMENT OF SEXUAL PARTNER IS NEEDED
- 23. the Whitish discharge of candidiasis varying from thin to crud consistency. Cottage cheese–like .
- 24. Common Causes III. Trichomonas Vaginitis : i. Protozoa. Most common cause of vaginitis world wide. • Humans are the only host • Sexually transmitted i. Diagnosis : • Vulvar erythema and edema • A profuse, malodorous, forthy, yellowish discharge. • Trichomonas cervicitis with red, punctuated lesions ( strawberry patches). • Vaginal pH > 4.5 • Wet prep: detects 70% • Culture: is most sensitive.
- 25. Common Causes I. Trichomonas Vaginitis : iii. Management : CDC, 1998 Metronidazole 500 mg PO bid for 7 days TREATMENT OF SEXUAL PARTNER IS NEEDED
- 26. • Flagellated protozoa : Trichomonas • Trichomonas as it appears on wet prep
- 27. Uncommon Causes
- 28. Uncommon Causes • Atrophic vaginitis • Infectious Cervicitis – Neisseria gonorrhoeae – Chlamydia trachomatis – Herpes Simplex Virus • Vaginitis or Vulvitis – Vaginal or vulvar trauma – Irritant Contact Dermatitis – Vulvar Vestibulitis – Malignancy • Cervical polyp and malignancy.
- 29. Uncommon Causes I. Atrophic Vaginitis: 1. Etiology: Extremely low estrogen production. Vulvovaginal atrophy is considered a natural process after estrogen withdrawal; atrophic vaginitis, however, is not. 2. Clinical : The most common symptom is vaginal spotting . vaginal soreness, postcoital burning, dyspareunia, burning leukorrhea also present. 3. Exam: The vagina is noted to be thin, with occasional petechia and diffuse redness with few or no vaginal folds. Vaginal pH 5-7. 4. Treatment : Topical estrogen for 1-2 weeks symptomatically.
- 30. Uncommon Causes III. Vulvar Vestibulitis: Unknown etiology. Many theories present including candida, HPV, previous surgery, chemical irritants Freidrich’s criteria 1. severe pain upon touching the vestibule or attempted vaginal entry, 2. tenderness to pressure localized within the vulvar vestibule, and 3. physical findings confined to vestibular erythema of various degrees. Clinical: 1. young, sexually active 2. Usual symptoms include pain, soreness, burning. 3. pain usually is not considered constant; it is elicited by any attempt to enter the vagina 4. Irritating vaginal discharge 5. pelvic examination typically reveals no physical findings. Treatment : Symptomatic with life style modification
- 31. Uncommon Causes II. STD : Were discussed in previous presentation. Chlamydia Gonorrhea
- 32. Uncommon Causes: Chlamydia • Symptoms: 70% show no symptoms; abnormal vaginal discharge &/or bleeding, abnormal cramping, abdominal pain, fever, painful urination. • Incubation: 1 to 4 weeks • Organism: Chlamydia trachomatis & Ureplasma urealyticum, Infectivity: people can infect other when they have symptoms & some times when they do not, the partner is infected in approximately 33% of the sexual contacts with an infected partner. • Treatment: antibiotics • If Untreated: pelvic inflammatory disease, ectopic pregnancies, sterility • Prevention: limit the number of sexual partner & use condoms & spermicides
- 33. Uncommon Causes: Gonorrhea • Symptoms: foul smelling vaginal discharge &/or bleeding, abnormal cramping &/or painful urination; • Incubation: 2 to 7 days • Infectivity: people can infect others when they have symptoms & some times when they do not; women are more easily infected by men than vice versa; the partner is infected in approximately 25% of the sexual contacts with an infected partner • Treatment: antibiotics • If Untreated: pelvic inflammatory disease, ectopic pregnancies, sterility, arthritis, heart problems, blindness • Prevention: limit number of sexual partners & use condoms & sperimicides
- 34. Uncommon Causes IV. Tumors : • Must be ruled out • Include: 1. Vaginal cancer 2. Cervical cancer
- 35. Uncommon Causes I. Cervical Cancer: 1. 3rd most common female reproductive malignancy (20%) 2. Risk factors include : age > 45 years, HPV 16-18, multiple sexual partners, smoking. 3. Clinically, vaginal bleeding with discharge. However, early stages are asymptomatic 4. Screening by PAP smear. Definite diagnosis by biopsy. 5. Surgical staging is not needed. 6. Management : surgical according to clinical stage.