Vaginal Discharge

Front 1

DDx vaginal discharge

Back 1

normal discharge

vaginitis

infective or chemical

STIs

UTIs

Front 2

2 most common causes of dishcarge

Back 2

physiological and infective

Front 3

Physiological discharge

Back 3

milky white or clear mucoid

no odur

no puritis

egg white during ovulation

normal discharge usually shows on underclothing by the end of the day and clear white it oxidises to yellow, borwn on contact with air and is increased by sexual stimulation

Front 4

Normal vaginal flora

Back 4

Lactobacilli that produce lactic acid from glucose in epithieal cells that make the pH <4.7

- stap, deptheroids, strep

Front 5

Mx of physiological discharge

Back 5

reassurance and explanation

• wear cotton underwear (not synthetic)
• bathe instead of showering
• avoid douching and feminine deodorants
• use tampons instead of pads

Front 6

Commonest cause of infective vaginitis

Back 6

1. bacterial vaginosis (bacterial vaginitis, garderella vaginalis, haemophilus vaginalis) 40-50% of cases

2. 20-30% Candida albicans

3. Trichomonas vaginalis 20%

Front 7

Serious disorders not to be missed

Back 7

cancer of the
vagina, cervix or uterus and STIs, including PIDs caused
by Chlamydia trachomatis and Neisseria gonorrhoeae.

Front 8

Watery pink or blood stained discharge

Back 8

benign or malignant neoplasm anywhere in the gential tract

Front 9

Probability diagnosis

Back 9

A. Normal physiological discharge
Vaginitis:
• bacterial vaginosis 40–50%
• candidiasis 20–30%
• Trichomonas 10–20%

Front 10

Q. Serious disorders not to be missed

Back 10

Neoplasia:
• cancer
• fi stulas
STIs/PID (i.e. cervicitis):
• gonorrhoea
• Chlamydia
• herpes simplex
Sexual abuse, esp. children
Tampon toxic shock syndrome (staphylococcal
infection)
Streptococcal vaginosis (in pregnancy)

Front 11

Q. Pitfalls (often missed)

Back 11

A. Chemical vaginitis (e.g. perfumes)
Retained foreign objects (e.g. tampons, IUCD)
Endometriosis (brownish discharge)
Ectopic pregnancy (‘prune juice’ discharge)
Poor toilet hygiene
Genital herpes (possible)
Atrophic vaginitis
Threadworms

Front 12

Seven masquerades checklist

Back 12

Depression
Diabetes (reccurent thrush discharge)
Drugs
Anaemia
Thyroid disorder
Spinal dysfunction
UTI
–
✓
✓
–
–
–
✓ (association)

Front 13

Psychogenic considerations

Back 13

Needs careful consideration; possible sexual
dysfunction.

Front 14

History of vaginal discharge

Back 14

• nature of discharge: colour, odour, quantity, relation to
menstrual cycle, associated symptoms
• exact nature and location of irritation
• sexual history: arousal, previous STIs, number of
partners and any presence of irritation or discharge in
them
• use of chemicals, such as soaps, deodorants, pessaries
and douches
• pregnancy possibility
• drug therapy
• associated medical conditions (e.g. diabetes)

Front 15

Examination

Back 15

- Sims speculum

sterile wabs (slides and cover slips)

inspect vulva, introitus, urethra, vagina, cervix

looking for dicharge, polyps, warts, prolapse, fistulas

DDx vaginal and cervical discharge wipe the cervix clean with a cotton ball and observe the cervix, a mucopurlent discharge appearing from endometrium is a clue of Chlamydia and gonorrhoea

ph test

wet film

Front 16

Pitfalls on physical Exam

Back 16

• The patient may have had a bath or a ‘good wash’
beforehand and may need to return when the
discharge is obvious.
• A retained tampon may be missed in the posterior
fornix, so the speculum should slide directly along the
posterior wall of the vagina.
• Candida infection may not show the characteristic
curds, ‘the strawberry vagina’ of Trichomonas is
uncommon and bubbles may not be seen.

Front 17

Investigating discharge

Back 17

• pH test with paper of range 4 to 6
• Amine or ‘whiff’ test: add a drop of 10% KOH to
vaginal secretions smeared on glass slide
• Wet fi lm microscopy of a drop of vaginal secretions
A culture is necessary if no diagnosis is made after
this routine.

Front 18

A full STI work-up

Back 18

• First-pass urine and ThinPrep samples—for Chlamydia
and gonorrhoea NAAT (PCR)
• Swabs from the cervix for Chlamydia, N. gonorrhoeae:
— swab mucus from cervix fi rst
— swab endocervix
— place in transport media
• Pap smear
• Viral culture (herpes simplex):
— scrape base of ulcer or, ideally, deroof a vesicle
— immediately immerse in culture medium
— transport rapidly to laboratory
• Group B Streptococcus:
— swabs from endocervix, urethra, rectum

Front 19

Preparing a wet film

Back 19

To make a wet fi lm preparation2 (see Fig. 98.1), place
one drop of normal saline (preferably warm) on one end
of an ordinary slide and one drop of 10% KOH on the
other half of the slide. A sample of the discharge needs
to be taken with a swab stick, either directly from the
posterior fornix of the vagina or from discharge that has
collected on the posterior blade of the speculum during
the vaginal examination. A high vaginal swab is required
for C. albicans. A small amount of the discharge is mixed
with both the normal saline drop and the KOH drop. A
cover slip is placed over each preparation. The slide is
examined under low power to get an overall impression,
and under high power to determine the presence of
lactobacilli, polymorphs, trichomonads, spores, clue
cells and hyphae.

Front 20

Cells on wet film

Back 20

Lactobacilli
are long, thin Gram-positive rods; clue cells are vaginal
epithelial cells that have bacteria attached so that the
cytoplasm appears granular and often the entire border
is obscured. They are a feature of bacterial vaginosis.
Trichomonads are about the same size as polymorphs;
to distinguish between the two, one needs to see the
movement of the trichomonad and the beating of its fl agella under high power of the microscope. Warming
the slide will often precipitate movement.

Front 21

Vaginal Discharge in children

Back 21

Most newborn girls have some mucoid white vaginal
discharge. This is normal and usually disappears by
3 months of age. From 3 months of age to puberty,
vaginal discharge is usually minimal.3 Staining
on a child’s underclothes may be due to excess
physiological discharge, especially in the year
before the menarche.

Front 22

Most common gynaecological disorder of childhood

Back 22

vulvovaginitis (non-specific bacterial infections)

Front 23

Vaginal discharge in the elderly causes

Back 23

infective vaginitis,

atrophic vaginitis,

foreign bodies,

poor hygiene and

neoplasia.

Front 24

Atrophic vaginitis

Back 24

In the absence of oestrogen stimulation the vaginal and
vulval tissues begin to shrink and become thin and dry.
This renders the vagina more susceptible to bacterial
attack because of the loss of vaginal acidity. Rarely, a
severe attack can occur with a very haemorrhagic vagina
and heavy discharge:
• yellowish, non-offensive discharge
• tenderness and dyspareunia
• spotting or bleeding with coitus
• the vagina may be reddened with superfi cial
haemorrhagic areas

Front 25

Treating atrophic vaginitis

Back 25

local oestrogen cream or tablet (e.g. Vagifem). The tablet is preferred as it is less messy
or
zinc and castor oil soothing cream

Front 26

Vaginal candidiasis

Back 26

common
and important problem with a tendency to recurrence.
However, with the widespread use of over-thecounter
antifungals, resistant non-albicans species,
such as Candida glabrata (in particular), Candida
parapsilosis and Candida tropicalis are becoming more
common.4

Front 27

Clincal features of vaginal candidiasis

Back 27

• Intense vaginal and vulval pruritus
• Vulval soreness
• Vulvovaginal erythema (brick red)
• Vaginal excoriation and oedema
• White, curd-like discharge
• Discomfort with coitus
• Dysuria

Front 28

FActors predisposing to vaginal candidiasis

Back 28

Endogenous
• Diabetes mellitus
• AIDS syndrome
• Pregnancy
• Debilitating diseases
Exogenous
• Oral contraceptives
• Antibiotics
• Immunosuppressants
• Carbohydrate-rich diet
• Orogenital/anogenital intercourse
• IUCD
• Tight-fi tting jeans
• Nylon underwear
• Humidity/wet bathing suit

Front 29

Treating Vaginal Candidiasis

Back 29

For the fi rst attack of candidiasis it is appropriate
to select one of the range of vaginal imidazole
therapies (clotrimazole, econazole, miconazole) for 1–7 days. (NO SIGNIFICANT DIFFERENCE BETWEEN IMIDAZOLES)

-Nystatin reserved for recurrent cases or if there is local reaction to imidazoles

- CREAM preferred (tablet and cream can be combined in severe infection)

- gentian violet (-0.5% aqueous solution) is useful for rapid relief if available

Front 30

Sx's in a male

Back 30

A male sexual partner does not usually require
treatment.4 If symptomatic (usually balanitis in an
uncircumcised male), treat with clotrimazole 1% +
hydrocortisone 1% topically, 12 hourly until 2 weeks
after symptoms resolve.

Front 31

Recalcitrant cases (proven by microscopy and if
not pregnant) treatment (candidiasis)

Back 31

Recalcitrant cases (proven by microscopy and if
not pregnant)6
fl uconazole 150 mg (o) as a single dose
or
itraconazole 100 mg (o) once daily for 14 days

Front 32

Recommended intial regimen for candiadiasis

Back 32

clotrimazole 500 mg vaginal tablet as a single dose or
100 mg for 6 nights
±
clotrimazole 2% cream applied to vulvovaginal and
perineal areas 8–12 hourly (for symptomatic relief)
An alternative regimen, especially for recurrent
infections:
nystatin pessaries twice daily for 7 days
and/or
nystatin vaginal cream (100 000 U per 5 g) twice daily
for 7 days

Front 33

Candida (Torulopsis) glabrata

Back 33

A signifi cant number of cases of recurrent vulvovaginal
candidiasis are due to non-albicans species of Candida.
Candida glabrata is the commonest non-albicans
species, which exhibit reduced susceptibility to azoles.
In resistant infections use boric acid 600 mg (in a
gelatin capsule) intravaginally for 10 to 14 days. Do not
use in pregnancy.

Front 34

Advice to patients with vaginal candidiasis

Back 34

• Bathe the genital area gently two or three times a day for symptomatic relief. In preparing for the antifungal preparation, use 1–3% acetic acid or sodium bicarbonate solution (1 tablespoon to 1 litre of water). Thoroughly cleanse the vagina, including recesses
between rugae and the fornices and also the folds around the vulva.
• Dry the genital area thoroughly after showering or bathing.
• Wear loose-fitting, cotton underwear.

• Avoid wearing pantyhose, tight jeans or tight
underwear or using tampons.
• Avoid having intercourse or oral sex during the infected period.
• Do not use vaginal douches, powders or deodorants or take bubble baths.

Front 35

Trichomonas vaginalis

Back 35

fl agellated protozoan, which is thought to originate
in the bowel, infects the vagina, Skene’s ducts and lower
urinary tract in women and the lower genitourinary tract
in men. It is transmitted through sexual intercourse
and is relatively common in the female after the onset
of sexual activity. The most sensitive and specifi c test
available (if necessary) is PCR.

Front 36

Clinical features of trichomonas vaginalis

Back 36

• Profuse, thin discharge (grey to yellow–green in colour)
(see Fig. 98.4)
• Small bubbles may be seen in 20–30%
• Pruritus
• Malodorous discharge
• Dyspareunia
• Diffuse erythema of cervix and vaginal walls
• Characteristic punctate appearance on cervix

Front 37

Trichomonas vaginalis treatment

Back 37

oral metronidazole 2 g as a single dose (preferable) or 400 mg bd for 5 days (if relapse) or
tinidazole 2 g as a single dose (see Table 98.5)
• Use clotrimazole 100 mg vaginal tablet daily for 6 days
during pregnancy
• Attention to hygiene
• The sexual partner must be treated simultaneously
• The male partner should wear a condom during
intercourse
• For resistant infections a 3–7 day course of either
metronidazole or tinidazole may be necessary

Front 38

Bacterial vaginosis

Back 38

clinical entity of mixed aetiology
characterised by the replacement of the normal vaginal
microfl ora (chiefl y Lactobacillus) with a mixed fl ora
consisting of Gardnerella vaginalis, other anaerobes such
as Mobiluncus species, and Mycoplasma hominis. This
accounts for the alkalinity of the vaginal pH.

Front 39

Bacterial vaginosis Clinical features

Back 39

• A grey, watery, profuse discharge (see Fig. 98.5)
• Malodorous
• No obvious vulvitis or vaginitis
• Liberates an amine-like, fi shy odour on admixture of
10% KOH (the amine whiff test)
• Clue cells
• ± Dyspareunia and dysuria
• ± Pruritus

Front 40

Bacterial vaginosis Treatment

Back 40

metronidazole 400 mg (o) bd for 5 days or 2 g stat
Clindamycin 300 mg (o) bd for 7 days or 2%
clindamycin cream can be used for resistant infections or during pregnancy. Normal vaginal pH can be restored using a variety of topical douches such as povidone iodine solution (1 tablespoon per litre of water), vinegar (3–4 tablespoons per litre of water), topical Acigel or a milky solution of yoghurt to restore Lactobacillus levels.

Front 41

Group B Streptococcus vaginosis

Back 41

Group B Streptococcus (Streptococcus agalactiae) is
a commensal in up to 40% of healthy humans.

Front 42

Group B Streptococcus vaginosis pregnant women treatment

Back 42

It is a
problem if detected in the pregnant woman because
of serious infection in the neonate. In certain at-risk
circumstances, such as premature rupture of the
membranes or a previous infected neonate, give:
benzylpenicillin 1.2 g IV stat, then 600 mg IV 4 hourly
until delivery

Front 43

Group B Streptococcus vaginosis non-pregnant women treatment

Back 43

In the non-pregnant woman give amoxycillin
500 mg (o) tds for 7 days if there is signifi cant pyogenic
infection

Front 44

Retained vaginal tampon

Back 44

A retained tampon, which may be impacted and cannot
be removed by the patient, is usually associated with
an extremely offensive vaginal discharge. Its removal
can cause considerable embarrassment to both patient
and doctor.

Front 45

Methods of removal

Back 45

Using good vision the tampon is seized with a pair of sponge-holding forceps and quickly immersed under water without releasing the forceps. A bowl of water (an old plastic ice-cream container is suitable) is kept as close to the introitus as possible. This results in minimal malodour. The tampon and water are immediately fl ushed down the toilet if the toilet system can accommodate tampons. An alternative method is to grasp the tampon with a gloved hand and quickly peel the glove over the tampon for disposal.

Front 46

Tampon toxic shock syndrome:
staphylococcal infection

Back 46

This rare, dramatic condition is caused by the production
of staphylococcal exotoxin associated with tampon use
for menstrual protection. The syndrome usually begins
within 5 days of the onset of the period.
The clinical features include sudden onset fever,
vomiting and diarrhoea, muscle aches and pains, skin
erythema, hypotension progressing to confusion, stupor
and sometimes death.

Front 47

Tampon toxic shock syndrome:
staphylococcal infection

Managment

Back 47

Active treatment depends on the severity of the illness.
Cultures should be taken from the vagina, cervix,
perineum and nasopharynx. The patient should be
referred to a major centre if ‘shock’ develops. Otherwise
the vagina must be emptied, ensuring there is not a
forgotten tampon, cleaned with a povidone iodine
solution tds for 2 days, and fl ucloxacillin or vancomycin
antibiotics administered.
• These women should not use tampons in the future.

Front 48

Tampon toxic shock syndrome:
staphylococcal infection

Prevention

Back 48

• Good general hygiene with care in handling and
inserting the tampons.
• Change the tampon 3–4 times a day.
• Use an external pad at night during sleep.

Front 49

When to refer discharge

Back 49

• Evidence of sexual abuse in children to an experienced
sexual assault centre
• Recurrent, recalcitrant infections
• Presence of cancer or fi stula
• Staphylococcal toxic shock syndrome