Download Problem 87-Vaginal discharge

Vaginal discharge (VD):
Structure and function of female genital tract/flora of genital
tract:
-Physiological causes of vaginal discharge include pregnancy, puberty and sexual
arousal.
-Apart from Lactobacillus vaginalis, Candida + Escherichia coli represent
commensal organisms in the vagina
Causes of pathological (VD):
By age:
-Young children:
- precocious puberty, foreign body..always consider sexual abuse
-Adults of reproductive age:
-Cervical: Chlamydia trachomatis, Neisseria gonorrhoea, Trichomoniasis
vaginalis, neoplasia of cervix, cervical carcinoma, cervical polyps
-Vagina: Candidiasis, Bacterial vaginosis, neoplasia of vagina (rare)
-Bartholin’s abscess
-Post-menopausal + eldery
-Bacterial vaginosis, atrophic vaginitis (increases susceptibility to
infections, treat with oestrogen cream), STIs, cancers, fistulas
Important organisms:
Bacterial vaginosis:
-Aetiology:
-Overgrowth of several bacterial species in vagina, specifically a decrease
in lactobacilli and an increase in anaerobic organisms (Mycoplasma
hominis etc.).
-Risk factors include regular douching and having new or multiple sexual
partners.
-Most common cause of vaginits in young women.
- Increased risk of preterm labour, intra-amniotic infection in pregnancy,
susceptibility to HIV.
-Symptoms/signs:
-Mostly asymptomatic
-Vagina not inflamed
-Fishy odour, pruritis uncommon
-Diagnosis:
-High vaginal swab
-+ve KOH “whiff” (ammonia) test
-Clue cells (+no leukocytes, adherent cocci) on saline wet-mount
microscopy
-pH>4.5
-Treatment:
-Oral/intravaginal metronidazole or clindamycin.
Candidiasis:
-Aetiology:
-95% C. albicans, risk factors include: pregnancy, contraceptive pill and
other steroids, immunodeficiency’s and diabetes.
-Partner maybe asymptomatic.
-2nd most common cause of symptomatic vaginitis.
-Symptoms/signs:
-Vulva + vagina sore and fissured.
-Discharge non-offensive with classic white curds.
-Candida elsewhere (e.g. mouth, nasal cleft) which can cause reinfection.
-Diagnosis:
-High vaginal swab
-KOH wet-mount microscopy with presence of branching and hyphae.
-pH<4.5 (normally).
-Treatment:
-Topical clotrimazole (Canestin) or oral fluconazole (diflucan)
Trichomoniasis:
-Aetiology:
- Trichomonas vaginalis (protozoan) is a common STI
-Symptoms/signs:
-Vaginitis
-Strawberry cervix (due to petechial haemorrhages)
-Post coital bleeding
-Bubbly, thin, fishy smelling discharge
-Diagnosis:
-High vaginal swab
-Motile flagellates (trichomonads) seen on wet film microscopy
-pH>4.5
-Leukocytes >10/HPF
-Exclude gonorrhoea (often coexists)
-Treatment:
-Metronidazole
-Boric acid if recalcitrant disease
Chlamydial cervicitis:
-Aetiology
-Chlamydia trachomatis is obligate intracellular parasite of columnar
epithelium.
-Most prevalent STD in USA and UK.
-30% of infections associated with gonorrhoea
-Obstetric complication of neonatal conjunctivitis
-Long term complications of infertility and ectopic pregnancies
-Symptoms/signs
-Salphingitis (pain, fever, infertility)
-Vaginitis
-Cervicitis
-Purulent discharge
-Post coital bleeding
-Asymptomatic women can be identified through contact tracing or
screening
-Reiter’s syndrome: can’t pee, can’t see, can’t bend knee i.e.
uveitis/conjuctivitis, reactive arthritis, urethritis/cervicitis
-Diagnosis:
-First void (early morning) urine
with PCR, DNA probe test or ELISA (enzyme-linked immunosorbent
assay)
-Endocervical swab (with same tests)
-Treatment:
-Oral azithromycin or doxycycline
Gonococcal cervicitis/vaginitis:
-Aetiology
-Neisseria gonorrhoea is a gram –ve intracellular aerobic diplococcus
-Can infect any columnar epithelium e.g. urethra, cervix, rectum, pharynx,
conjuctiva
-Common but less prevalent STD than Chlamydia
-Obstetric complications of ophthalmia neonatorum
-Long term complications of urethral stricture and infertility
-Symptoms/signs
-Maybe asymptomatic
-Vaginitis
-Cervicitis
-Profuse, odourless, non-irritating, creamy white or yellow discharge
-Acute salphingitis (10-20% of women develop; acute fever and pelvic
pain)
-Disseminated gonorrhoea infection (5% of women develop with chills,
fever, malaise, asymmetric polyarthralgias, and painful skin lesions)
-Reiter’s syndrome
-Diagnosis:
-Endocervical swab
-MC+S: +ve culture on selective media.
-Treatment:
-Ceftriaxone IM or cefixime PO stat (uncomplicated infection of cervix,
rectum + urethra), plus treatment for Chlamydia
Syphilis (doesn’t really cause VD…as in vaginal discharge):
-Aetiology
-Treponema pallidum enters via a graze during sex
-Spirochete
-All signs due to endarteritis obliterans
-Intrauterine syphilis as a complication
-Symptoms/signs
-Primary
-Primary chancre formed, an infectious painless hard ulcer
-Secondary
-Constellation of stuff 6 weeks to 6 months after initial infection;
hepatosplenomegaly, lymphadenopathy, glomerulonephritis etc.
-Tertiary
- after >2yrs latency; gummas (granulomas in skin, viscera and
other structures)
-Quaternary
-Vascular; aortic regurgitation/ascending aorta aneurysm,
Neurosyphilis, Meningovascular; cranial palsies, stroke, General
paresis of insane, Tabes dorsalis, Argyll Robertson pupils
-Diagnosis
-Cardiolipin antibody (detectable in primary disease) e.g. Venereal
Disease Research Laboratory slide test (VDRL) etc.
-Treponeme-specific antibody is +ve in primary disease but remains +ve
after treatment e.g. T.pallidum haemagglutination assay (TPHA).
-Syphilis ELISA IgG or IgM
-Other tests: dark ground microscopy, look for other STIs, in
neurosyphilis CSF antibody tests are +ve.
-Treatment
-Benzathine penicillin G IM
-Others include procaine penicillin +probenecid, doxycycline, ceftriaxone,
if pregnant give erythromycin
-Beware Jarisch-Herxheimer reaction: pyrexia,tachycardia +
vasodilatation hours after 1st dose of antibiotics.