Vaginal Discharge; Diagnosis and Management

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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.

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