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9 - Abnormal Vaginal Discharge

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29 views29 pages

9 - Abnormal Vaginal Discharge

Uploaded by

Blind Dlawar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Abnormal vaginal discharge

HMU department of
OBG DR-ZAINAB
ZWAIN
Content

Objective
Key concept
What are common causes of abnormal
vaginal discharge
1st scenario
2nd scenario
Conclusion
qeustion
Objective

Know common type of infection and their


presentation
Differentiate between types of infection
from history, investigations
Prophylaxis and treatement
Key concept

Features of the discharge such as its timing,


color, consistency, smell, and presence of itch
are important in distinguishing between
infections.
Pelvic pain, pelvic tenderness, and fever should
be considered as red flags for pelvic inflammatory
disease.
Taking a sexual history will help identify patients
at high risk of a sexually transmitted infection.
The need for examination and investigations is
usually determined on the basis of such a history.
Vaginal Discharge and Ageing
Abnormal vaginal discharge may include:
1. An unusual increase in the amount of discharge
2. An unusual and unpleasant smell
3. An unusual yellow or green color
4. A discharge which is accompanied by itching,
irritation or vulval swelling and pain
Causes of vaginal discharge

Non-infective
Physiological ----leucorrhea
Cervical ectopy
Foreign bodies, such as retained tampon
Vulval dermatitis

Non-sexually transmitted infection


Bacterial vaginosis
Candida infections

Sexually transmitted infection


Chlamydia trachomatis
Neisseria gonorrhoeae
Trichomonas vaginalis
Case scenario

1st scenario Sara is 34 yr G4P3A1


complaining of vaginal discharge &
itching for past 4 days
Differential diagnosis

1) Trichomonas
caused by the flagellated Trichomonas vaginalis which lives in vagina
&male urethra
25% infected females asymptomatic
history of pruritis, burning, urinary frequency, dyspareunia
discharge is bubbly and grayish green with a foul odor
strawberry cervix (petechiae)
pear shaped motile organism on wet mount
Tx: flagyl 500 mg bid X 7 d (partner also) or 2 g flagyl X1. Use
clotrimazole (local cream or supp)
Differential diagnosis (Cont.)

2. Bacterial vaginosis
Common cause of infective vaginal discharge
Causes profuse & fishy smelling discharge (without itch or soreness).

spontaneously.
Tx: flagyl tab & supp; partner also included

3. Molluscum contagiosum
Caused by a growth stimulating virus
Usually asymptomatic
red to yellow papules
Tx: carbonic acid, trichloroacetic acid, silver nitrate and manually expressing
the caseous content of lesions
Published with b
bacterial
vaginosi
s
Differential diagnosis

4. Candidiasis
vaginal discharge with cottage cheese appearance
20% asymptomatic
pruritis, burning, dyspareunia
hyphae / spores on KOH prep
Tx: Miconazole (Monistat) / Clotrimazole (Gyne-Lotrimin) /
Butoconazole (Femstat) / fluconazole 150 mg po (Diflucan)
5. allergic vulvovaginitis
6. irritative vulvovaginitis
Fig 2 Appearance of typical vaginal discharge associated with
candidiasis on examination with a speculum
Case scenario

2nd scenario: Lava is 25yrs old G2P1A1


has severe pelvic pain, fever 38.5
V/E: vaginal discharge & cervical
tenderness
Introduction

Definition:
Salpingitis is an inflammation of the fallopian tubes.
PID makes up a spectrum of inflammatory disorders of the upper
genital tract, including salpingitis, endometritis, tubo-ovarian abscess
and pelvic peritonitis.
Pathophysiology:
Sexual activity is responsible for moving organisms from the lower
genital tract to the upper genital tract.
Current evidence supports a multibacterial etiology of Acute PID
anaerobic bacteria and facultative gram-negative rods
Cont.

Trichomonas vaginalis can cause an offensive yellow vaginal


discharge, which is often profuse &frothy, along with
associated symptoms of vulval itch & soreness, dysuria,and
superficial dyspareunia, although many patients are
asymptomatic
Chlamydia trachomatis, an STD caused by a bacterial infection.
Chlamydia can cause a purulent vaginal discharge. It is
asymptomatic in 80% of women. It was thought that 10-40% of
untreated chlamydial infections will result in PID (Recent
research suggests that fewer women with untreated chlamydial
infection may develop pelvic inflammatory disease than
previously thought only 1-5.6%)
Neisseria gonorrhoeae may present with a purulent vaginal
discharge but is asymptomatic in up to 50% of women.
Gonorrhea may be complicated by PID.
Differential Diagnosis

1. Acute Appendicitis
2. Diverticulitis
3. Inflammatory bowel disease
4. UTI
5. Adnexal torsion
6. Ectopic pregnancy
7. Bleeding corpus luteum
8. Ruptured ovarian cyst
9. Endometriosis
10. Degenerating fibroids
11. Spontaneous abortion
Physical examination

Patient is usually febrile and tachycardic with


normal BP.
There is generalized lower abdominal tenderness
w/o palpable masses.
On spec exam, there may be purulent discharge.
On bimanual exam, cervical motion tenderness and
bilateral adnexal tenderness are present without
masses.
Pregnancy
What Investigations help in diagnosis

Pregnancy test - r/o ectopic


CBC - neutrophil leukocytosis indicates acute infection (not totally
reliable since less than 50% of cases will have WBC > 10,000)
ESR - elevated
Urinalysis - r/o UTI
Cervical culture - esp. for Chlamydia and Gonorrhoeae
Pelvic Ultrasound - may help define adnexal masses, IUD, or
intrauterine or ectopic pregnancy.
Triple swabs

High vaginal swab to identify bacterial vaginosis,


Candida infections, and Trichomonas vaginalis
Endocervical swab in transport medium (charcoal or
non-charcoal) to diagnose gonorrhea
Endocervical swab for a chlamydial DNA
amplification test to diagnose Chlamydia
trachomatis
Management

Hospitalization for acute salpingo-oophoritis (PID) is indicated in these


situations:
1. Dx is uncertain
2. Surgical emergencies (i.e., appendicitis or ectopic) are to be ruled
out
3. Pelvic abscess is suspected
4. Severe illness precludes outpatient management
5. Patient is unable to tolerate or follow outpatient management
6. Patient failure to respond to outpatient management
7. Patient is pregnant
8. Clinical follow-up after 48-72 hr. of antibiotic therapy cannot be
arranged. If patient shows no response in this time frame, surgery
must be considered.
Management of vaginal infections

Bacterial vaginosis
Metronidazole 2 g as a single oral dose, metronidazole 400-500 mg
twice daily for five to seven days,
intravaginal clindamycin cream (2%) once daily for seven days, or
intravaginal metronidazole gel (0.75%) once daily for five days4
Partner notification not needed
Vulvovaginal candidiasis
Vaginal imidazole preparations (such as clotrimazole, econazole,
miconazole various preparations are available including single dose
ones), or fluconazole 150 mg orally
Oral versus vaginal treatment depends on preference
Partner notification not needed
Cont.

Chlamydia trachomatis
Doxycycline 100 mg twice daily for seven days (contraindicated in pregnancy), azithromycin
1 g orally in a single dose (WHO recommends azithromycin in pregnancy but the British
National Formulary advises against its use unless no alternatives are available)
A test of cure is not indicated
Partner notification required
Gonorrhea
Cefixime 400 mg as a single oral dose or ceftriaxone 250 mg intramuscularly as a single
dose16
Referral to a genitourinary medical unit is encouraged because of the existence of resistant
strains of the organism16
A test of cure is not routinely indicated if an appropriately sensitive antibiotic has been
given, symptoms have resolved, and there is no risk of reinfection16
Partner notification required
Trichomonas vaginalis
Metronidazole 2 g orally in a single dose or metronidazole 400-500 mg twice daily for five
to seven days17
Partner notification required
Hygiene advice

Patients should be advised to avoid using local irritants, like


perfumed soaps and shower gels, and to be wary of feminine hygiene
products such as wipes, powders, and sprays, which may upset the
vaginal flora or cause allergic reactions.
Vaginal douching should be avoided as it is associated with bacterial
vaginosis and pelvic inflammatory disease.
Summary points

Vaginal discharge is caused by non-sexually and sexually transmitted


infections
Non-sexually transmitted infections may not need treatment, but
sexually transmitted ones must be treated and partners notified
Recent research suggests that fewer women with untreated
chlamydial infection may develop pelvic inflammatory disease than
previously thought only 1-5.6%
Concurrent infection depends on the population studied
Molecular techniques are more sensitive than culture but are
expensive, do not provide antibiotic sensitivities, and results can
remain positive after treatment
Self taken vaginal swabs, urine samples, and clinical tampons show
comparable results to traditional vaginal specimens

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