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

Infectious causes

Non-sexually transmitted infection:

• Bacterial vaginosis 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-infectious causes

Physiological:

• Puberty

• Menstrual Cycle

• Sexual Activity

• Pregnancy

• Menopause

Non-physiological:

• Foreign body vaginitis

• Cervical cancer

• Vaginal cancer

• Diabetes

• Drug side effects of antibiotic or steroid use such 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

• Gynaecological causes:
  • Atrophic vaginitis or senile vaginitis, as a result of estrogen deficiency that leads to vaginal dryness, itching, irritation, discharge, and dyspareunia.
  • Vulval dermatitis
  • Cervical ectopy

Diagnosis

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

Abbreviations: BP: Blood pressure, RR=Respiratory rate, HR=Heart Rate, OCP= Oral Contraceptive Pill, NAAT= Nucleic Acid Amplification Test

Patient with history of Vaginal discharge

Take complete history

Record 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 menstruation 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 complaints : ❑ 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 complaints : ❑ 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 recognized 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 complaints : ❑ 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.

Abbreviations: QHS : Every bedtime , BID: 2 times daily, TID: Three times a day, QID: Four times a day, IM :Intramuscular

Organisms	Recommended Drugs	Alternative drugs
Candidiasis	Over-the-Counter Intravaginal Agents Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days OR Clotrimazole 2% cream 5 g intravaginally daily for 3 days OR Miconazole 2% cream 5 g intravaginally daily for 7 days OR Miconazole 4% cream 5 g intravaginally daily for 3 days OR Miconazole 100 mg vaginal suppository, one suppository daily for 7 days OR Miconazole 200 mg vaginal suppository, one suppository for 3 days OR Miconazole 1,200 mg vaginal suppository, one suppository for 1 day OR Tioconazole 6.5% ointment 5 g intravaginally in a single application Prescription Intravaginal Agents: Butoconazole 2% cream (single dose bioadhesive product), 5 g intravaginally in a single application OR Terconazole 0.4% cream 5 g intravaginally daily for 7 days OR Terconazole 0.8% cream 5 g intravaginally daily for 3 days OR Terconazole 80 mg vaginal suppository, one suppository daily for 3 days Oral Agent: Fluconazole 150 mg orally in a single dose	Nystatin 1,00,000 unit tab vaginally QHS for 2 weeks
Trichomoniasis	Metronidazole 2 g orally in a single dose OR Tinidazole 2 g orally in a single dose	Metronidazole 500 mg orally twice a day for 7 days OR Clotrimazole 2 X 100 mg vaginal tabs QHS for 7days
Bacterial Vaginosis	Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days	Tinidazole 2 g orally once daily for 2 days OR Tinidazole 1 g orally once daily for 5 days OR Clindamycin 300 mg orally twice daily for 7 days OR Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days
Neisseria gonorrhoea	Amoxicillin orally 3 gm 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 500 mg 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 mg 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 gynecologist 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 tumor 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

Treatment in pregnancy:

• Vulvovaginal Candidiasis: It frequently occurs during pregnancy. Only topical azole therapies for 7 days are recommended for use among pregnant women.

• Trichomoniasis: Metronidazole 2 g orally single dose is recommended. Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.

• Bacterial vaginosis: Treatment is recommended for all symptomatic pregnant women. Metronidazole 250-mg regimen is effective. But, Metronidazole 500 mg twice daily can be used.

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 gynecologist 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 tumor 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.

• Women should be advised to avoid alcohol consumption during treatment for up to 24 hours after completion of Metronidazole or 72 hours after completion of Tinidazole to reduce the possibility of a disulfiram-like reaction.

• Women with Trichomoniasis should be advised to abstain from sexual intercourse until treatment is completed and symptoms have resolved, as it is sexually transmissible.

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 doucheing.

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

References

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