Vaginal discharge resident survival guide
|Vaginal discharge Resident Survival Guide Microchapters|
Vaginal discharge is a common complaint in primary care which can be a subjective complaint or an objective finding. So, it is important to differentiate between normal physiological discharge and pathological discharge. Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina. It is produced by the cells of the vagina and cervix. Normal vaginal discharge changes with the menstrual cycle, such as the character of the discharge is clearer with a stretchable consistency around ovulation, then may be thicker and slightly yellow during the luteal phase. Normal healthy discharge should not be associated with symptoms such as itching, redness and swelling, and does not have a strong odor. It is important to take complete history and ask about the associated symptoms like dysuria, dyspareunia, lower abdominal pain, itching, and fever. While considering the causes, it is necessary to distinguish between infectious and non-infectious. The infectious causes are infection with Candida albicans, Trichomonas vaginalis, Gardnerella vaginalis, Chlamydia trachomatis, Neisseria gonorrhea, Herpes Simplex Virus. Diagnosis must be confirmed by laboratory tests and cultures. Non-infectious causes include puberty, menstrual cycle, foreign body, cervical cancer, vaginal cancer, diabetes etc. Treatment depends on the cause of the discharge.
Non-sexually transmitted infection:
- Bacterial vaginosis mostly happens during the reproductive age of women characterized by a shift in the vaginal flora from the dominant Lactobacillus to a polymicrobial flora.
Sexually transmitted infection:
- Drug side effects of antibiotic or steroid use such as, Amoxicillin and Clavulanic Acid , Butoconazole Vaginal Cream , Clotrimazole , Combined oral contraceptive pill, Estradiol Topical , Estradiol Transdermal , Estrogen and Progestin (Oral Contraceptives) ,Estrogen Injection , Estrogen Vaginal , Etonogestrel and Ethinyl Estradiol Vaginal Ring , Glatiramer Injection ,Hormone replacement therapy (trans), Letrozole, Leuprolide , Medroxyprogesterone Injection , Metronidazole Topical ,Miconazole , Nafarelin , Natalizumab injection , Norelgestromin and ethinyl estradiol transdermal system , Ospemifene, Oxcarbazepine , Pramipexole, Progesterone, Tamoxifen , Terconazole Vaginal Cream, Vaginal Suppositories , Toremifene, Zoledronic Acid Injection
- Gynaecological causes:
|Patient with history of Vaginal discharge|
|Take complete history|
Ask the following questions about menstrual history :
❑ Age of menarche
❑ Last menstrual period
❑ Is the menstrual flow normal? How many pads she has to use in a day?
❑ Is there any foul smell or colour change?
❑ How many days does the menstruation stay?
❑ Contraceptive history for example oral contraceptives, intrauterine device
Ask the following questions about general health :
❑ Ask about medical and drug history including recent antibiotic use and type of contraceptive use
❑ Assess for the possibility of a foreign body in situ
❑ Ask if there was any surgery or instrumentation to the genital region recently
❑ Is there any other health conditions like Diabetes Mellitus?
❑ Is there any history of fever, lower abdominal pain?
|Ask the following questions about colour, appearance of the discharge|
|Is the discharge white or cream coloured, resembling "cottage cheese"?|
|Ask if the following factors are present|
|Examination of direct vaginal secretions or scrapping from vaginal wall via direct microscopy|
|When a drop of 10% Potassium Hydroxide is added, typical myecelis or pseudo hyphae is seen|
|Is the discharge greenish?|
Check if they have the following complaints :
❑ Purulent, frothy discharge
❑ Foul smelling discharge with vulval soreness and irritation, if severe vulval oedema
❑ Punctate hemorrhagic area or strawberry cervix is path gnomic
❑ Lower abdominal pain anddyspareunia may be seen in patients with long standing infection
❑ Male partners are usually asymptomatic except having penile pruritus after coitus
|Wet mount test: a drop of vaginal secretion is mixed with saline and examined under microscope|
|Trichomonads are recognized by their twitching motility|
|Vaginal pH > 5 helps to distinguish between trichomoniasis and candidiasis which has pH of less than 4.5|
|Is the discharge thin, homogenous, bubbly?|
|While it does not produce vaginal discharge itself, it causes cervicitis and vaginitis that are associated with severe leukorrhea|
|Whiff test: When a drop of 10% potassium hydroxide is added to a drop of vaginal secretion fishy amine odour is released|
|Vaginal pH > 5 with presence of clue cells are diagnostic|
|Bacterial vaginosis (Gardnerella vaginosis)|
|Neisseria gonorrhoea||Chlamydia trachomatis|
Shown below is an algorithm summarizing the treatment of Vaginal discharge.
Abbreviations: QHS : Every bedtime , BID: 2 times daily, TID: Three times a day, QID: Four times a day, IM :Intramuscular
|Organisms||Recommended Drugs||Alternative drugs|
Over-the-Counter Intravaginal Agents
Prescription Intravaginal Agents:
- Retained foreign bodies.
- Recent instrumentation or surgery of the genital tract such as hysterosalpingography, dilation and curettage, hysteroscopy, termination of pregnancy/evacuation of retained products of conception, laparoscopy and major gynaecological surgical procedure.
- Suspected tumor of the genital tract.
- Cervical ectopy or polyps.
- Recurrent vulvovaginal candida infections.
- Pregnant woman with abnormal vaginal discharge
- Symptoms of upper genital tract infections as fever, lower abdominal pain
Treatment in pregnancy:
- Vulvovaginal Candidiasis: It frequently occurs during pregnancy. Only topical azole therapies for 7 days are recommended for use among pregnant women.
- Trichomoniasis: Metronidazole 2 g orally single dose is recommended. Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.
- Bacterial vaginosis: Treatment is recommended for all symptomatic pregnant women. Metronidazole 250-mg regimen is effective. But, Metronidazole 500 mg twice daily can be used.
- The use of topical azole formulations can weaken latex condoms and diaphragms. This risk should be mentioned to the woman prior to starting these medications.
- Referral to a gynecologist should be considered if there is a history of recent instrumentation or surgery of the genital tract, retained foreign body, cervical ectopy or polyp, or suspicion of tumor on examination; or in women with symptoms of upper genital tract infection or recurrent vulvovaginal candida infections, pregnant women with abnormal vaginal discharge, or women who have failed routine treatment strategies.
- Women should be advised to avoid alcohol consumption during treatment for up to 24 hours after completion of Metronidazole or 72 hours after completion of Tinidazole to reduce the possibility of a disulfiram-like reaction.
- Women with Trichomoniasis should be advised to abstain from sexual intercourse until treatment is completed and symptoms have resolved, as it is sexually transmissible.
- Patient should be advised to avoid tight-fitting synthetic clothing.
- Patient should be told to avoid local irritants such as perfumed products and soap gels and vaginal doucheing.
- There is no clear and consistent evidence across currently published studies regarding the role of probiotics for vaginal health.
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