Vaginal discharge: Difference between revisions

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'''HR'''=Heart Rate, '''OCP'''= [[Oral contraceptive|Oral Contraceptive Pill]], '''NAAT'''= [[NAAT|Nucleic Acid Amplification Test]]
'''HR'''=Heart Rate, '''OCP'''= [[Oral contraceptive|Oral Contraceptive Pill]], '''NAAT'''= [[NAAT|Nucleic Acid Amplification Test]]
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<br />
{{Family tree/start}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{Family tree | | | | | | | A01 | | | | | | | |A01= Patient with history of [[Vaginal discharge ]]}}
{{familytree | | | | A01 | | | A01= }}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{familytree | | | | |!| | | | }}
{{Family tree | | | | | | | B01 | | | | | | | |B01= Take complete history}}
{{familytree | | | | B01 | | | B01= }}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{familytree | | |,|-|^|-|.| | }}
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;  height: 17em; width: 20em;; "> '''Record [[Vital signs|vitals]]:'''<br>
{{familytree | | C01 | | C02 | C01= | C02= }}
----
❑ [[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==

Revision as of 08:44, 22 May 2021


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shankar Kumar, M.B.B.S. [2] Samah ObaiahRinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords: Discharge from the vagina

Overview

Vaginal discharge is a common patient complaint that is paired with anxiety regarding sexually transmitted diseases. If a STD is detected, a search for all other STDs should be done. Advise the infected patient to inform all sexual partners of their diagnosis.Also there is normal vaginal discharge depends on periodic hormonal change[1]

Causes

Common Causes

Classification

Normal vaginal discharge as in Neonatal, Pediatric, Puberty, Menstrual cycle[7], Pregnancy, and Menopause. -Abnormal vaginal discharge as


Laboratory findings

Initial tests include:

Other Diagnostic Studies

Type pH Discharge Odor Wet Mount
Trich >4.5 yellow-green, copious present motile, flagellated
BV >4.5 white-grey fishy clue cells
Candida <4.5 white, curd-like none pseudo-hyphae
GC mucopurulent varies PMNs
A.V. thin, gray, watery none few epithelial cells

Diagnosis

Abbreviations: BP: Blood pressure, RR=Respiratory rate, HR=Heart Rate, OCP= Oral Contraceptive Pill, NAAT= Nucleic Acid Amplification Test

Treatment

'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[8]

  • Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days

OR

OR

  • Miconazole 2% cream 5 g intravaginally daily for 7 days

OR

  • Miconazole 4% cream 5 g intravaginally daily for 3 days

OR

OR

OR

OR


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


Oral Agent:



Nystatin 1,00,000 unit tab vaginally QHS for 2 weeks[9]

Trichomoniasis

OR


OR

Bacterial Vaginosis

OR

  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days[11]

OR

  • Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days[11]

OR

OR

OR

Neisseria gonorrhoea


Amoxicillin orally 3 gm single dose
or
Ampicillin orally 3.5 gm single dose
or
Procaine PCN G 4.8 million IM single dose [9]


PLUS


Probenecid 1 gm orally single dose [9]


AND


Tetracycline 500 mg orally QID for 7 days
or
Doxycycline 100 mg orally BID for 7 days
or
Ceftriaxone 250 mg IM single dose[9]

Erythromycin 500 mg orally QID for 7 days[9]
or
Tetracycline 500 mg orally QID for 7 days[9]
or
Doxycycline 100 mg orally BID for 7 days[9]
or
Spectinomycin 2 gm IM single dose

Chlamydia trachomatis

Tetracycline 500 mg orally QID for 7 days[9]
or
Doxycycline 100 mg orally BID for 7 days[9]

Erythromycin base 500 mg orally QID for 7 days[9]
or
Erythromycin ethylsuccinate 800 mg orally QID for 7 days[9]
or
Sulfamethoxazole 1gm orally BID for 10 days

Herpes Simplex


Acyclovir[9]


Patient should be referred to a gynecologist if following are present. [12]

Treatment in pregnancy:

Acute pharmacotherapies

Bacterial Vaginosis

Candida and Chlamydia

Gonorrhea

Trichomonas

References

  1. Spence D, Melville C (2007). "Vaginal discharge". BMJ. 335 (7630): 1147–51. doi:10.1136/bmj.39378.633287.80. PMC 2099568. PMID https://www.ncbi.nlm.nih.gov/pubmed/18048541 Check |pmid= value (help).
  2. Hainer BL, Gibson MV (2011). "Vaginitis". Am Fam Physician. 83 (7): 807–15. PMID 21524046.
  3. 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).
  4. 4.0 4.1 4.2 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).
  5. 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).
  6. 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).
  7. Feingold KR, Anawalt B, Boyce A, Chrousos G, Dungan K, Grossman A; et al. (2000). "Endotext". PMID https://pubmed.ncbi.nlm.nih.gov/25905282 Check |pmid= value (help).
  8. 8.0 8.1 "Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines".
  9. 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 Watson WJ, Demarchi G (August 1987). "Vaginal discharge: an approach to diagnosis and management". Can Fam Physician. 33: 1847–52. PMC 2218224. PMID 21263805.
  10. 10.0 10.1 10.2 10.3 10.4 "Trichomoniasis - 2015 STD Treatment Guidelines".
  11. 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 "Bacterial Vaginosis - 2015 STD Treatment Guidelines".
  12. 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.

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