Vaginal Discharge

VAGINAL
VAGINAL DISCHARGE
DISCHARGE

Very common gynaecological complaint

(Approx 9 million GP visits / year)

Consists of : Cervical mucus,,Vaginal transudate, Uterine

secretions, Bartholin Gland secretions
NORMAL VAGINAL FLORA & DISCHARGE

The vagina is a dynamic ecosystem

A healthy equilibrium exists between:

- Stratified epithelial cells
- Normal Commensal Organisms - mostly Lactobacilli SPP
- Local Cellular Immune Factors
- Acidic Vaginal pH (3.8 – 4.2) - unfavourable for pathogens
Normal Vaginal Flora

LACTOBACILLI

Gram Positive Rods

Excrete Hydrogen Peroxide

Present in 100% of women with

normal flora

Affects adherence of epithelial cells

Protect against bacterial/candidial

infections
Normal pH mechanism

‡ Oestrogen increases epithelial glycogen

‡ Lactobacilli metabolise glycogen into lactic acid
‡ Lactic Acid maintains acid pH

ABNORMAL pH
Alkaline pH (> 4.2)
o Alters ecosystem
o Causes epithelial desquamation
Factors that further alter pH : trauma, low oestrogen, menses &
alkaline seminal fluid
‘Normal’ Vaginal Discharge
The quality and quantity of vaginal discharge may
alter cyclically in the same woman and over time

The following situations can increase the amount of

normal vaginal discharge:

Sexual excitement
Emotional stress
Ovulation
Pregnancy & Postpartum
Hormonal Contraception
The following changes may indicate a problem:

‡ change in odour

‡ change in colour or texture (especially greenish, grayish, or

anything looking like pus)

‡ vaginal itching, burning, swelling, or redness

‡ change in colour that is caused by vaginal bleeding or

spotting that is not a menstrual period
SYMPTOMS associated with vaginal discharge

Malodour
Vulval pruritus / soreness / irritation
Dyspareunia
Cystitis
Cancerophobia
Psychosexual Dysfunction
Pathological Discharge

ƒ Microbial
ƒ Non-Microbial
NON-MICROBIAL VAGINAL DISCHARGE

* Cervical ectopy and polyps

* Foreign body in vagina
* IUCD
* Cervical / uterine / tubal neoplasia
* Oestrogen deficiency
* Local allergies and drug reactions
* Vault granulation
* Rectovaginal & Vesicovaginal fistulae
Leucorrhoea (‘white discharge’)

‡ Leucorrhea is defined as non-infective, heavy, white

vaginal discharge

‡ Ayurvedic concept of ‘dhatu’ - genital secretions are

considered a highly purified bodily substance, loss of
which is thought to result in progressive weakness or
even death

‡ Many South Asian women who complain of vaginal

discharge also report a variety of somatic symptoms
such as dizziness, backache, weakness and malaise
MICROBIAL VAGINAL DISCHARGE

* Mixed Vaginal Bacteria (eg BV, b-haem Strep)

* Fungi (usually Candida)
* Protozoa (eg TV)
* STD (GC /CT /HSV /HPV)
* Parasites (Pinworm, Giardia)
 MICROBIAL VAGINAL DISCHARGE

‡ Common causes :
Bacterial vaginosis Candida albicans
Trichomonas vaginalis Chlamydia trachomatis
Neisseria gonorrhea

‡ Less common causes :

Human papillomavirus Neoplasia
Primary syphilis Mycoplasma genitalium
Ureaplasma urealyticum Escherichia coli

1:4 of the women sitting in our waiting rooms will have Candida, BV or
sometimes both
 VAGINAL INFECTION

Vaginitis : Inflammatory disorder (pus cells+)

Vaginosis : Non-inflammatory (no pus cells)

Features pointing to STIs

‡ Age under 25 years

‡ No condom use

‡ Change of sexual partner in past 3 months

‡ Multiple sexual partners

‡ Symptoms in partner—for example dysuria

‡ Previous sexually transmitted infection

‡ Symptoms imply complications of STIs

‡ Partner's sexual risk behaviour

Should partners be tested routinely?

In all cases of – Chlamydia,,Gonorrhoea

TV, Syphilis, Herpes

Recurrent cases of - BV, VVC

Not required for – HPV infection

DIAGNOSIS OF VAGINAL DISCHARGE

* Inspection of vulva, vagina & cervix

* Swabs for culture
* Cervical cytology & Colposcopy
* Measure Vaginal pH
* Direct microscopy (N-saline, KOH)
AIMS OF MANAGEMENT

‡ Distinguish physiological from pathological

‡ Identify the pathologic process

‡ Initiate appropriate therapy

TREATMENT OF VAGINAL DISCHARGE

* Treat specific infections

* Cervical cautery for ectopies

* HRT for atrophic vaginitis

British Association for Sexual Health and HIV

Established 2003
 Vulvovaginal Candidiasis (VVC)

‡ >50% of women will have one episode of VVC by their mid-20s

‡ Up to 25% will also have recurrent vulvo-vaginal candidiasis,

defined as four or more episodes a year

‡ Cost of Rx of VVC in the USA = > 0.5 billion dollars/year, with

about half this amount spent on OTC preparations

‡ Candida Albicans infection – in 80-92% of cases

Non-albicans infection eg C.glabrata
Signs & Symptoms of yeast infections

‡ White, cottage cheese-like discharge

‡ Swelling and soreness around the vulva

‡ Intense itching

‡ Superficial dyspareunia

‡ External dysuria
 Management of VVC

‡ General vulval care advice – eg avoidance of irritants, tight clothing,

synthetic fabrics, perfumes (Grade C)

‡ Mycological & Clinical cure (Grade A)

„ All oral and topical Azoles – 80-95% of cases
„ Nystatin preparations – 70-90% of cases
„ Oral preparations are contraindicated in pregnancy
– longer doses of topical treatments are required

‡ Topical preparations may affect efficacy of Barrier methods

‡ Treatment of asymptomatic male partners not required (Grade A)

‡ Test of cure unnecessary

 Recurrent VVC

‡ Recurrent vulvovaginal candidiasis is defined as four or more

episodes of symptomatic infection per year

‡ It occurs in 5% of healthy women.

‡ Candida glabrata and other non-albicans species are found in

10-20% of cases
 Recurrent VVC
‡ Predisposing conditions include poorly controlled diabetes,
systemic immunosuppression or immunodeficiency, and use of
antibiotics & corticosteroids

‡ Breakdown of the normal mucosal immune processes that allow

for mucosal "tolerance" to the organism

‡ C glabrata is inherently less sensitive to the azole group of

drugs - request ‘speciation’ on HVS sample
 Management of Recurrent VVC

No RCTs - management remains empirical and 50% of cases relapse after

cessation of treatment

‡ Cyclical Treatments :
„ Oral or vaginal azoles at identified cyclical trigger points over three months

‡ Maintenance treatment regimens:

„ Fluconazole 100mg oral x weekly for six months
„ Clotrimazole 500mg pessary x weekly for six months
„ Itraconazole 400mg oral x monthly for 6 months

(LFTs & Contraceptive precautions)

‡ Non-albicans species
„ may respond to Nystatin pessaries for 14 days
 Management of Recurrent VVC

‡ Modify allergic component of the problem:

„ Hydrocortisone ointment 1% topically
„ Chlorpheniramine 4 mg orally at bedtime

‡ Alternative Remedies:
„ Candida Diet – carb-free, garlic, cloves, onions,caprylic acid, olive oil
„ Tea tree pessaries
„ Probiotics –lactobacillus & bifidobacterium
„ Homeopathic Rx – calcarea, sepia, lycopodium,,graphite, pulsatilla
„ Gentian Violet, Boric Acid and Vinegar douches
BACTERIAL VAGINOSIS

‡ Commonest cause of abnormal vaginal discharge

‡ True prevalence of this condition is uncertain as 50% of

cases are asymptomatic

‡ Due to an overgrowth of anaerobic organisms

„ Gardnerella vaginalis
„ Mycoplasma hominis
„ Ureaplasma urealyticum
„ Prevotella species
„ Mobilincus species
 BACTERIAL VAGINOSIS

‡ Bacterial vaginosis is not a STI

‡ Associated with new sexual partner and frequent change of

sexual partners, but it can occur in virginal women

‡ Increased incidence in certain groups of women, such as black

African women, lesbians, smokers and users of IUCDs and
diaphragms
Signs of bacterial vaginosis

‡ A white, gray or yellowish vaginal discharge

‡ A fishy odour that is strongest after sex or after washing

with soap

‡ Vulval itching or burning

‡ Slight redness and swelling of the vagina or vulva

Diagnosis of BV

‡ Amsel’s Criteria
(3 of the following four needed for positive diagnosis) :

„ Thin white/gray homogenous discharge

„ Clue cells on microscopy
„ Vaginal pH >5
„ Fishy odour on adding 10% KOH
 Bacterial Vaginosis

‡ 12-30% of UK pregnant women have BV –

„ late miscarriage
„ preterm birth, preterm rupture of membranes
„ postpartum endometritis

‡ BV may also facilitate the transmission of viruses such as HIV2

Treatment of Bacterial Vaginosis

‡ Treatment is indicated for:

‡ Symptomatic women
‡ Perioperatively

Routine Antenatal Screening not recommended

‡ General advice – avoid douching, using antiseptics, bath gels,

shampoos in bath (Grade C)
Treatment of Bacterial Vaginosis

70-80% cure rates (Grade A)

‡ Oral Treatments:
„ Metronidazole 400mg BD x 5-7 days, or, 2gm stat
„ Clindamycin 300mg BD x 7 days
„ Tinidazole 2gm stat dose

‡ Vaginal Treatments:
„ 0.75% Metronidazole gel - 1 suppository daily x 5 days
„ 2% Clindamycin cream once daily x 7 days
 Recurrent BV
‡ A longer course of metronidazole (400 mg) BD x 7 days is more
effective in preventing or delaying recurrence

‡ Acetic acid preparations may also be beneficial

‡ Acidophillous supplements

‡ Offer psychological support and psychosexual counselling when

appropriate

‡ Remove intrauterine device in situ and advise male partner to use

condoms

‡ No evidence for treatment of partner

TRICHOMONAS VAGINALIS

o Humans are the only host (75% of

prostitutes)

o Urethral infection is present in

90% of cases, male and female

o Asymptomatic infection in up to
50% of men and women

o Both partners require treatment

o TV “travels with friends” – GC,

HIV, syphillis
Signs & Symptoms of Trichomoniasis

‡ 50% asymptomatic and 15% have no abnormal findings

‡ Variable appearance of discharge - watery, thick yellowish, or

the classic greenish frothy loss

‡ An unpleasant odour

‡ Pain and itching when urinating

‡ Symptoms worse after period

Concurrent STIs found in a survey of women
with T vaginalis

BMJ 2004;328
Treatment of Trichomoniasis
‡ Treat both sexual partners simultaneously and screen for other
STIs

‡ Metronidazole 2 gm stat or 400mg BD x 7days

‡ Test of cure advised after 2 weeks

‡ Resistant or recurrent infections

‡ Metronidazole 2g daily x 3-5 days
‡ Oral or vaginal Tinidazole
‡ Paromomycin sulphate pessaries 250mg BD x 2 weeks
CHLAMYDIA

‡ Commonest bacterial infection in the world

‡ Caused by Chlamydia trachomatis (Types D-K)

‡ Most patients are asymptomatic (70% of women; 50% of men)

‡ Danger of silent tubal destruction

‡ May cause intermenstrual & post-coital bleeding, mucopurulent

vaginal discharge, pelvic & hypochondrial pain, dyspareunia and
dysuria
Intracellular chlamydial replication
Screening for Chlamydia

1 in 8 of all
sexually active
16-24 yr olds are
chlamydia
positive in the UK

Cost of treating
complications of
chlamydial
infection = £100
million/yr
Diagnostic tests
‡ NAATs – 90-95% sensitive

‡ EIAs - 45-60% sensitive and are no longer advised

‡ DFAs - 80% sensitive, not recommended

‡ Cell Culture - 60-80% sensitive; 100% specific

‡ Sites sampled
‡ Endocervical cells
‡ FCU
‡ HVS
Management of Chlamydial Infection
‡ All positive cases and their contacts should be offered a full GUM
screen including HIV, Hep B and Syphilis

‡ Rx Regimes (Grade A)

‡ Azithromycin 1gm stat (>95% cure)

‡ Doxycycline 100mg BD x 7days (>95% cure)

‡ Erythromycin 500mg BD x 14 days (75-95% cure)

‡ Ofloxacillin 400mg daily x 7 days (75-95% cure)
‡ Amoxycillin 500mg TDS X 7 days (75-95% cure)

‡ Doxycycline & Ofloxacillin are contra-indicated in pregnancy and

lactation

‡ Test of cure advised after 6 weeks

Gonorrhoea

‡ Is caused by the Gram negative diplococcus Neisseria

gonorrhoea

‡ Primary sites of infection are the mucous membranes of the

cervix, urethra, rectum, pharynx and conjunctiva

‡ Transmission is by direct innoculation of infected secretions

from one mucous membrane to another
Gonorrhoea
‡ Endocervical infection is often asymptomatic (up to 50%)

‡ Increased or altered vaginal discharge (up to 50%)

‡ Pelvic pain (up to 25%)

‡ Dysuria (in 12%)

‡ Rarely menorrhagia and intermenstrual bleeding

‡ Pharyngeal and rectal infection is usually asymptomatic

Diagnostic Tests

‡ Culture – method of choice

‡ NAATs
‡ Microscopy

Samples are taken from:

- cervix – done routinely - detects 90-95% of cases
- urethra – routinely taken; FCU if urethral swab not feasible
- rectum – only if symptomatic or if partner affected
- throat – only if symptomatic or if partner affected
Treatment of Gonorrhoea
‡ Screen patient and all sexual contacts for other STIs

‡ Following regimes suitable for pregnant and non-pregnant

patients:

‡ Ceftriaxone 250mg IM stat (Grade A)

‡ Cefixime 400mg oral stat (Grade A)
‡ Spectinomycin 2gm IM stat (Grade A)

‡ Test of cure not necessary, but if undertaken should be as a culture

>72hrs of completing Rx, or, a NAAT 2-3 wks after Rx
Genital Herpes

‡ Caused by HSV 1 & 2

‡ Infection may be initial (primary /non-primary) or recurrent

‡ After primary infection the virus lays dormant in the local

sensory ganglia

‡ Recurrent episodes could be associated with asymptomatic

viral shedding or with typical ulcerative lesions
Signs and symptoms of Genital Herpes

‰ Vulval soreness and burning pain

‰ Painful ulcers on vulva, cervix, anus

‰ Vaginal & urethral discharge

‰ Dysuria & acute urinary retention

‰ Inguinal lymphadenopathy

‰ Rarely, fever, malaise, myalgia

‰ Aseptic meningitis
Diagnostic tests for Herpes Genitalis

¾Viral swab from

base of lesion - for
culture

¾Serological tests
for HSV 1 & 2
antibody titres; may
need to be repeated
in 3 months
 Treatment of Herpes Genitalis

First Episode:
¾ General advice – saline bathing, analgesics & topical
anaesthetics, astringents

¾ Antivirals – start within 5 days of lesions appearing

¾Oral better than topical – and combination no more
effective than oral alone - give for 5 days

•Aciclovir 200mg five times daily (£20)

•Valaciclovir 500mg BD (£23)
•Famciclovir 250mg TDS (£84)

¾ Counselling & Support – ‘de-stigmatise’

Treatment of Herpes Genitalis
Recurrent Episodes:
¾ General advice – as before

¾ Antivirals – patient-initiated depending on severity

•Aciclovir 200mg five times daily (£20)

•Valaciclovir 500mg BD (£23)
•Famciclovir 125mg BD (£84)

¾ Counselling & Support – ‘de-stigmatise’

¾ Suppressive therapy x 1yr – >6 recurrences / yr

Aciclovir 400mg BD (£966)
Valaciclovir 500mg OD
(£857)
Famciclovir 250mg BD
(£4100)
‘Chancre’ of Primary syphilis

Typically presents as a single

painless anogenital ulcer with a
clean base discharging clear serum

Occasionally may present as

multiple painful ulcers discharging
mucopurulent fluid

Regional lymphadenopathy
Treponema pallidum

Demonstration of T. pallidum in
lesions and lymph nodes
¾Dark field Microscopy
¾DFA test
¾PCR

Serological Tests for Syphilis

¾VDRL ( >1:8)
¾TPHA/TPPA/FTA
Treatment of Syphilis

9IM Benzathine Penicillin 2.4 MU stat (Grade B)

9Doxycycline 100mg BD x 14 days (Grade B)

¾ Azithromycin 1gm stat (2nd line therapy)

Vaginal discharge in children

Lack of an acidic pH (typical

pH being 6-7.5)

Lack of the protective

effects of oestrogen, which
leads to a thin vaginal
epithelium

Relative lack of lactobacilli,

which help prevent bacterial
colonization and infection

Immature antibody response

Poor hygiene
Causes of Childhood Vaginitis

Commonest causes
Pinworm
Foreign body in vagina

STIs from sexual abuse

GC, TV, Chlamydia, herpes

Poor hygiene
Faecal material
Tight clothing

Allergic dermatitis
Laundry detergents
Soaps, shampoos

Rare causes
cavernous haemangioma
sarcoma botyroides
Persistent vaginal discharge

If infection screen negative and no local causes

found, proceed to :

¾Pelvic ultrasound scan – to exclude

intrauterine polyps, fallopian tube tumours,
bladder or bowel pathology

¾Hysteroscopy and endometrial biopsy

¾EUA – to exclude foreign bodies and fistulae

Conclusion

¾Varied presentation
¾ Varied Aetiology
¾ Usually Curable
¾ Persistent or recurrent problems need
more intensive investigation and Rx
¾Multidisciplinary and Complimentary
medical management may be required