VAGINAL

DISCHARGEDR.TARIG MAHMOUD

MD SUDAN

HAIL UNIVERSITY KSA

TWO TYPE

Physiological

CAUSES OF PHYSIOLOGICAL VAGINAL DISCHARGE

Result mainly from cervical secretion in response to hormonal levels during the menstrual cycle there is increased mucous production from the cervix at the time of ovulation .

Physiological discharge usually white

Physiological discharge increase during pregnancy and oral contraceptive users.

Causes of vaginal discharge1. Candidal

infection

2. Bacterial

vaginosis

3. Trichomonas

4. N. gonorrhea

5. Chlamydia

6. Cervical

ectropin

7.Endometrial

cancer

8.Cervical cancer

9.Vaginal cancer

10.Foreign body,

IUD, vaginal ring

CANDIDAL VULVOVAGINOSIS

Candida albicans is a diploid fungus and is a

common commensal in the gut flora.

Predisposing factors:

DM

Pregnancy

HIV

Immunosuppression drug

Oral contraceptive pill

Antibiotics

hormone replacement therapy

S IGNS AND SYMPTOMS

Vulvar itching

White cheesy vaginal discharge that

adheres to vaginal wall

Superficial dyspareunia and dysuria.

Vulval oedema, vulval excoriation,

redness and erythema.

Normal vaginal pH.

Diagnosisdirect microscopy[budding yeast]

Vaginal swap and culture

TreatmentAvoid local irritant soaps, perfumes and

synthetic underwear.

Topical or systemic imidazoles

[clotrimazole,econazole & miconazole.]

nystatin cream or pessary

There is no evidence to treat the asymptomatic male partner

RECURRENT INFECTION

Recurrent infection is defined as at least four

episodes of infection per year

Commonly treated by fluconazole 150 mg given

in three doses orally every 72 hours followed by

a maintenance dose of 150 mg weekly for six

months.

PREGNANCY AND CANDIDA

There is no evidence of any adverse effects

in pregnancy to either the mother or the

baby if treated with topical imidazoles.

The oral imidazoles are contraindicated in

pregnancy.

TRICHOMONAS VAGINALIS

Flagellated protozoon

Affect vagina, urethra ,Para urethral

gland

Transmitted sexually

SIGNS AND SYMPTOMS

Vaginal discharge[froth ,yellow or green

offensive]

Vulval soreness and itching

Dysuria and abdominal discomfort

strawberry cervix

Asymptomatic

D IAGNOSIS

Direct microscopy observation of wet

smear

Culture

TREATMENT

Metronidazol

Treat the partner

BACTERIAL VAGINOSIS

This condition is due to an imbalance in the vaginal micro flora, although the exact mechanisms which result in this change remain uncertain.

It occurs due to the growth and increase in anaerobic species with simultaneous reduction in the lactobacilli in the vaginal flora causing an increase in the vaginal pH making it more alkaline .

The common species involved are Gardnerellavaginalis, Mycoplasma hominis, Bacteroidesspp. and Mobilincus spp.

SIGNS AND SYMPTOMS

1. Asymptomatic carriers

2. Fishy odorous vaginal discharge.

3. More prominent during and following

menstruation

4. Creamy or grayish-white vaginal

discharge commonly adherent to the

wall of the vagina.

COMPLICATION

Post termination endometritis In

pregnancy

Late miscarriage

Preterm labour

Preterm prelabour rupture of the

membrane

Postpartum endometritis

DIAGONOSTIC FEATURES

AMSEL CRITERIA:

1.Presence of clue cells on microscopic

examination

2.Creamy greyish white discharge which is

seen on naked eye examination.

3.Vaginal pH of more than 4.5.

4.Released of a characteristics fishy odour

on addition on alkali 10 per potassium

hydroxide.

There should be at least three criteria for

diagnosis.

HAY/ISON CRITERIA :

Grade1. Normal: Lactobacillus

predominate.

Grade2. Intermediate: Lactobacillus seen

with the presence of Gardnerella and\or

Mobiluncus spp.

Grade3. Bacterial vaginosis: Lactobacilli

absent or markedly reduced with

predominance of Gardnerella and\or

Mobiluncus spp.

NUGENT CRITERIA:

Based on the proportion of anaerobic

species giving a quantitive score between

0 and 10.

Less than 4: Normal

4 to 6: Intermediate

More than 6: Bacterial vaginosis

TREATMENT

Metronidazole 2 gm single dose or 400mg BD

for 7days

Clindamycin 300 mg twice daily or a topical

vaginal cream

PREGNANCY AND BACTERIAL VAGINOSIS

Presence of bacterial vaginosis in the first

trimester can lead to late second trimester

miscarriages and preterm labour.

a previous history of second trimester loss or

preterm delivery should have a vaginal swab

performed in early pregnancy and if bacterial

vaginosis is detected, it should be actively

treated.

GONORRHOEA

Nesseria gonorrhoea is a sexually

transmitted disease caused by the

Gram-negative diplococci.

It infects the mucous membranes of the

endocervical and urethral mucosa.

It can also infect the rectal and the

oropharyngeal mucous membrane

during anal and oral intercourse.

SIGNS AND SYMPTOMS

Asymptomatic

Increased vaginal discharge with lower abdominal/pelvic pain

Dysuria with urethral discharge

Proctitis with rectal bleeding, discharge and pain

Endocervical mucopurulent discharge and contact bleeding

Mucopurulent urethral discharge

Pelvic tenderness with cervical excitation.

DIAGNOSTIC TESTS

Endocervical swabs should be taken

Gram staining: visualization of Gram-

negative intercellular diplococci .

Culture medium using an agar medium

containing antimicrobials to reduce

growth of other organisms.

Nucleic acid amplification tests (NAATs)

Nucleic acid hybridization tests

TREATMENT

It is more important to screen both

partners and refer them to a

genitourinary medicine (GUM) clinic.

Contact tracing should be encouraged if

there is exposure to multiple partners.

They should be counseled regarding the

long-term implications of the infections

leading to chronic pelvic pain, tubal

infection and subfertility.

ANTIBIOTIC TREATMENT

Cephalosporins are the mainstay of treatment.

1. Single oral dose of cefixime 400 mg

2. Single intramuscular dose of ceftriaxone 250 mg

Single intramuscular dose of spectinomycin 2 g

Single oral dose of ciprofloxacin 500 mg or ofloxacin 400 mg

Ampicillin 2 g or amoxycillin 1 g with probenecid 2 gm as a single oral dose.

PREGNANCY AND GONORRHOEA

In pregnancy, it is safe to use the

penicillins and cephalosporins, but

tetracycline and ciprofloxacin/ofloxacin

should be avoided.

GENITOURINARY CHLAMYDIA

Chlamydia is an obligate intercellular

bacterium affecting the columnar

epithelium of the genital tract.

It causes one of the most common

sexually transmitted infections.

SIGNS AND SYMPTOMS

Asymptomatic

Vaginal discharge and lower abdominal

pain

Postcoital bleeding

Intermenstrual bleeding

Mucopurulent cervical discharge with

contact bleeding

Dysuria with urethral discharge

COMPLICATIONS

1.Pelvic inflammatory disease

Ectopic pregnancy

Infertility

Chronic pelvic pain

2.Perihepatitis: Fitz-Hugh-Curtis syndrome

3.Neonatal conjunctivitis and pneumonia

4.Adult conjunctivitis

5. Reiter’s syndrome: reactive arthritis

DIAGNOSTIC TESTS

1. Nucleic acid amplification technique:>90

per cent sensitive, should replace the old

enzyme immunoassays .

2. Real-time polymerase chain reaction

3.Culture is expensive with limited

availability. It is only around 60 per cent

sensitive, hence not routinely

recommended.

SCREENING AND APPORTUNISTIC

TESTING

1.Partners of patients diagnosed or

suspected with infection

2.History of chlamydia in the last year

3.Patients attending GUM clinics

4.Patients with two or more partners within

12months

5.Women undergoing termination of

pregnancy

6.History of the other sexually transmitted

infection and HIV.

TREATMENT

refer them to a genitourinary medicine

(GUM) clinic

Contact tracing should be encouraged if

there is exposure to multiple partners

General advice avoid intercourse, before

treatment of both partners is complete.

ANTIBIOTIC TREATMENT

1. Doxycycline 100mg orally twice a day x

7days

2.Azithromycin 1g orally in a single dose

3. Erythromycin 500mg orally four times a

day x 7days

4.Amoxicillin 500mg three times a day x

7days

5.Ofloxacin 200mg orally twice a day x

7days.

VAGINAL SWABS

PRE-PROCEDURE:

Consultation (medical history, explain

procedure & counsel)

Gain consent & offer a chaperone.

Prepare: Empty bladder, provide privacy,

dorsal position, position light, attend

hand hygiene & apply gloves / eye

protection

PROCEDURE

Inspect the labia, external meatus & vulva; Insert speculum

High Vaginal Swab(HVS): Swab, make smear on glass slide & place in charcoal medium.

Endo Cervical Swab(ECS): Pap smear first (if required), then clean mucous from cervix & take ECS PCR swab & place in tube. If pus/ inflammation of cervix, take ECS for culture, smear on glass slide & place in charcoal medium

Low Vaginal Swab & Rectal swab(LVS):

May be self-obtained by the woman if

asymptomatic.

LVS: Insert swab 1-2 cm into vagina & place

into transport tube (use charcoal medium

tube for culture & a separate thin plastic/

wire shaft swab if PCR).

Rectal: Around/inside rectum just past

external sphincter & place into charcoal

tube.

POST PROCEDURE

Provide privacy for redressing.

Offer tissues as required.

Document: Procedure, consent, persons

attending examination (e.g. chaperone,

family), swab details (swab site, date,

time, patient details- but sticker or hand

write on glass slides)

Send specimens to pathology

Thank you for attention