Vaginal discharge resident survival guide

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 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 odour.It is important to take complete history and ask about associated symptoms like dysuria, dyspareunia, lower abdominal pain, itching, fever. While considering the causes, it is necessary to distinguish between the infectious and non-infectious causes. The infectious causes are infection with Candida albicans, Trichomonas vaginalis, Bacterial vaginosis, Chlamydia trachomatis, Neisseria gonorrhoea, 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

Non-sexually transmitted infection

• Bacterial vaginosisis mostly happens during the reproductive age of women characterized by a shift in the vaginal flora from the dominant Lactobacillus to a polymicrobial flora.
• Vaginal yeast infection

Sexually transmitted infection

• Chlamydia,sexually transmitted infections.
• Gonorrhea,sexually transmitted infections
• Herpes
• Trichomoniasis,a parasitic infection typically contracted and caused by having unprotected sex

Non-infective causes

Physiological:

• Puberty
• Menstrual Cycle
• Sexual Activity
• Pregnancy
• Menopause

Non-physiological:

• Foreign body vaginitis
• Cervical cancer
• Vaginal cancer
• Diabetes
• Drug side effect as antibiotic or steroid use 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
• Gynaeocological causes:
  • Atrophic vaginitis or senile vaginitis, it as a result of estrogen deficiency lead to vaginal dryness, itching, irritation, discharge, and dyspareunia.
  • Vulval dermatitis
  • Cervical ectopy

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Vaginal discharge.

Patient with history of Vaginal discharge

Take complete history

Record the vitals: ❑ Blood pressure ❑ Temperature ❑ Respiratory rate ❑ Heart rate

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 menstrual period 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 complains : ❑ 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: ❑ Glycosuria ❑ 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 complains : ❑ 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

Associated factors: ❑Multiple sexual partners ❑Increased level sexual activity

Wet mount test: a drop of vaginal secretion is mixed with saline and examined under microscope

Trichomonads are recognised 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

Check if they have the following complains : ❑ Malodorous, fishy discharge ❑ No itching or discomfort ❑No inflammation of vulva

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 ❑ Partner and children of the patient may complain of odour that may need the use of frequent douches or perfumed bath

Diagnosis : ❑ Diagnosis is made from history and appearance of typical, multiple, painful vesicles ❑ Culture is done to confirm

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.

Treatment

Shown below is an algorithm summarizing the treatment of Vaginal discharge.

Organisms	Recommended Drugs	Alternative drugs
Candidiasis	Clotrimazole/Miconazole 100 mg vaginally QHS for 7 days Or 200 mg vaginally QHS for 3 days Or Clotrimazole 500 mg tab vaginally single dose	Nystatin 1,00,000 unit tab vaginally QHS for 2 weeks
Trichomoniasis	Metronidazole 2gm orally single dose Or 250 mg TID orally for 7 days	Clotrimazole 2 X 100 mg vaginal tabs QHS for 7days
Bacterial Vaginosis	Metronidazole 500 mg orally bid X 7 days	Ampicillin/Amoxicillin or 500 mg tab QUD for 7 days or Doxycycline 100 mg bid for 7 days
Neisseria gonorrhoea	Amoxicillin orally 3gm single dose or Ampicillin orally 3.5 gm single dose or Procaine PCN G 4.8 million IM single dose PLUS Probenecid 1 gm orally single dose 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	Erythromycin 500mg orally QID for 7 days or Tetracycline 500 mg orally QID for 7 days or Doxycycline 100 mg orally BID for 7 days or Spectinomycin 2 gm IM single dose
Chlamydia trachomatis	Tetracycline 500 ng orally QID for 7 days or Doxycycline 100 mg orally BID for 7 days	Erythromycin base 500 mg orally QID for 7 days or Erythromycin ethylsuccinate 800 mg orally QID for 7 days or Sulfamethoxazole 1gm orally BID for 10 days
Herpes Simplex	Acyclovir

Patient should be referred to a gynaecologist if following are present.

• 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 tumour 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

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.
• Referral to a gynaecologist 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 tumour 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.

Don'ts

• 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 douching.
• There is no clear and consistent evidence across currently published studies regarding the role of probiotics for vaginal health.

References

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