Vaginal Discharge Diagnosis and Management

Vaginal Discharge - Differential Diagnosis

• Sexually Transmitted Infections (STIs):

  • Chlamydia

  • Gonorrhea

  • Herpes

• Vaginal Infections:

  • Candidiasis (Yeast infection)

  • Bacterial Vaginosis (BV)

  • Trichomoniasis

• Pelvic Inflammatory Disease (PID)

• Foreign Body (e.g., Tampons)

• Cervical Causes:

  • Cervical Cancers

  • Ectropion

  • Ectopic Vaginitis

• Dermatological Conditions:

  • Lichen Planus

• Bartholin Abscess

• Physiological or Hormonal Changes

Patient History Taking

• Opening Questions:

  • "How can I help you today?"

  • Acknowledge patient's concern: "I'm so sorry to hear that. It must be really concerning for you."

  • Reassure the patient: "I will help you and take the best care of you."

• Explore the Complaint:

  • Timing: "Since when? Is it on and off? Is it constant? Is it getting worse? Is this happening for the first time?"

• Discharge Assessment (CCVO):

  • Color (C):

    • White, thick, cheesy: Suggestive of Candida (yeast infection).

    • Thin, gray: Suggestive of Bacterial Vaginosis (BV) with a fishy smell.

    • Purulent: Suggestive of Gonorrhea.

    • Frothy, bubbly, yellow to greenish: Suggestive of Trichomoniasis, often with a bad odor.

  • Content (C):

    • Ask about blood in the discharge.

  • Volume (V):

    • "How many pads have you used? Are they fully soaked?"

  • Odor (O):

    • "Does it have any bad smell?"

• Associated Symptoms:

  • Itchiness

  • Soreness

  • Pain in the private parts

  • Rashes or redness

  • Ulcers in the private parts

  • Urinary symptoms: Burning or pain on passing urine

Sexual History

• Sensitive Introduction: "I'm going to ask you a few sensitive questions about your sexual life. Is that okay with you?"

• Sexual Activity:

  • "Are you sexually active? Have you ever been sexually active?"

• Partner Information:

  • "Are you in a stable relationship? Do you have multiple partners?"

• Safe Sex Practices:

  • "Do you practice safe sex and use condoms?"

• Types of Sexual Activity:

  • "What kind of sexual activities do you do? Is it oral, anal, and vaginal?"

• High-Risk Sexual Activity:

  • "Have you ever been diagnosed with a sexually transmitted infection?"

• Pelvic Inflammatory Disease (PID) Symptoms:

  • "Do you have any fever and chills? Do you have any abdominal pain? Do you have any nausea, vomiting? Do you have any tiredness?"

• Cervical Problems or Cancer:

  • "Are you up to date with cervical screening?"

  • "Have you taken your Gardasil vaccination?"

  • "Do you have any pain or bleeding during sexual intercourse?"

  • "Do you have any loss of weight, loss of appetite? Do you have any lumps and bumps?"

  • "Have you seen any bloating?" (related to ovarian cancer concerns)

• Foreign Bodies and Medications:

  • "Do you use tampons? Are you on any oral contraceptive pills?"

• Dermatological Conditions:

  • "Any rashes, any ulcers, any redness?"

• Physiological Changes:

  • "Have you ever noticed any discharge? Have you noticed physiological discharge?"

  • "Have you noticed the discharge is better or worse at a certain time of your cycle? Is it like on fourteen days it gets thin?"

• Five P's:

  • Period History:

    • "When was your last menstrual period?"

    • "Is your bleeding regular or irregular? Do you have any heavy bleeds?"

  • Partner (already addressed)

  • Pill (already addressed)

  • Pregnancy:

    • "How many pregnancies have you had so far? Did you have any postpartum lochia?"

  • Past cervical screening test.

• SADMA (Social history, Allergies, Drug history, Medical history):

  • Family History

  • Past Medical History

  • Medications:

    • OCPs (Oral Contraceptive Pills)

    • Antibiotics

Case Example: History Findings

• Patient has yellowish, foul-smelling discharge.

• Abdominal pain is present.

• History of multiple partners.

• No condom use.

• Previous chlamydia infection.

Physical Examination Findings

• Yellowish discoloration.

• Positive cervical motion tenderness (CMT).

• Uterine tenderness on bimanual palpation.

• Tender adnexa.

• Negative Urine Pregnancy Test (UPT).

Diagnosis

• Most likely Pelvic Inflammatory Disease (PID).

  • Infection of the womb tubes, usually caused by an STI or normal vaginal flora.

• Other Differential Diagnoses (DDx):

  • Sexually Transmitted Infections (STIs)

  • Non-Sexually Transmitted Infections

  • Cervical Causes

  • Foreign Bodies

  • Medicines

  • Dermatological Conditions

Management and Investigations

• Investigations:

  • Swabs:

    • Endocervical swabs for STI screening (Chlamydia, Gonorrhea).

    • High vaginal swab (HVS) for Candida, Bacterial Vaginosis, Trichomoniasis.

  • Offer other STI screening: HIV, Hepatitis B, Syphilis.

  • If cervical screening test (CST) is not up to date, perform CST.

• Empirical Treatment:

  • Administer treatment today.

  • Ceftriaxone: $500 \text{ mg IM stat}$

  • Doxycycline: $100 \text{ mg BD for two weeks}$

  • Metronidazole 400 mg bd for 2 weeks