Vaginal Discharge Notes

Vaginal Discharge

Vaginal Discharge: Background

  • Vagina:
    • Diverse echo systems
    • 10910^9 bacteria forming units/g vaginal fluid
    • Dominated by lactobacilli
      • Convert glycogen to lactic acid à helps maintain an acidic vaginal fluid
      • Produce H<em>2O</em>2H<em>2O</em>2 à serves as a host defense mechanism
  • Normal Vaginal discharge:
    • Clear to white
    • Odourless
    • High viscosity
  • Normal Vaginal PH: Unspecified in the transcript.

Causes of Vaginitis

  • Common among women of reproductive age
    • Characterized by
      • Vaginal discharge
      • Vulval itching
      • Vulval irritation
      • Vaginal odour

Causes of Vaginitis:

Non-infectious
  • Normal physiologic variation
  • Allergic reactions (e.g., spermicides, deodorants)
  • Mucopurulent cervicitis
  • Atrophic vaginitis
  • Vulvar vestibulitis
  • Lichen simplex chronicus
  • Lichen sclerosis
  • Foreign bodies (e.g., retained tampons)
  • Desquamative inflammatory vaginitis
Infection Related
  • Sexually Transmitted
    • Genital herpes
    • Chlamydia
    • Gonorrhoea
    • Trichomonas
  • Non-Sexually Transmitted
    • Candida
    • Bacterial Vaginosis

Vaginal Discharge: Diagnostic approach

  • History
  • Examination
  • Investigations

Case 1: Bacterial Vaginosis

  • 30 yr old Female RMP
  • 3 week history of offensive “fishy” smelling discharge
  • No other symptoms
  • On IUS
  • No PMHx
  • Nil Medication
  • NKDA

Bacterial Vaginosis (BV) Aetiology:

  • Commonest cause of abnormal discharge in women of childbearing age.
  • The pH of vaginal fluid is elevated above 4.5 and up to 6.0.
  • Lactobacilli may be present, but the flora is dominated by many anaerobic and facultative anaerobic bacteria:
    • Gardnerella vaginalis (biofilm)
    • Prevotella spp
    • Mycoplasma hominis
    • Mobiluncus spp.
    • Atopobium vaginalis (biofilm)
  • Risk factors include:
    • Vaginal douching
    • Receptive cunnilingus
    • Black race
    • Recent change of sex partner
    • Smoking
    • Presence of an STI e.g. chlamydia or herpes. Debate ongoing whether BV is imbalance v. STI

Bacterial Vaginosis: Symptoms

  • Offensive fishy smelling vaginal discharge
  • Not associated with soreness, itching, or irritation
  • Many women (approximately 50%) are asymptomatic

Bacterial Vaginosis: Signs

  • Thin, white, homogeneous discharge, coating the walls of the vagina and vestibule.
  • BV is not usually associated with signs of inflammation

BV - diagnosis:

  • Gram staining and nugant score
  • Clue Cells: Squamous epithelial cells with bacteria attached.

Bacterial Vaginosis: Diagnosis

Hay/Ison Criteria (BASHH recommended)
  • grade 1 (Normal): Lactobacillus morphotypes predominate
  • grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present
  • grade 3 (BV): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli.
  • grade 0: No bacteria present
  • grade 4 Gram positive cocci predomina
Amsel’s criteria
  • At least three of the four criteria are present for the diagnosis to be confirmed:
    • Thin, white, homogeneous discharge
    • Clue cells on microscopy of wet mount
    • pH of vaginal fluid >4.5
    • Release of a fishy odour on adding alkali (10% KOH)

Bacterial Vaginosis: Management

General advice
  • Avoid vaginal douching
  • Avoid use of shower gel
  • Avoid use of antiseptic agents or shampoo in the bath etc
Treatment indicated:
  • Symptomatic women
  • Women undergoing some surgical procedures
  • Women who do not volunteer symptoms may elect to take treatment if offered

Bacterial Vaginosis: Treatment

  • Metronidazole 400mg twice daily for 5-7 days
  • Metronidazole 2 g single dose
  • Intravaginal metronidazole gel (0.75%) once daily for 5 days
  • Intravaginal clindamycin cream (2%) once daily for 7 days
Alternative regimens
  • Tinidazole 2G single dose
  • Or
  • Clindamycin 300 mg twice daily for 7 days
  • TOC not indicated
  • PN not indicated

Case 2: Trichomonas Vaginalis

  • 25 yr old Female
  • 1/52 Vaginal soreness
  • Profuse offensive discharge
  • Dysuria
  • Discomfort during SI
  • LSI 2/52
  • CMP ONS UPSI
  • 4 SP in last 3/12 – P/UPSI
  • On implant for contraception
  • PMhx – NAD

Trichomonas Vaginalis

  • Flagellated protozoon.
  • Found in
    • the vagina,
    • urethra (90% )
    • paraurethral glands.
  • Infection can only follow intravaginal or intraurethral inoculation of the organism.

Trichomonas Vaginalis: Symptoms

  • 10-50% are asymptomatic.
  • Commonest symptoms are:
    • vaginal discharge
    • vulval itching
    • dysuria
    • offensive odour (+/-)low abdo pain
    • (+/-) vulval ulceration.

Trichomonas Vaginalis: Signs

  • Up to 70% have vaginal discharge, from thin and scanty to profuse and thick.
  • Classical frothy yellow discharge occurs in 10-30%.
  • Other signs include vulvitis, vaginitis and 2% of patients have strawberry cervix.

Trichomonas Vaginalis: Complications

  • Associated with preterm delivery and low birth weight in pregnancy
  • May predispose to maternal postpartum sepsis
  • May enhance HIV transmission

Trichomonas Vaginalis: Diagnosis

  • TV testing should be done in women complaining of vaginal discharge or vulvitis, or found to have evidence of vulvitis, and/or vaginitis on examination
  • Swab taken from posterior fornix during speculum examination
  • Self-taken swabs are likely to give equivalent results
  • Nucleic acid amplification tests (NAAT) if available.

Trichomonas Vaginalis: Diagnosis

Microscopy
  • Detection of motile trichomonads by light-field microscopy.
  • The wet preparation should be read within 10 minutes of collection.
Culture
  • Culture has a higher sensitivity compared to microscopy and can detect TV in men.
Point of care tests
  • OSOM Trichomonas Rapid Test (Genzyme Diagnostics, USA) has demonstrated a high sensitivity and specificity
Molecular detection
  • NAATs offer the highest sensitivity. They should be the test of choice where resources allow and are becoming the current ‘gold standard’.

Trichomonas Vaginalis: Management

General Advice
  • Full explanation of diagnosis with written information.
  • Screening for other STIs
Recommended Regimens
  • Metronidazole 400-500mg twice daily for 5-7 days
Alternative Regimens
  • Tinidazole 2g orally in a single dose
  • TOC is recommended in 1/52 for symptomatic patient
  • PN: partners should be treated

Case 3: Vulvovaginal Candidiasis

  • 19 yr Female
  • 3/7 Severe vulval soreness
  • Itching
  • Cuts on vulval skin
  • Burns when PU
  • Clumpy white discharge
  • Not sexually active
  • Normally fit and well
  • Recent chest infection Rx with abx
  • No contraception
  • Periods normale 5/28

Vulvovaginal Candidiasis

  • An acute inflammatory dermatitis of the vulva and vagina caused by mucosal invasion of commensal yeast species, caused in 80-92% by Candida albicans
  • Non-albicans species e.g. C. glabrata, C. tropicalis, C. krusei, C.parapsilosis, and Saccharomyces cerevisiae

Vulvovaginal Candidiasis: Symptoms:

  • Vulval itch
  • Vulval soreness
  • Vaginal discharge
  • Superficial dyspareunia
  • External dysuria

Vulvovaginal Candidiasis: Signs:

  • Erythema
  • Fissuring
  • Discharge, typically curdy but may be thin. Non-offensive.
  • Oedema
  • Satellite lesions
  • Excoriation

Vulvovaginal Candidiasis: Complicated Candidiasis:

  • Severe symptoms (by subjective assessment)
  • Pregnancy
  • Recurrent vulvovaginal candidiasis (at least 4 episodes per year)
  • Non-albicans species
  • Abnormal host (e.g. hyperoestrogenic state, diabetes mellitus, immunosuppression)

Vulvovaginal Candidiasis: Diagnosis

  • Microscopy and culture is standard for symptomatic women
  • Vaginal swab should be taken from the anterior fornix (for the following:
    • Gram or wet film examination
    • Direct plating to solid fungal media.
    • Speciation to albicans/non-albicans is essential if complicated disease suspected/present

Vulvovaginal Candidiasis: Management

General Advice:
  • Vulval moisturisers as soap substitute and regular skin conditioner (not for internal use)
  • Avoid tight fitting synthetic clothing
  • Avoid irritants e.g. perfumed products

Vulvovaginal Candidiasis: Management

Non complicated
Topical
  • Clotrimazole Pessary
  • Clotrimazole Vaginal cream (10%)
  • Fenticonazole Pessary
  • Isoconazole Vaginal tablet
  • Miconazole Ovule
  • Miconazole Pessary
  • Nystatin Vaginal cream
  • Nystatin Pessary
Oral
  • Fluconazole* Capsule 150mg stat
  • Itraconazole* Capsule 200mg bd x 1 day

Vulvovaginal Candidiasis: Management

Complicated
  • Severe symptoms (a subjective assessment)
  • Pregnancy
  • Recurrent vulvovaginal candidiasis (more than 4 attacks per year)
  • Non-albicans species
  • Abnormal host (e.g. hyperoestrogenic state, diabetes mellitus, immunosuppression)
Treatment:
  • fluconazole 150mg should be repeated after 3 days
  • If oral treatment is contra- indicated repeat a single dose pessary after 3 days
  • Low-potency corticosteroids are also thought to improve symptomatic relief in conjunction with antifungal therapy

Summary:

  • Vaginal discharge is a commonly diagnosed condition among women of child bearing age
  • Vaginitis depend on the organism causing the infection
    • bacterial vaginosis à fishy odour; clear, white or grey PV discharge
    • vulvovaginal candidiasis à pruritus , soreness, dyspareunia, burning and dysuria
    • trichomoniasis à frothy grey or yellow/green discharge; pruritus

Summary:

  • BV and TV linked to
    • O&G complications à PROM; Pre-term labour
    • Increased risk of HIV acquisition and transmission
  • Candida species may be isolated in ~ 20% of asymptomatic women without abnormal discharge
  • Estimated that 70% to 75% of women will experience at least one episode of vulvovaginal candidiasis

Summary: Treatment Options

Bacterial vaginosis:
  • Oral or intravaginal metronidazole
  • Oral tinidazole (not recommended in pregnancy)
  • Oral or intravaginal clindamycin.
Trichomoniasis:
  • Single-dose metronidazole or tinidazole therapy
  • (HIV +ve women may require 7 days of metronidazole)
Vulvovaginal candidiasis:
  • can be treated with a wide array of short-course topical antifungal agents or oral fluconazole