Vaginal discharge resident survival guide: Difference between revisions
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{{WikiDoc CMG}}; {{AE}} {{RAB}} | {{WikiDoc CMG}}; {{AE}} {{RAB}} | ||
{{SK}} | {{SK}} Approach to [[Vaginal discharge]], [[Leukorrhea]] | ||
==Overview== | ==Overview== | ||
[[Vaginal|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|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]]. | |||
==Causes== | ==Causes== | ||
*[[Bacterial vaginosis]] | '''Infectious causes''' | ||
Non-sexually transmitted infection<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref>: | |||
*[[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]].<ref name="pmidhttp://www.ncbi.nlm.nih.gov/pmc/articles/pmc478688">{{cite journal| author=Cettl L, Dvorak J, Felkel H, Feuereisl R| title=Results of simulation of non-homogeneous ventilatory mechanics for a patient-computer arrangement. | journal=Int J Biomed Comput | year= 1979 | volume= 10 | issue= 1 | pages= 67-74 | pmid=http://www.ncbi.nlm.nih.gov/pmc/articles/pmc478688 | doi=10.1016/0020-7101(79)90042-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=478688 }} </ref> | |||
*[[Vaginal yeast infection]] | *[[Vaginal yeast infection]] | ||
===== | Sexually transmitted infection: | ||
*[[Chlamydia]],[[Sexually transmitted disease|sexually transmitted infections]]. | |||
*[[Gonorrhea (patient information)|Gonorrhea]],[[sexually transmitted infections]]<ref name="pmidhttps://doi.org/10.1016/j.ogrm.2016.08.002">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/j.ogrm.2016.08.002 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> | |||
*[[Herpes]]<ref name="pmidhttps://pubmed.ncbi.nlm.nih.gov/7817733">{{cite journal| author=Wathne B, Holst E, Hovelius B, Mårdh PA| title=Vaginal discharge--comparison of clinical, laboratory and microbiological findings. | journal=Acta Obstet Gynecol Scand | year= 1994 | volume= 73 | issue= 10 | pages= 802-8 | pmid=https://pubmed.ncbi.nlm.nih.gov/7817733 | doi=10.3109/00016349409072509 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7817733 }} </ref> | *[[Herpes]]<ref name="pmidhttps://pubmed.ncbi.nlm.nih.gov/7817733">{{cite journal| author=Wathne B, Holst E, Hovelius B, Mårdh PA| title=Vaginal discharge--comparison of clinical, laboratory and microbiological findings. | journal=Acta Obstet Gynecol Scand | year= 1994 | volume= 73 | issue= 10 | pages= 802-8 | pmid=https://pubmed.ncbi.nlm.nih.gov/7817733 | doi=10.3109/00016349409072509 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7817733 }} </ref> | ||
=====Non- | *[[Trichomoniasis]],a [[parasitic infection]] typically contracted and caused by having [[Unprotected sex|unprotected]] [[Sex (activity)|sex]]<ref name="pmidhttps://pubmed.ncbi.nlm.nih.gov/18048541">{{cite journal| author=Spence D, Melville C| title=Vaginal discharge. | journal=BMJ | year= 2007 | volume= 335 | issue= 7630 | pages= 1147-51 | pmid=https://pubmed.ncbi.nlm.nih.gov/18048541 | doi=10.1136/bmj.39378.633287.80 | pmc=2099568 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18048541 }} </ref> | ||
'''Non-infectious causes''' | |||
Physiological<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref>: | |||
*[[Puberty]] | |||
*[[Menstrual cycle|Menstrual Cycle]] | |||
*[[Sexual activities|Sexual Activity]] | |||
*[[Pregnancy]] | |||
* | *[[Menopause]] | ||
Non-physiological: | |||
*[[Foreign body vaginitis]] | *[[Foreign body vaginitis]] | ||
*[[Cervical cancer]]<ref name="pmidhttps://doi.org/10.1016/j.ogrm.2016.08.002">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/j.ogrm.2016.08.002 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> | *[[Cervical cancer]]<ref name="pmidhttps://doi.org/10.1016/j.ogrm.2016.08.002">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1016/j.ogrm.2016.08.002 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> | ||
*[[Vaginal cancer]] | *[[Vaginal cancer]] | ||
*[[Diabetes]] | *[[Diabetes]] | ||
**[[Atrophic vaginitis]] or senile vaginitis, | *[[Drug]] [[side effect]]s 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 ]] | ||
**[[Vulval dermatitis]] | |||
*[[Gynaecology|Gynaecological]] causes: | |||
**[[Atrophic vaginitis]] or [[senile]] [[vaginitis]], as a result of [[estrogen]] [[deficiency]] that leads to [[vaginal dryness]], [[itching]], [[irritation]], [[discharge]], and [[dyspareunia]].<ref name="pmid21524046">{{cite journal| author=Hainer BL, Gibson MV| title=Vaginitis. | journal=Am Fam Physician | year= 2011 | volume= 83 | issue= 7 | pages= 807-15 | pmid=21524046 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21524046 }} </ref> | |||
**[[Vulva|Vulval]] [[dermatitis]] | |||
**[[Cervical]] [[ectopy]] | **[[Cervical]] [[ectopy]] | ||
==Diagnosis== | ==Diagnosis== | ||
Shown below is an algorithm summarizing the diagnosis of Vaginal discharge. | Shown below is an algorithm summarizing the diagnosis of [[vaginal discharge]].<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref><ref name="urlVaginal Discharge - Clinical Methods - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK281/ |title=Vaginal Discharge - Clinical Methods - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | ||
<span style="font-size:85%"> | |||
'''Abbreviations:''' BP: Blood pressure, '''RR'''=Respiratory rate, | |||
'''HR'''=Heart Rate, '''OCP'''= [[Oral contraceptive|Oral Contraceptive Pill]], '''NAAT'''= [[NAAT|Nucleic Acid Amplification Test]] | |||
<br /> | |||
{{Family tree/start}} | |||
{{Family tree | | | | | | | A01 | | | | | | | |A01= Patient with history of [[Vaginal discharge ]]}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B01 | | | | | | | |B01= Take complete history}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left; height: 17em; width: 20em;; "> '''Record [[Vital signs|vitals]]:'''<br> | |||
---- | |||
❑ [[Blood pressure]]<br><br> | |||
❑ [[Temperature]]<br><br>❑ [[Respiratory rate]]<br><br>❑ [[Heart rate]] </div>| | | | | | | |}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;"> '''Ask the following questions about [[menstrual]] history :'''<br> | |||
---- | |||
❑ Age of [[menarche]] <br><br>❑ Last [[menstrual]] period<br><br>❑ Is the [[menstrual]] flow normal? How many pads she has to use in a day? <br><br>❑ Is there any foul smell or colour change?<br><br>❑ How many days does the [[menstruation]] stay?<br><br>❑ [[Contraceptive]] history for example [[oral]] [[contraceptives]], [[intrauterine device]]<br><br></div>| | | | | | | |}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B01 | | | | | | | |B01= <div style="float: left; text-align: left;"> '''Ask the following questions about general health :'''<br> | |||
---- | |||
❑ Ask about medical and [[drug]] history including recent [[antibiotic]] use and type of [[contraceptive]] use <br><br>❑ Assess for the possibility of a [[foreign body]] in situ <br><br>❑ Ask if there was any [[surgery]] or instrumentation to the genital region recently <br><br>❑ Is there any other health conditions like [[Diabetes Mellitus]]?<br><br>❑ Is there any history of [[fever]], [[lower abdominal pain]]?<br><br></div>| | | | | | | | }} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B01 | | | | | | | |B01= Ask the following questions about [[colour]], appearance of the [[discharge]] }} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B01 | | | | | | | |B01= Is the [[discharge]] white or cream coloured, resembling "cottage cheese"?}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | |,|-|^|-|.| | | | |}} | |||
{{Family tree | | | | | |!| | | |!| | | | |}} | |||
{{Family tree | | | | |C03| | |C04| | | | |C03= Yes|C04=No}} | |||
{{Family tree | | | | |!| | | | |!| | | | |}} | |||
{{Family tree | | | | |D04| | |!| | |D04=<div style="float: left; text-align: left; height: 30em; width: 20em;"> '''Check if they have the following complaints :'''<br> | |||
---- | |||
❑ [[Pruritus]] <br><br>❑ [[Vaginal]] [[Burn|burning]], usually with increased [[vaginal discharge]] <br><br>❑ Vague but inoffensive [[odour]] <br><br>❑ [[Dysuria]], [[dyspareunia]] in patients with intense [[scratch|scratching]] and [[itching]] that led to skin [[excoriation|excoriations]]<br><br>❑ Presence of [[Erythema|vulval erythema]], [[fissures]]<br><br></div>| | | | | | | ||R08=}} | |||
{{Family tree | | | | |!| | | | |!| | | |}} | |||
{{Family tree | | | | B01 | | | |!| | | |B01= Yes }} | |||
{{Family tree | | | | |!| | | | |!| | | |}} | |||
{{Family tree | | | | B01 | | | |!| | | |B01= Ask if the following factors are present}} | |||
{{Family tree | | | | |!| | | | |!| | | |}} | |||
{{Family tree | | | | B02 | | | |!| | | |B02=<div style="float: left; text-align: left; height: 26em; width: 20em; "> '''Associated factors:'''<br> | |||
---- | |||
❑ [[Glycosuria]]<br><br> | |||
❑ [[Diabetes Mellitus]] <br><br>❑ [[Obesity]]<br><br>❑ [[Pregnancy]]<br><br>❑ Recent use of [[steroids]]/ [[antibiotics]]/ [[immunosuppressive]] agents<br><br> </div>| | | | | | | |}} | |||
{{Family tree | | | | |!| | | | |!| | | |}} | |||
{{Family tree | | | | |!| | | | |!| | | | | | | |}} | |||
{{Family tree | | | |b02| | | |!| | | | | |b02=Examination of direct [[vaginal]] secretions or scrapping from [[vaginal]] wall via direct [[microscopy]] |}} | |||
{{Family tree | | | | |!| | | | |!| | | | | | | |}} | |||
{{Family tree | | | |p09| | | |!| | | | | |p09= When a drop of 10% [[Potassium Hydroxide]] is added, typical myecelis or pseudo hyphae is seen| |}} | |||
{{Family tree | | | | |!| | | | |!| | | | | | | |}} | |||
{{Family tree | | | | B01 | | | |!| | | |B01= [[Candidiasis]] }} | |||
{{Family tree | | | | | | | | | B01 | | |B01=Is the [[discharge]] greenish? |}} | |||
{{Family tree | | | | | | | | | |!| | | | | | | |}} | |||
{{Family tree | | | | | | | | | |!| | | | | | | |}} | |||
{{Family tree | | | | | | | |,|-|^|-|.| | | | |}} | |||
{{Family tree | | | | | | | |!| | | |!| | | | |}} | |||
{{Family tree | | | | | | | |C03| |C04| | | | |C03= Yes|C04=No}} | |||
{{Family tree | | | | | | | |!| | | |!| | | |}} | |||
{{Family tree | | | | | | | B01 | | |!| | | |B01= <div style="float: left; text-align: left; height: 37em; width: 20em;"> '''Check if they have the following complaints :'''<br> | |||
---- | |||
❑ [[Purulent]], frothy [[discharge]] <br><br>❑ Foul smelling [[discharge]] with [[Vulva|vulval]] [[soreness]] and [[irritation]], if severe [[Vulva|vulval]] [[oedema]] <br><br>❑ Punctate [[hemorrhagic]] area or strawberry [[cervix]] is path gnomic <br><br>❑ [[Lower abdominal pain]] and[[dyspareunia]] may be seen in patients with long standing infection<br><br>❑ Male partners are usually asymptomatic except having [[Penis|penile]] [[pruritus]] after [[coitus]]<br><br></div>}} | |||
{{Family tree | | | | | | | |!| | | |!| | | |}} | |||
{{Family tree | | | | | | | B02 | | |!| | | |B02=<div style="float: left; text-align: left; "> '''Associated factors:'''<br> | |||
---- | |||
❑ Multiple [[sexual]] partners<br><br> | |||
❑ Increased level [[sexual]] activity <br><br> </div>| | | | | | | |}} | |||
{{Family tree | | | | | | | |!| | | |!| | | |}} | |||
{{Family tree | | | | | | |b02| | |!| | | | | |b02=Wet mount test: a drop of [[vaginal]] secretion is mixed with [[saline]] and examined under microscope |}} | |||
{{Family tree | | | | | | | |!| | | |!| | | | | | | |}} | |||
{{Family tree | | | | | | |p09| | |!| | | | | |p09= [[Trichomonad|Trichomonads]] are recognized by their twitching motility |}} | |||
{{Family tree | | | | | | | | | | | |!| | | | | |}} | |||
{{Family tree | | | | | | |p09| | |!| | | | | |p09=[[Vaginal|Vaginal]] [[pH]] > 5 helps to distinguish between [[trichomoniasis]] and [[candidiasis]] which has [[pH]] of less than 4.5|}} | |||
{{Family tree | | | | | | | | | | | |!| | | | | |}} | |||
{{Family tree | | | | | | | B01 | | |!| | | |B01= [[Trichomoniasis]] }} | |||
{{Family tree | | | | | | | | | | | |!| | | | }} | |||
{{Family tree | | | | | | |,|-|-|-|-|'| | | | }} | |||
{{Family tree | | | | | | |!| | | | | | | | | }} | |||
{{Family tree | | | | | | B01 | | |B01=Is the [[discharge]] thin, homogenous, bubbly? |}} | |||
{{Family tree | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | |,|-|^|-|.| | | | |}} | |||
{{Family tree | | | | |!| | | |!| | | | |}} | |||
{{Family tree | | | | |C03| |C04|-|p01| |C03= Yes|C04=No|p01=[[Herpes Simplex]]}} | |||
{{Family tree | | | | |!| | | |!| |!|}} | |||
{{Family tree | | | | | B01 | |!| |k01|B01= <div style="float: left; text-align: left; height: 17em; width: 20em;"> '''Check if they have the following complaints :'''<br> | |||
---- | |||
❑ Malodorous, fishy [[discharge]] <br><br>❑ No itching or discomfort <br><br>❑ No inflammation of [[vulva]]<br><br></div>|k01=While it does not produce [[vaginal discharge]] itself, it causes [[cervicitis]] and [[vaginitis]] that are associated with severe [[leukorrhea]]}} | |||
{{Family tree | | | | |!| | | |!| |!|}} | |||
{{Family tree | | | | B02 | | |!| |l01|B02=<div style="float: left; text-align: left; height: 17em; width: 20em; "> '''Associated factors:'''<br> | |||
---- | |||
❑ Vary in intensity during [[menstrual cycle]], worse at mid-cycle and especially after [[intercourse]]<br><br> | |||
❑ Partner and children of the patient may complain of [[odour]] that may need the use of frequent [[Douche|douches]] or perfumed bath <br><br> </div>|l01=<div style="float: left; text-align: left; height: 17em; width: 20em;"> '''Diagnosis :'''<br> | |||
---- | |||
❑ Diagnosis is made from history and appearance of typical, multiple, painful [[vesicle|vesicles]]<br><br>❑ [[Culture]] is done to confirm</div> | | | | | | |}} | |||
{{Family tree | | | | |!| | | |!| | | |}} | |||
{{Family tree | | | | b02 | | |!| | | | | |b02=Whiff test: When a drop of 10% [[potassium hydroxide]] is added to a drop of [[vaginal]] secretion fishy amine odour is released |}} | |||
{{Family tree | | | | |!| | | |!| | | | | | | |}} | |||
{{Family tree | | | | p09 | | |!| | | | | |p09=[[Vaginal|Vaginal]] [[pH]] > 5 with presence of [[clue cell|clue cells]] are diagnostic}} | |||
{{Family tree | | | | |!| | | |!| | | |}} | |||
{{Family tree | | | | B01 | | |!| | | |B01= [[Bacterial vaginosis]] ([[Gardnerella vaginalis|Gardnerella vaginosis]]) }} | |||
{{Family tree | | | | | | | | |!| | | |}} | |||
{{Family tree | | | | | | | | b01 | | |b01= [[Mucopurulent]] [[discharge]] |}} | |||
{{Family tree | | | | | | | | |!| | | |}} | |||
{{Family tree | | | | | | |,|-|^|-|.| | | | |}} | |||
{{Family tree | | | | | | |!| | | |!| | | | |}} | |||
{{Family tree | | | | | | C03 | | C04 | | | | |C03= [[Neisseria gonorrheae|Neisseria gonorrhoea]]|C04=[[Chlamydia trachomatis]]}} | |||
{{Family tree | | | | | | |!| | | |!| | | |}} | |||
{{Family tree | | | | | | C03 | | C04 | | | | |C03= <div style="float: left; text-align: left; height: 17em; width: 20em;"> '''Check if they have the following complains :'''<br> | |||
---- | |||
❑ [[Mucopurulent]] [[cervicitis]] and [[urethritis]] <br><br>❑ [[Dysuria]], [[Urethritis|urethral irritation]] <br><br>❑Infection of peri-urethral glands and [[Bartholin's ducts|Bartholin's duct]]<br><br>❑ As [[infection]] progresses, patient may experience [[abdominal pain]].<br><br></div>|C04=<div style="float: left; text-align: left; height: 37em; width: 30em;"> '''Check if they have the following complains :'''<br> | |||
---- | |||
❑ Watery, thinner discharge with dysuria and lower abdominal discomfort <br><br>❑ [[Cervical]] friability and [[oedema]] with [[ectopy]] of [[cervix]] <br><br>❑ Infection of peri-urethral glands and [[Bartholin's ducts|Bartholin's duct]]<br><br></div>}} | |||
{{Family tree | | | | | |!| | | | |!| | | |}} | |||
{{Family tree | | | | | | C03 | | | C04 | | | | |C03= <div style="float: left; text-align: left; height: 17em; width: 20em;"> '''Diagnosis :'''<br> | |||
---- | |||
❑ Culture of endo-cervical specimen shows gram negative [[diplococci]], [[Neisseria gonorrhoeae|Neisseria gonorrhoea ]]<br><br></div>|C04=<div style="float: left; text-align: left;"> '''Diagnosis :'''<br> | |||
---- | |||
❑ First void [[urine]] and [[vaginal]] [[swab|swabs]] are the recommended specimens for [[NAAT]]( [[Nucleic Acid Amplification Test]]) for diagnosis of [[Chlamydia trachomatis]].<ref name="pmid27681919">{{cite journal |vauthors=Meyer T |title=Diagnostic Procedures to Detect Chlamydia trachomatis Infections |journal=Microorganisms |volume=4 |issue=3 |pages= |date=August 2016 |pmid=27681919 |pmc=5039585 |doi=10.3390/microorganisms4030025 |url= |issn=}}</ref> <br><br></div>}} | |||
{{Family tree | | | | | | | | | | | | | | | | | | | |}} | |||
{{Family tree/end}} | |||
==Treatment== | ==Treatment== | ||
Shown below is an algorithm summarizing the treatment of < | Shown below is an algorithm summarizing the treatment of [[Vaginal discharge]]. | ||
{{ | |||
{{ | <span style="font-size:85%">'''Abbreviations:''' '''QHS''' : Every bedtime , '''BID''': 2 times daily, '''TID''': Three times a day, '''QID''': Four times a day, '''IM''' :Intramuscular | ||
{{ | |||
{{ | <br /> | ||
{{ | |||
{{ | {| style="border: 2px solid #4479BA; align=" left" | ||
{{ | ! style="width: Organism; background: #4479BA;" |{{fontcolor|#FFF|[[Organisms]]}} | ||
{{ | ! style="width: Recommended Drugs; background: #4479BA;" |{{fontcolor|#FFF|Recommended [[Drugs]]}} | ||
{{ | ! style="width: Alternative drugs; background: #4479BA;" |{{fontcolor|#FFF|Alternative [[drugs]]}} | ||
{{ | |- | ||
{{ | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Candidiasis]] | ||
{{ | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
{{ | '''Over-the-Counter Intravaginal Agents'''<ref name="urlVulvovaginal Candidiasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/candidiasis.htm |title=Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | ||
*[[Clotrimazole]] 1% cream 5 g intravaginally daily for 7–14 days | |||
OR | |||
*[[Clotrimazole]] 2% cream 5 g intravaginally daily for 3 days | |||
OR | |||
*[[Miconazole]] 2% cream 5 g intravaginally daily for 7 days | |||
OR | |||
*[[Miconazole]] 4% cream 5 g intravaginally daily for 3 days | |||
OR | |||
*[[Miconazole]] 100 mg vaginal suppository, one [[suppository]] daily for 7 days | |||
OR | |||
*[[Miconazole]] 200 mg vaginal suppository, one [[suppository]] for 3 days | |||
OR | |||
*[[Miconazole]] 1,200 mg vaginal [[suppository]], one [[suppository]] for 1 day | |||
OR | |||
*[[Tioconazole]] 6.5% [[ointment]] 5 g intravaginally in a single application | |||
'''Prescription Intravaginal Agents:''' | |||
*[[Butoconazole]] 2% cream (single dose bioadhesive product), 5 g intravaginally in a single application | |||
OR | |||
*[[Terconazole]] 0.4% cream 5 g intravaginally daily for 7 days | |||
OR | |||
*[[Terconazole]] 0.8% cream 5 g intravaginally daily for 3 days | |||
OR | |||
*[[Terconazole]] 80 mg [[Vagina|vaginal]] [[suppository]], one [[suppository]] daily for 3 days | |||
'''Oral Agent:''' | |||
*[[Fluconazole]] 150 mg orally in a single dose | |||
<br /> | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
[[Nystatin]] 1,00,000 unit tab [[Vagina|vaginally]] QHS for 2 weeks<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Trichomoniasis]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[Metronidazole]] 2 g orally in a single dose<ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
OR | |||
*[[Tinidazole]] 2 g orally in a single dose<ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
<br /> | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[Metronidazole]] 500 mg orally twice a day for 7 days<ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
OR | |||
*[[Clotrimazole]] 2 X 100 mg [[Vagina|vaginal]] tabs QHS for 7days<ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
* | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Bacterial Vaginosis]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[Metronidazole]] 500 mg orally twice a day for 7 days<ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
OR | |||
*[[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days<ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
OR | |||
*[[Clindamycin]] cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days<ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[Tinidazole]] 2 g orally once daily for 2 days <ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
OR | |||
*[[Tinidazole]] 1 g orally once daily for 5 days <ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
OR | |||
*[[Clindamycin]] 300 mg orally twice daily for 7 days <ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
OR | |||
*[[Clindamycin]] ovules 100 mg intravaginally once at bedtime for 3 days<ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Neisseria gonorrheae|Neisseria gonorrhoea]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
[[Amoxicillin]] orally 3 gm single [[dose]] <br> or <br>[[Ampicillin]] [[Oral|orally]] 3.5 gm single dose <br> or <br>[[Procaine]] PCN G 4.8 million IM single [[dose]] <ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> | |||
<br> '''PLUS''' | |||
<br> [[Probenecid]] 1 gm orally single [[dose]] <ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> | |||
<br> '''AND''' | |||
<br> [[Tetracycline]] 500 mg orally QID for 7 days <br> or<br> [[Doxycycline]] 100 mg [[Oral|orally]] BID for 7 days <br> or<br> [[Ceftriaxone]] 250 mg IM single dose<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
[[Erythromycin]] 500 mg orally QID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br> or<br>[[Tetracycline]] 500 mg orally QID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br> or<br> [[Doxycycline]] 100 mg orally BID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br> or <br>[[Spectinomycin]] 2 gm IM single [[dose]] | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Chlamydia trachomatis]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
[[Tetracycline]] 500 mg orally QID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br>or<br> [[Doxycycline]] 100 mg [[Oral|orally]] BID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
[[Erythromycin]] base 500 mg orally QID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br> or<br> [[Erythromycin]] ethylsuccinate 800 mg orally QID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br> or<br> [[Sulfamethoxazole]] 1gm [[Oral|orally]] BID for 10 days | |||
<br /> | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Herpes simplex|Herpes Simplex]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
[[Acyclovir]]<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> | |||
<br /> | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
|- | |||
|} | |||
Patient should be referred to a [[gynecologist]] if following are present. <ref name="SimLogan2020">{{cite journal|last1=Sim|first1=M|last2=Logan|first2=S|last3=Goh|first3=LH|title=Vaginal discharge: evaluation and management in primary care|journal=Singapore Medical Journal|year=2020|pages=297–301|issn=00375675|doi=10.11622/smedj.2020088}}</ref> | |||
*Retained [[foreign bodies]]. | |||
*Recent instrumentation or [[surgery]] of the [[Genital area|genital tract]] such as [[hysterosalpingography]], [[Dilation and curettage (patient information)|dilation and curettage]], [[hysteroscopy]], termination of [[pregnancy]]/evacuation of retained products of [[conception]], [[laparoscopy]] and major [[Gynaecology|gynaecological]] [[surgical procedure]]. | |||
*Suspected [[tumor]] of the [[Genital area|genital tract]]. | |||
*[[Cervical]] ectopy or [[Polyp|polyps]]. | |||
*Recurrent [[Vulvovaginal Candidosis|vulvovaginal]] [[Candidiasis|candida infections]]. | |||
*[[Pregnancy|Pregnant]] woman with abnormal [[vaginal discharge]] | |||
*Symptoms of upper [[Genital|genital tract]] [[Infection|infections]] as [[fever]], [[lower abdominal pain]] | |||
'''Treatment in pregnancy:''' | |||
*[[Vulvovaginal Candidosis|Vulvovaginal]] [[Candidiasis]]: It frequently occurs during [[pregnancy]]. Only topical [[azole]] therapies for 7 days are recommended for use among pregnant women.<ref name="urlVulvovaginal Candidiasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/candidiasis.htm |title=Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
*[[Trichomoniasis]]: [[Metronidazole]] 2 g orally single dose is recommended. Symptomatic [[Pregnancy|pregnant]] women, regardless of [[pregnancy]] stage, should be tested and considered for treatment.<ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
*[[Bacterial vaginosis]]: Treatment is recommended for all symptomatic [[Pregnancy|pregnant]] women. [[Metronidazole]] 250-mg regimen is effective. But, [[Metronidazole]] 500 mg twice daily can be used.<ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
==Dos== | ==Dos== | ||
*The | *The use of [[topical]] [[azole]] formulations can weaken [[latex]] [[Condom|condoms]] and [[Diaphragm (contraceptive)|diaphragms]]. This risk should be mentioned to the woman prior to starting these [[Medication|medications]].<ref name="SimLogan2020">{{cite journal|last1=Sim|first1=M|last2=Logan|first2=S|last3=Goh|first3=LH|title=Vaginal discharge: evaluation and management in primary care|journal=Singapore Medical Journal|year=2020|pages=297–301|issn=00375675|doi=10.11622/smedj.2020088}}</ref> | ||
*Referral to a [[gynecologist]] should be considered if there is a history of recent instrumentation or [[surgery]] of the [[Genitalia|genital tract]], retained [[foreign body]], [[cervical]] ectopy or [[polyp]], or suspicion of [[Tumor|tumor]] on examination; or in women with symptoms of upper [[Genital area|genital tract]] [[infection]] or recurrent [[Vulvovaginal Candidosis|vulvovaginal candida infections]], [[Pregnancy|pregnant]] women with abnormal [[vaginal discharge]], or women who have failed routine [[treatment]] strategies.<ref name="SimLogan2020">{{cite journal|last1=Sim|first1=M|last2=Logan|first2=S|last3=Goh|first3=LH|title=Vaginal discharge: evaluation and management in primary care|journal=Singapore Medical Journal|year=2020|pages=297–301|issn=00375675|doi=10.11622/smedj.2020088}}</ref> | |||
*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.<ref name="SimLogan2020">{{cite journal|last1=Sim|first1=M|last2=Logan|first2=S|last3=Goh|first3=LH|title=Vaginal discharge: evaluation and management in primary care|journal=Singapore Medical Journal|year=2020|pages=297–301|issn=00375675|doi=10.11622/smedj.2020088}}</ref><ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
*Women with [[Trichomoniasis]] should be advised to abstain from [[sexual]] [[intercourse]] until [[treatment]] is completed and symptoms have resolved, as it is [[Sexual|sexually]] transmissible.<ref name="SimLogan2020">{{cite journal|last1=Sim|first1=M|last2=Logan|first2=S|last3=Goh|first3=LH|title=Vaginal discharge: evaluation and management in primary care|journal=Singapore Medical Journal|year=2020|pages=297–301|issn=00375675|doi=10.11622/smedj.2020088}}</ref><ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
==Don'ts== | ==Don'ts== | ||
* | *Patient should be advised to avoid tight-fitting synthetic clothing.<ref name="SimLogan2020">{{cite journal|last1=Sim|first1=M|last2=Logan|first2=S|last3=Goh|first3=LH|title=Vaginal discharge: evaluation and management in primary care|journal=Singapore Medical Journal|year=2020|pages=297–301|issn=00375675|doi=10.11622/smedj.2020088}}</ref> | ||
*Patient should be told to avoid local irritants such as perfumed products and soap gels and [[vaginal]] [[Douche|doucheing]]. | |||
*There is no clear and consistent evidence across currently published studies regarding the role of probiotics for [[vaginal]] [[health]].<ref name="SimLogan2020">{{cite journal|last1=Sim|first1=M|last2=Logan|first2=S|last3=Goh|first3=LH|title=Vaginal discharge: evaluation and management in primary care|journal=Singapore Medical Journal|year=2020|pages=297–301|issn=00375675|doi=10.11622/smedj.2020088}}</ref> | |||
==References== | ==References== | ||
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[[Category:Resident survival guide]] | [[Category:Resident survival guide]] | ||
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[[category:Up-To-Date]] | |||
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Latest revision as of 15:23, 8 February 2021
Vaginal discharge Resident Survival Guide Microchapters |
---|
Overview |
Causes |
Diagnosis |
Treatment |
Dos |
Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.
Synonyms and keywords: Approach to Vaginal discharge, Leukorrhea
Overview
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.
Causes
Infectious causes
Non-sexually transmitted infection[1]:
- 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.[2]
Sexually transmitted infection:
- Trichomoniasis,a parasitic infection typically contracted and caused by having unprotected sex[5]
Non-infectious causes
Physiological[1]:
Non-physiological:
- 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:
- Atrophic vaginitis or senile vaginitis, as a result of estrogen deficiency that leads to vaginal dryness, itching, irritation, discharge, and dyspareunia.[6]
- Vulval dermatitis
- Cervical ectopy
Diagnosis
Shown below is an algorithm summarizing the diagnosis of vaginal discharge.[1][7]
Abbreviations: BP: Blood pressure, RR=Respiratory rate,
HR=Heart Rate, OCP= Oral Contraceptive Pill, NAAT= Nucleic Acid Amplification Test
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"? | |||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||
Check if they have the following complaints : ❑ Pruritus ❑ Vaginal burning, usually with increased vaginal discharge ❑ Vague but inoffensive odour ❑ Dysuria, dyspareunia in patients with intense scratching and itching that led to skin excoriations ❑ Presence of vulval erythema, fissures | |||||||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||||
Ask if the following factors are present | |||||||||||||||||||||||||||||||||||||||||||||||
Associated factors: ❑ Diabetes Mellitus ❑ Obesity ❑ Pregnancy ❑ Recent use of steroids/ antibiotics/ immunosuppressive agents | |||||||||||||||||||||||||||||||||||||||||||||||
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 | |||||||||||||||||||||||||||||||||||||||||||||||
Candidiasis | |||||||||||||||||||||||||||||||||||||||||||||||
Is the discharge greenish? | |||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||
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 | |||||||||||||||||||||||||||||||||||||||||||||||
Trichomoniasis | |||||||||||||||||||||||||||||||||||||||||||||||
Is the discharge thin, homogenous, bubbly? | |||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Herpes Simplex | |||||||||||||||||||||||||||||||||||||||||||||
While it does not produce vaginal discharge itself, it causes cervicitis and vaginitis that are associated with severe leukorrhea | |||||||||||||||||||||||||||||||||||||||||||||||
Associated factors: ❑ Vary in intensity during menstrual cycle, worse at mid-cycle and especially after intercourse | |||||||||||||||||||||||||||||||||||||||||||||||
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) | |||||||||||||||||||||||||||||||||||||||||||||||
Mucopurulent discharge | |||||||||||||||||||||||||||||||||||||||||||||||
Neisseria gonorrhoea | Chlamydia trachomatis | ||||||||||||||||||||||||||||||||||||||||||||||
Check if they have the following complains : ❑ Mucopurulent cervicitis and urethritis ❑ Dysuria, urethral irritation ❑Infection of peri-urethral glands and Bartholin's duct ❑ As infection progresses, patient may experience abdominal pain. | Check if they have the following complains : ❑ Watery, thinner discharge with dysuria and lower abdominal discomfort ❑ Cervical friability and oedema with ectopy of cervix ❑ Infection of peri-urethral glands and Bartholin's duct | ||||||||||||||||||||||||||||||||||||||||||||||
Diagnosis : ❑ Culture of endo-cervical specimen shows gram negative diplococci, Neisseria gonorrhoea | Diagnosis : ❑ First void urine and vaginal swabs are the recommended specimens for NAAT( Nucleic Acid Amplification Test) for diagnosis of Chlamydia trachomatis.[8] | ||||||||||||||||||||||||||||||||||||||||||||||
Treatment
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 |
---|---|---|
Candidiasis |
Over-the-Counter Intravaginal Agents[9]
OR
OR
OR
OR
OR
OR
OR
Prescription Intravaginal Agents:
OR
OR
OR
Oral Agent:
|
|
Trichomoniasis |
OR
|
OR
|
Bacterial Vaginosis |
OR
OR
|
OR
OR
OR
|
Neisseria gonorrhoea |
Amoxicillin orally 3 gm single dose
|
Erythromycin 500 mg orally QID for 7 days[1] |
Chlamydia trachomatis |
Tetracycline 500 mg orally QID for 7 days[1] |
Erythromycin base 500 mg orally QID for 7 days[1] |
Herpes Simplex |
|
Patient should be referred to a gynecologist if following are present. [12]
- 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.[9]
- Trichomoniasis: Metronidazole 2 g orally single dose is recommended. Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.[10]
- 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.[11]
Dos
- 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.[12]
- 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.[12]
- 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.[12][11]
- Women with Trichomoniasis should be advised to abstain from sexual intercourse until treatment is completed and symptoms have resolved, as it is sexually transmissible.[12][10]
Don'ts
- Patient should be advised to avoid tight-fitting synthetic clothing.[12]
- 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.[12]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 Watson WJ, Demarchi G (August 1987). "Vaginal discharge: an approach to diagnosis and management". Can Fam Physician. 33: 1847–52. PMC 2218224. PMID 21263805.
- ↑ Cettl L, Dvorak J, Felkel H, Feuereisl R (1979). "Results of simulation of non-homogeneous ventilatory mechanics for a patient-computer arrangement". Int J Biomed Comput. 10 (1): 67–74. doi:10.1016/0020-7101(79)90042-4. PMID http://www.ncbi.nlm.nih.gov/pmc/articles/pmc478688 Check
|pmid=
value (help). - ↑ 3.0 3.1 Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/j.ogrm.2016.08.002 Check
|pmid=
value (help). - ↑ Wathne B, Holst E, Hovelius B, Mårdh PA (1994). "Vaginal discharge--comparison of clinical, laboratory and microbiological findings". Acta Obstet Gynecol Scand. 73 (10): 802–8. doi:10.3109/00016349409072509. PMID https://pubmed.ncbi.nlm.nih.gov/7817733 Check
|pmid=
value (help). - ↑ Spence D, Melville C (2007). "Vaginal discharge". BMJ. 335 (7630): 1147–51. doi:10.1136/bmj.39378.633287.80. PMC 2099568. PMID https://pubmed.ncbi.nlm.nih.gov/18048541 Check
|pmid=
value (help). - ↑ Hainer BL, Gibson MV (2011). "Vaginitis". Am Fam Physician. 83 (7): 807–15. PMID 21524046.
- ↑ "Vaginal Discharge - Clinical Methods - NCBI Bookshelf".
- ↑ Meyer T (August 2016). "Diagnostic Procedures to Detect Chlamydia trachomatis Infections". Microorganisms. 4 (3). doi:10.3390/microorganisms4030025. PMC 5039585. PMID 27681919.
- ↑ 9.0 9.1 "Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines".
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 "Trichomoniasis - 2015 STD Treatment Guidelines".
- ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 "Bacterial Vaginosis - 2015 STD Treatment Guidelines".
- ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 Sim, M; Logan, S; Goh, LH (2020). "Vaginal discharge: evaluation and management in primary care". Singapore Medical Journal: 297–301. doi:10.11622/smedj.2020088. ISSN 0037-5675.