APPROACH TO PT

WITH VAGINAL
DISCHARGE
Gemechu
INTRODUCTION
 common, accounting for over 10 million
office visits per year
 self-diagnosis and therapy
 As an example, a random telephone survey in
the United States found that 8 percent of
Caucasian women and 18 percent of African
American women reported an episode of
vaginal symptoms
 Most women purchased an over-the-counter
antifungal preparation to treat their
symptoms,
 Lifetime risk for yeast vaginitis 75%
 – Antifungal medication among top 10 of all
nonprescription meds
 • Estimated $275 million annually
 • Self-diagnosis based upon symptoms
frequently incorrect
 The etiology of vaginal complaints includes
infection of the vagina, cervix, and upper
genital tract, and a number of noninfectious
causes, such as reactions to allergens and
irritants
 occur during the normal menstrual cycle
 estrogen deficiency, and, rarely, systemic
diseases
 Regrettably, the management of vaginitis
remains largely empirical, although this practice
should be avoided because of frequent
misdiagnosis and inappropriate therapy.
 most common infectious causes of vaginitis:
bacterial vaginosis, candida vulvovaginitis,
and trichomoniasis, which account for at
least 90 percent of vaginitis
NORMAL VAGINAL PHYSIOLOGY
AND FLORA
 normal vaginal discharge - 1 to 4 mL fluid
(per 24 hours
 white or transparent, thick, and mostly
odorless
 The discharge may become more noticeable
at times, such as during pregnancy, use of
estrogen-progestin contraceptives, or at
midmenstrual cycle close to the time of
ovulation
 pH of the normal vaginal secretions is 4.0 to
4.5
MICROBIOLOGY
 The microbiology of the vagina is complex,
containing 109 bacterial colony forming units
per gram of secretions
 The most abundant normal isolates are
lactobacilli , diphtheroids, and S.
epidermidis
FACTORS
 Age, phase of the menstrual cycle,
 sexual activity, contraceptive choice,
 pregnancy,
 presence of necrotic tissue or foreign bodies,
and use of hygienic products or antibiotics
can disrupt the normal ecosystem.
 Under the influence of estrogen, the normal
vaginal epithelium cornifies and produces
glycogen, which acts as a substrate for
lactobacilli, thereby protecting women
against infection from a number of
pathogens.
 In contrast, the endocervix is lined with
columnar epithelium and is more susceptible
to infection with certain pathogenic
organisms
 In premenarchal and postmenopausal women
in whom estrogen levels are low, the vaginal
epithelium is thin and the pH of the normal
vaginal secretions is 4.7 or more. The higher
pH is due to reduced colonization of
lactobacilli and less glycogen in epithelial
cells.
HISTORY
 Abnormal vaginal discharge, pruritus,
irritation, burning, soreness, odor, and, less
commonly, dyspareunia, bleeding, and
dysuria.
 Candida vulvovaginitis, as an example, often
presents with scant discharge but marked
inflammatory symptoms (pruritus and
soreness)
 Bacterial vaginosis are asymptomatic or
present with only malodorous vaginal
discharge and no inflammatory complaints
 Dyspareunia is a common feature of atrophic
vaginitis.
 Is there abdominal pain? Abdominal pain is
suggestive of pelvic inflammatory disease and
suprapubic pain is suggestive of cystitis, both are
rare with vaginitis.
 Has there been exposure to a new sexual
partner?
 A new sexual partner increases the risk of
acquiring sexually transmitted diseases such as
Trichomonas vaginalis, or cervicitis related to
Neisseria gonorrhoeae or Chlamydia trachomatis.
 When did the symptoms start in relation to
menses?
 Candida vulvovaginitis often occurs in the
premenstrual period, while trichomoniasis
often occurs during or immediately after the
menstrual period.
 Antibiotics and high-estrogen contraceptives
may predispose to candida vulvovaginitis;
increased physiologic discharge can occur
with estrogen-progestin contraceptives
 What are the patient's hygienic practices ?
 irritants and allergens in her environment
and habits unhealthy for the vulvar skin.
Mechanical, chemical, or allergic irritation
may cause vulvar symptoms mistakenly
attributed to an infectious source
 eg. Soap , perfume ,underwear made from
linen ,powder , Synthetic underwear , Jeans
and other tight pants
P/E
 The vulva usually appears normal in bacterial
vaginosis
 Erythema, edema, or fissure formation
suggest candidiasis trichomoniasis, or
dermatitis.
 Trichomonas is classically associated with a
greenish-yellow purulent discharge
 candidiasis with a thick, white, adherent,
"cottage cheese-like" discharge
 bacterial vaginosis with a thin,
homogeneous, "fishy smelling" gray
discharge. However, the appearance of the
discharge is extremely unreliable and should
never form the basis for diagnosis
 erythematous and friable cervix, with a
mucopurulent discharge is suggestive of
cervicitis
 Ectropion the normal physiologic presence
of endocervical glandular tissue on the
exocervix
 not friable and is more common in women
taking estrogen-progestin contraceptives

 Abdominal or cervical motion tenderness is

suggestive of PID.
VULVOVAGINAL CANDIDIASIS

 • Accounts for 17-30% of cases of vaginitis

 – >90% of cases due to C. albicans
Signs and symptoms:
 – Thick, curdy, white, nonodorous discharge
 – Burning, itching, irritation, dyspareunia
Risk factors
 Antibiotic use steroid use
 Diabetes
 HIV
 Pregnancy
DIAGNOSIS

Physical exam findings

 • Erythema and edema of vulva and vagina
 • white adherent discharge
 – Wet mount

• pH normal (4-4.5)
• Yeast/hyphae seen in 50% on KOH stain
• No increase in PMN’s on saline stain
 – Culture

-Recurrent Candida vaginitis or for vaginitis

unresponsive to antimycotic RX
 Sabouraud agar,
 Nickerson's medium
 Microstix-candida medium perform equally
well .
 Culture should also be performed in patients
with persistent or recurrent symptoms
because many of these women have non-
albicans infection that is resistant to azoles
KOH FOR BUDDING YEAST &
HYPHAE
 Complicated infections
 Poorly controlled diabetes, pregnancy,
 Recurrent infection, immunocompromised,
 Infection with non-albicans Candida like c. galbrata,
or severe symptom
 Pregnant women
 > 4 episiodes/yr
 Disease choose prolonged therapy
 • 2 doses of oral fluconazole 72 hours apart
 • 7-10 days of topical therapy
 • Maintenance regimen of fluconazole 150 mg po
once weekly x 6 months
 C galbrata responds to boric acid 600mg
capsule pv or flucytocine vaginal cream
5gm/night for two week
 50% azole resistant
 C. krusei — Candida krusei is usually resistant
to fluconazole but sensitive to topical
meconazole , clotrimazole
BACTERIAL VAGINOSIS

 Replacement of Lactobacillus species by

 vareity of anaerobic bacteria
 Gardnerella vaginalis
 Mycoplasma hominis
 Most frequent cause of vaginal discharge
 22-50% of all cases
 > 50% of affected women are asymptomatic
BV

Risk factors
 – Multiple sex partners
 – Douching
 – IUD use
 – AA race
 – Exposure to STI’s
BV

Diagnosis Hx and PE:

1. Thin, white-gray vaginal discharge
2. Malodor noticed after intercourse or menses
3. Itching, burning, irritation of vagina
Wet mount:
4. Clue cells on saline prep
5. Fishy odor on KOH prep
6. Vaginal pH >4.5
 – Inclusion of any 3 of either 1,4,5,6 gives sensitivity
of 92% and specificity of 77% = Amsel’s criteria
CLUE CELL
TREATMENT OF BV

 – Metronidazole 500 mg po BID x 7 days

- Preferred regimen in pregnant women
 – Metronidazole gel 0.75% - 1 applicator full
(5g) intravaginally for 5 days
 Clindamycin cream 2% - 1 applicator full (5g)
IV x 7 days
• Preferred regimen if metronidazole
allergy
RX OF BV
Recurrent disease
 30 % of women will develop recurrence
 Women with more than 3 episodes in one
year
 Suppressive therapy with metro gel 2x/wk x
6 months
TRICHOMONAS VAGINALIS

 Infection with protozoan trichomonas

vaginalis
 Accounts for anywhere b/w 4-35% of cases
of vaginitis
 Sexually transmitted
 incubation period of 4 to 28 days
 organism can be identified in 30 to 40
percent of the male sexual partners
TRICHOMONAS VAGINALIS

Clinical features:
 Purulent, malodorous, thin discharge
 Vaginal burning, pruritis, dysuria,
dyspareunia
 Postcoital bleeding can occur

PE findings:
 Vulvar and vaginal erythema
 Green frothy discharge (10-30%)
 Punctate hemorrhages on cervix
("strawberry cervix," 2 percent of cases).
TRICHOMONAS VAGINALIS

Diagnosis
 – Motile trichomonads on wet mount (50-70%)
 – Ph > 4.5
 – Increased WBC’s on wet mount ( >5 per high

power field)
-Culture on Diamond's medium has a high
sensitivity (95 percent) and specificity (>95
percent
-PcR
-
-
T.V. ON WET MOUNT
COMPLICATIONS
 post-hysterectomy cellulitis
 tubal infertility
 facilitates transmission of the human
immunodeficiency virus
 premature rupture of the membranes and
preterm delivery
TRICHOMONAS

Treatment
 – Metronidazole
 • 2 grams po x one
 • 500 mg po BID x 7 days
 • 85-90% cure rate
 • No alcohol for 24 hrs after treatment
 • Do not use intravaginal therapy
 • Treat partner
 • No intercourse for one week after
treatment completed
ATROPHIC VAGINITIS
Clinical manifestations
 – Vaginal dryness
 – Burning
 – Dyspareunia
 – Vaginal itching
 – Vaginal discharge
 – Vaginal spotting or bleeding
 – Urinary tract symptoms
PELVIC EXAM

 • Loss of pelvic hair

 • Diminished elasticity and turgor of vulvar
skin
 • Urethral prolapse
 • Pale, dry,smooth and shiny vaginal
epithelium
 • Friability of epithelium
TREATMENT

 Local moisturizers and lubricants

 – estrogen therapy
 • Intravaginal therapy
- estrogen ring
– estrogen tablets
– Estrogen cream
 • Dose: 1/8th of applicator q day x one week then
2-3 x per week
 • Progestin not necessary in women on low dose
therapy
 • No estrogen therapy in women with hx of breast
cancer
THANK YOU !