Vaginitis and Vaginal discharge

General Dr Osama Omar Amer

FRCOG, MD
2021
 ILOs
• Evaluate, investigate, diagnose and plan
treatment of a woman, and her partner if
needed, with symptoms of reproductive tract
infections as vaginal discharge, itching, soreness,
dysuria or pain. However, STIs will be included in
separate lecture.
• Management of special situations as:
– Recurrent vaginitis
– Vaginitis in pregnancy
– Vaginitis and contraception
– Personal Hygeine and Douching
Introduction
 Physiological discharge
• It is normal and healthy for women of reproductive age
to have some degree of vaginal discharge.
• The quantity and type of cervical mucus changes during
the menstrual cycle as a result of hormonal
fluctuations.
• Prior to ovulation, estrogen levels increase, altering
cervical mucus from non-fertile (thick and sticky) to
fertile (clearer, wetter, stretchy and slippery).
• Afterovulation, estrogen levels fall and progesterone
levels increase; cervical mucus becomes thick, sticky
and hostile to sperm.
 Normal vaginal flora
• The vagina is colonised with commensal bacteria.
• Rising estrogen levels at puberty lead to colonisation
with lactobacilli which metabolise glycogen in the
vaginal epithelium to produce lactic acid. Thus the
vaginal environment is acidic and normally has a
pH≤4.5.
• Other commensal bacteria include anaerobes,
diphtheroids, coagulase-negative staphylococci and α-
haemolytic streptococci.
• Some commensal organisms can cause a change in
discharge if they ‘overgrow’. These include Candida
albicans, Staphylococcus aureus and Streptococcus
agalactiae (Group B streptococcus).
Causes of Altered Vaginal Discharge in Women of
Reproductive Age
l Infective (non-sexually transmitted)
o Bacterial vaginosis
o Candida
l Infective (sexually transmitted)
o Chlamydia trachomatis
o Neisseria gonorrhoeae
o Trichomonas vaginalis
o Herpes simplex virus
l Non-infective
o Foreign bodies (e.g. retained tampons, condoms)
o Cervical polyps and ectopy and hydrosalpinx
o Genital tract malignancy
o Fistulae
o Allergic reactions.
o Bacterial vaginosis
o Candida
o Trichomonas vaginalis
 1-Bacterial vaginosis
• BV is the commonest cause of abnormal vaginal discharge
in women of reproductive age.
• It can occur and remit spontaneously .
• Characterised by an overgrowth of mixed anaerobic
organisms that replace normal lactobacilli, leading to an
increase in vaginal pH (>4.5).
• Typical signs and symptoms are shown in Table 1.
• Gardnerella vaginalis is commonly found in women with BV
. Other organisms associated with BV include Prevotella
species, Mycoplasma hominis and Mobiluncus species.
• BV is considered to be ‘sexually associated’ rather than
truly ‘sexually transmitted’.
• There is some evidence that consistent condom use may
help to reduce BV prevalence
• Clue Cells. Epithelial cells NOT a clue cell
with clusters of bacteria
adherent to their external Clue cells
surfaces,
• obscuring their normal, fine
border.
• They have a granular or
stippled appearance
• and are associated with
bacterial vaginosis.
NOT a clue cell
 Treatment of BV
• Metronidazole and clindamycin administered
either orally or vaginally are effective in the
treatment of BV,
• There is limited evidence for the effectiveness of
acidifying gels in the treatment of BV but the may
help prevent recurrence.
• In the management of BV, testing and treatment
of male sexual partners is not indicated but
testing and treatment of female sexual partners
can be considered.
 Treatment of BV
• Metronidazole and clindamycin administered
either orally or vaginally are effective in the
treatment of BV,
• There is limited evidence for the effectiveness of
acidifying gels in the treatment of BV but the may
help prevent recurrence.
• In the management of BV, testing and treatment
of male sexual partners is not indicated but
testing and treatment of female sexual partners
can be considered.
Treatment of BV
Treatment of BV
 2-Vulvovaginal candidiasis
• VVC is common among women of reproductive age.
• It is caused by overgrowth of yeasts; C. albicans, in 70–90% of
cases, with non-albicans species such as C. glabrata in the
remainder.
• The presence of candida in the vulvovaginal area does not
necessarily require treatment, unless symptomatic, as between
10% and 20% of women will have vulvovaginal colonisation.
• Candidiasis occurs most commonly when the vagina is exposed to
estrogen, therefore it is more common during the reproductive
years and during pregnancy.
• An episode of VVC is often precipitated by use of antibiotics.
• Immunocompromised women and women with diabetes are
predisposed to candidiasis.
• As VVC can be found in non-sexually active individuals, it is not
classed as an STI.
 Treatment of VVC
• Vaginal and oral azole antifungals are equally
effective in the treatment of VVCa clinical cure
of up to 80% and mycological cure of up to
83%.
• Women with vulval symptoms of VVC may use
topical antifungals (in addition to oral or
vaginal treatment) until symptoms resolve.
• There are no data to support routine
screening and treatment of partners.
 3-Trichomonas vaginalis
• TV is a flagellated protozoan that causes vaginitis.
• Women with TV commonly complain of vaginal
discharge and dysuria (due to urethral infection).
• TV is always sexually transmitted and is a rarer
condition than BV or VVC.
 Treatment of TV
• Nitroimidazole drugs (e.g. metronidazole, tinidazole)
are effective in achieving cure. While a single oral dose
can achieve cure, side effects may be more frequent
when compared with a longer course of treatment.
• Intravaginal treatment cure rates are low.
• In the UK, first-line recommended treatment is oral
metronidazole.
• Current sexual partners of women diagnosed with TV
should be offered a full sexual health screen and
should be treated for TV irrespective of the results of
their tests.
Other causes of vaginal discharge
 Non-infective

o Foreign bodies (e.g. retained tampons,

condoms)
o Cervical polyps and ectopy and hydrosalpinx
o Genital tract malignancy
o Fistulae
o Allergic reactions.
Management of Women Presenting
with Vaginal Discharge
 Assessment of symptoms
• Symptoms associated with vaginal discharge can guide a health professional to the most likely cause (Table 1).

The characteristics of the vaginal discharge should be determined:

• l What has changed
• l Onset
• l Duration
• l Odour
• l Cyclical changes
• l Colour
• l Consistency
• l Exacerbating factors (e.g. after intercourse).

Enquiry should also cover any associated symptoms:

• l Itchinga
• l Superficial dyspareuniaa
• l Vulval or vaginal pain
• l Dysuria
• l Abnormal bleeding (heavy, intermenstrual or postcoital)b
• l Deep dyspareuniab
• l Pelvic or abdominal painb
• l Feverb.
 Examination, point-of-care investigations
and STI testing
• History-taking alone may guide health professionals
towards the most likely diagnosis but diagnostic
accuracy varies. In addition to the clinical and sexual
history, physical examination and vaginal pH may be
helpful.
• It should be standard clinical practice to offer to
examine people presenting with genital symptoms.
• If the history indicates candidiasis or BV, the risk of STI
is low, and there are no symptoms indicative of upper
genital tract infection, treatment for candidiasis or BV
may be given without examination (i.e. syndromic
management). Women should be advised to undergo
examination if symptoms persist or reoccur
 Physical examination should include:

• Inspection of the vulva (for obvious discharge, vulvitis,

ulcers, other lesions or changes)
• Speculum examination (inspection of: vaginal walls,
cervix, foreign bodies; amount, consistency and colour
of discharge).
• Where there is any suggestion of upper genital tract
infection physical examination should also include:
– Abdominal palpation (for tenderness/mass)
– Bimanual pelvic examination (adnexal and/or uterine
tenderness/mass, cervical motion tenderness).
 Laboratory investigations
• Women who accept examination should have a vaginal
pH measurement using narrow range pH paper (pH 4–
7).
• Secretions should be collected from the lateral sides of
the vaginal wall using a loop or swab. Vaginal pH testing
can be used to assess the likelihood of candida
(pH≤4.5) or of BV or TV (pH >4.5) but it cannot
distinguish between BV and TV.
• If STI testing is indicated and/or requested,
endocervical swabs for chlamydia and gonorrhoea
should also be taken, and a high vaginal swab (HVS)
may be indicated in some cases .
• Whiff Test. A test used clinically. The smell of
vaginal discharge after the addition of 10%
potassium hydroxide. A positive sample
associated with either bacterial vaginosis or
Trichomonas infections will give off a fishy or
aminelike smell.
• Clue Cells. Epithelial cells with clusters of bacteria
adherent to their external surfaces, obscuring
their normal, fine border. They have a granular or
stippled appearance and are associated with
bacterial vaginosis.
Vaginitis in pregnancy
 1 Bacterial Vaginosis
Risks:
• adverse events and in particular an increased risk of
preterm birth.
Treatment:
• Treatment of BV before 20 weeks’ gestation and treatment
of women with a previous preterm birth may reduce
adverse pregnancy outcomes .
• There is currently little evidence that screening and treating
all women with asymptomatic BV will prevent preterm
birth.
• If BV is identified as a cause of vaginal discharge or as an
incidental finding it should be treated.
• Women with BV who are pregnant or breastfeeding may
use metronidazole 400 mg twice daily for 5–7 days or
intravaginal therapies. A 2 g stat dose of metronidazole is
not recommended in pregnancy or breastfeeding women.
 2 Vulvovaginal Candidiasis
Risks:
• VVC is common during pregnancy. There is no evidence
of any adverse effect on pregnancy.
Treatment:
• Topical imidazoles (e.g. clotrimazole, econazole,
miconazole, fenticonazole) have been found to be
effective in pregnant women with VVC but a longer
treatment regimen may be required ( 7days) (Appendix
3).
• Oral antifungals should be avoided during pregnancy
because of a lack of teratogenicity data.
 Trichomonas vaginalis
• Risks:
• TV may be associated with preterm delivery and
low birth weight.
• Treatment:
• Cochrane review: Over 90% of women were
cleared of vaginal TV after treatment with
metronidazole but it is not clear if this has any
impact on pregnancy outcomes.
• As with treatment of BV in pregnancy, single stat
doses of metronidazole should be avoided
(Appendix 3).
Recurrent vaginitis
 1 Recurrent BV
Definition:
• There is no specifically agreed definition of recurrent BV.
• Incidence:
• Despite high initial cure rates, recurrence of BV is high. At
12 months a cohort study reported a median recurrence
rate of 58% after treatment with metronidazole.
Risk factors for recurrence:
• female, new or multiple sexual partners, oral sex, and
• copper-bearing intrauterine device (Cu-IUD) use.
• Treatment:
Optimal treatment for recurrent BV has not been established.
• 1- Metronidazole:
• Evidence from an RCT comparing twice-weekly
metronidazole vaginal gel to placebo for 16 weeks
showed that women receiving maintenance therapy
were more likely to remain disease-free during
treatment, and for 12 weeks after, than those treated
with placebo.
• However, even with metronidazole maintenance
therapy only 35% of patients remained recurrence-free
12 weeks after stopping the treatment.
•
2- Acidifying gels :
• Women using acidifying gels for recurrent BV can be
advised to use them alternate evenings for 1 month or
longer if required.
• lactic acid vaginal gel products are currently available
• 3- Probiotics:
• A Cochrane review has suggested that there is
currently insufficient evidence to recommend the use
of probiotics either before, during or after antibiotic
treatment as a means of reducing recurrence.
 Recurrent VVC
Definition:
four or more episodes of symptomatic
mycologically proven VVC in 1 year.
Incidence:
• Recurrent VVC occurs in less than 5% of women.
Suppression and maintenance treatment is often
recommended.
Treatment:
• Of predisposing factors
• an induction and maintenance regimen may be
used for 6 months.
predisposing factors for recurrent VVC:
• antibacterial therapy, pregnancy, diabetes
mellitus and possibly oral contraceptive use.
• Reservoirs of infection e.g. other skin sites;
the digits, nail beds, and umbilicus as well as
the gastro-intestinal tract and the bladder.
• The partner may also be the source of
reinfection and, if symptomatic, should be
treated with cream at the same time.
• Treatment of recurrent VVC:
Treatment may need to be extended for 6 months in
recurrent vulvovaginal candidiasis. Some
recommended regimens include:
• Initially, fluconazole (section 5.2.1) by mouth 150 mg
every 72 hours for 3 doses, then 150 mg once every
week for 6 months.
• Initially, vaginal application of a topical imidazole for
10–14 days, then clotrimazole vaginally 500-mg
pessary once every week for 6 months;
• Initially, vaginal application of a topical imidazole for
10–14 days, then itraconazole (section 5.2.1) by mouth
50–100 mg daily for 6 months.
 Recurrent TV
• Recurrent TV is usually due to re-infection,
although resistance to treatment can also be a
cause.
• Treatment, advice on avoidance of sex or use
of condoms and partner notification are
required.
• Health professionals should consider
involvement of GUM services.
Contraception and Vaginal Discharge
Is the efficacy of contraception affected by
vaginal discharge treatments?
• Additional contraceptive precautions are not
required when using antibiotics that do not
induce liver enzymes ( Not Rifampicin).
• Women and male partners should be advised
that latex contraceptives may be damaged by
some vaginal/vulval antifungal treatments.
 Does contraception affect vaginal
discharge?
• Vulvovaginal candidiasis
• VVC occurs most commonly when the vagina is
exposed to estrogen. However,
– there is no clear evidence as to whether the use of
hormonal contraception increases the risk of VVC.
– One study has suggested that the progestogen-only
injectable may reduce a woman’s susceptibility to
recurrent VVC, possibly because of its anovulatory
effect and relative hypoestrogenism.
• Women using CHC who have recurrent VVC
may wish to consider alternative
contraception but there is a lack of evidence
to show whether there is any benefit from
switching to a lower dose combined
preparation or a progestogen-only method,
other than the injectable.
• The Cu-IUD has been identified as a possible risk
factor for acute or recurrent VVC but there is no
consistent evidence of an association.

• Although cervical cytology slides from

levonorgestrel-releasing intrauterine system
(LNG-IUS) users have shown increased presence
of candida with time from insertion, rates of
symptomatic infection did not change
significantly
• There is some evidence to demonstrate that
yeasts adhere to IUDs88,89 and the combined
vaginal ring (CVR). CVR users have been
reported as experiencing more vaginal
irritation and discharge compared with
combined pill users. However, a study of the
effect of CVR use on vaginal flora showed no
increase in numbers of inflammatory cells or
pathogenic bacteria.
• Bacterial vaginosis
• Oral combined contraception and condoms have
been associated with a reduced risk of BV, The
progestogen-only implant and injectable may be
associated with a decreased risk of BV
• whilst BV is more common in users of the Cu-
IUD.
• The association between BV and use of the LNG-
IUS is unclear.
Personal Hygiene and Vaginal Discharge
• Personal hygiene measures can be advised for
women who are prone to vaginal discharge
and/or pruritis (e.g.
– regular changing of sanitary protection,
– avoidance of douching and of potentially irritant
chemicals in toiletries, antiseptics, wipes, so-called
‘feminine hygiene’ products, washing powders,
fabric dyes, and so on).
 Hygiene Douching
• Douching is the process of intravaginal cleaning
with a liquid solution. Some women use the
practice of douching as part of their general
hygiene or cultural practice.
• Data suggest that douching changes vaginal flora
and may predispose women to BV, although not
all studies have reported this finding.
• Overall, the evidence suggests that douching
should be discouraged as there are no proven
health benefits.
 References
• Hacker and Moore Essentials of Obstetrics and
Gynecology, 6th Edition.
• Centers for Disease Control and Prevention
(CDC) Guidelines.
THANK YOU