What You Will Learn
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- Common presentations in gynecological clinics.
- Public and reproductive health concerns.
- Task family and health resources for care and treatment of complications.
- Causes intense psychological and physical stress on the patient.
Definition:
- Varies
- Discharge > 6 months
- Pattern
- Intractable – difficult to treat
- Protracted – long before seeking treatments
- Recurrent – treated less than three months
- Persistent – continues despite appropriate treatments
Anatomical –
- Vulva – constant apposition
- Vagina - exfoliation of the squamous epithelium. Epithelial cells lining the vagina constitute the initial point of contact between microorganisms and the host’s genital tract.
- Vaginal epithelial cells also release molecules with potent non-specific antimicrobial activity.
- Defensin -+vely charge electron binds with –vely charged bacteria in the tract.
Biological –
Endogenous flora—
- This is a complex interplay and reactions of non-pathogenic micro flora of the genital tract and the host with resultant protection against invasion by the pathogenic micro-organisms.
- Newly recognized important variable that influences the composition of the vaginal microflora, as well as the efficacy of the response to pathogens.
- Individual genetic capacity for production of high or low levels of anti- or pro-microbial factors.
- Influence of the quantitative and composition of bacterial flora in the vagina include.
- Polymorphisms in genes such as the anti-inflammatory mediator interleukin-1 receptor antagonist.
- The cell surface receptor for innate immune recognition of Gram-negative bacteria Toll-like receptor4.
Hormonal—
- Steroidal and non- steroidal
- Estrogen & progesterone – encourage the accumulation of glycogen in the epithelial cells of the vagina.
Biochemical—
- The PH of the genital tract- the PH of the vagina is highly acidic; upper genital tract are alkaline.
Immunological
- Local in the epithelium
- Systemic
- The innate immune system is the most primitive and evolutionary conserved arm of the immune system. It recognizes pathogen associated molecular patterns (PAMPs) on microbial invaders rather than specific antigens.
- Components of innate immunity operational in the vagina are soluble factors such as mannose-binding lectin, complement factors defensins, secretory leukocyte protease inhibitor (SLPI) and nitric oxide
- Recognition of a PAMP by an innate immune system component triggers a sequence of events leading to the release of pro-inflammatory cytokines and activation of the acquired immune.
Others—
- Abnormal specie or resistant strains.
Depend on the patient age and menstrual cycle.
None in childhood/premenarcheal females.
None in post-menopausal women.
Thin white in the follicular phase.
Thick clear in the mid cycle.
Thick white flaky in the mid luteal period .
Generally acellular, colorless, odorless, non-itchy.
Volume/quantity – copious, thick, require perineal padding.
Colour - watery, white, yellow, brownish, dark, blood stains, pussy.
Consistency- curdy, creamy, sticky, watery.
Odor – foul, fishy, offensive.
Others – itching, burning sensation, pains, excoriation.
Systemic: Fever
Leucorrhea- is the production of excess normal vaginal discharge. It is usually seen in women with
- DM
- Immunocompromised status
- Malignancy
- Pregnaancy
- Lactating
- Using OCP
- On prolonged antibiotics use
Poor hygiene
Perineal/vulvar
- Children
- Elderly
- Chronic illness
Socio–economic/poverty
- Cosmetics
- Douching
- Cigarette smoking
Cultural/religious- lack proper cleaning
Application of herbal/other substances
Environmental
Multiple factors and agents
Infective— acute & chronic infections - commonest
- Bacterial
- Gonorrhea
- Chlamydia
- Bacterial vaginosis
- TB
- Chronic granulomatous
- Virus – herpes/ HPV warty lesions
- Protozoa – trichomonas vaginalis
- Fungi – candida – resistant specie
Neoplasia of the genital tract, benign and malignant
- Polyps
- Cervical ectopion/erosions
- Lichen sclerosis
- Squamous cell hyperplasia
- Other dematosis - psoriasis
- Carcinomas
Foreign bodies
- IUCD
- Tampon, condom
- Pessaries, diaphragms
- Allergies – underwears, deodorants, powders
Systemic diseases- DM, CRD
Immunosupression— acquired/ congenital
Drugs – broad spectrum antibiotics
Steroids
Chemotherapy
Compliance to therapy?
An mpathetic approach should be adopted.
Good medical history
Age
Menstrual hx – menarche, cycle, abnormality of cycle and flow
Sexual hx
Contraceptive- COCP, IUCD, barrier methods
Associated Factors - Infertility, quality of life
Obstetrics – Parity
Past medical – systemic dx and drugs
Social Hx
Examinations
General, skin lesions other evidence of systemic dx.
Systemic – chest to exclude TB.
Vaginal – speculum exam, Pap smear, bimanual exam, vaginoscopy, colposcopy.
Hysteroscopy
Laparoscopy
Rectal exam for adnexal structure
Depends of findings on clinical evaluation
CBC – platelets / ESR
Urine analysis – proteins, glucose and others, culture for sensitivity
LFT, U/E/C, LIPID profile,
USS, DOPPLER, CT, MRI, Chest X-ray,
Immunological testing – infective agents
Cytology – smears, scraping/curettage
Biopsy – special stains for tumors and granulomatous infections
Microbiological- cultures and antimicrobial agents
Depends on diagnosis
General:
- Counseling with consultation with psychologist.
Medical:
- Underlying medical conditions
- Antimicrobial agents
Surgical:
- Tubo-ovarian complex
- Tumors
Outpatient antibiotic therapy
Regimen 1
- ofloxacin 400mg bd + Metronidazole 400mg oral bd + doxycycline 100mg bd
Regimen 2
- Ceftriaxone 250 mg IM stat
- Cefoxitin 2 g IM stat plus probenecid 1
- Metronidazole 400mg bd + doxycycline 100mg bd
Regimen 3
- Moxifloxacin 400mg OD
Inpatient treatment
Regimen 1
- IV cefoxitin 2 g QID or oral doxycycline 100 mg BD followed by oral doxycycline 100 mg BD + metronidazole 400 mg BD for 14 days
Regimen 2
- IV clindamycin 900 mg TID + IV gentamycin 2 mg/kg loading dose followed by 1.5 mg/kg TID (a single daily dose may also be used) followed by oral doxycycline 100 mg BD + Metronidazole 400mg bd for 14days.
Regimen 3
- IV ofloxacin 400 mg BD + IV metronidazole 500 mg TID followed by oral ofloxacin 400 mg BD, oral metronidazole 400 mg BD.
- Parenteral therapy continued 24hr after clinical improvement.
Regimen 4
- IV ciprofloxacin 200 mg BD + IV or oral doxycycline 100 mg BD + IV metronidazole 500 mg TID followed by oral ofloxacin 400 mg BD + oral metronidazole 400 mg BD.
- Treat up to 14 days
The most common recurrent infections are:
- Yeast infection - candidasis
- Bacterial Vaginosis
- Trichomonas
- Chronic Pelvic infections – PID, Abscesses
Vulvo-vaginal Candidiasis
Approximately 20% of all women will experience one in their lifetime.
Diabetes, pregnancy, antibiotic use and immuno-suppression are risk factors
Not commonly sexually transmitted - Penis is not a major reservoir
Symptoms may flare at the same time during the menstruation
Causes intense inflammatory reactions of the vagina
Characteristic curdy discharge, dyspareunia, itching and excoriation
Recurrent infection is defined as 4 infections/year.
Diagnosis is made from history and physical exam.
Usually a special fungal culture is obtained to identify the yeast organism.
Acute infection is occurring, this is treated aggressively for 7-14 days.
Treatment is administered either orally or vaginally- imidazoles
Chronic infection – Non-albican specie or resistance – culture is necessary
Bacterial Vaginosis
Bacterial vaginosis (BV) represents a change in the ecosystem of the vagina.
BV is not a sexually transmitted infection
Associated with chronic douching, sexual activity, spermicides, young age, IUD, and African American race.
Some women experience vaginal irritation accompanied with a thin, watery, yellow-green discharge.
There can also be a characteristically fishy odor.
Diagnosis is made with clinical criteria and laboratory findings
Chronic BV is defined as 3 episodes/year.
Treatment is often with an oral or vaginal antibiotics for 5-7days— Metroniazole, clindamycin.
Like other chronic infections, there has been great interest in products used to re-establish the vaginal bacterial environment.
Trichomonas
Trichamonas is a sexually transmitted infection caused by a single-celled organism.
Women often experience a copious, yellow discharge that can lead to intense irritation and painful intercourse.
Causes inflammatory reaction of the vaginal epithelium – moth bitten pattern
Treatment of both the patient and her partner is important
Chronic infection with trichomonasis is uncommon but can be troublesome.
Typical treatment is with oral metronidazole
If recurrent infection occurs, treatment may be extended or sensitivity testing using a vaginal culture may be performed to ensure effective treatment with Flagyl.
Vaginal discharge in children
Postmenopausal women
Immunosuppression
Pregnancy
Education of the populace
Eliminate risk factor
Effective treatment of primary infection
conclusion:
Chronic vaginal discharge is a very challenging public health problem.
Management require empathy.
Effective management in well selected patients often result in good outcome.
Practice Questions
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