vaginal disgarge
TRANSCRIPT
VAGINAL
DISCHARGEDR.TARIG MAHMOUD
MD SUDAN
HAIL UNIVERSITY KSA
TWO TYPE
Physiological
CAUSES OF PHYSIOLOGICAL VAGINAL DISCHARGE
Result mainly from cervical secretion in response to hormonal levels during the menstrual cycle there is increased mucous production from the cervix at the time of ovulation .
Physiological discharge usually white
Physiological discharge increase during pregnancy and oral contraceptive users.
Causes of vaginal discharge1. Candidal
infection
2. Bacterial
vaginosis
3. Trichomonas
4. N. gonorrhea
5. Chlamydia
6. Cervical
ectropin
7.Endometrial
cancer
8.Cervical cancer
9.Vaginal cancer
10.Foreign body,
IUD, vaginal ring
CANDIDAL VULVOVAGINOSIS
Candida albicans is a diploid fungus and is a
common commensal in the gut flora.
Predisposing factors:
DM
Pregnancy
HIV
Immunosuppression drug
Oral contraceptive pill
Antibiotics
hormone replacement therapy
S IGNS AND SYMPTOMS
Vulvar itching
White cheesy vaginal discharge that
adheres to vaginal wall
Superficial dyspareunia and dysuria.
Vulval oedema, vulval excoriation,
redness and erythema.
Normal vaginal pH.
Diagnosisdirect microscopy[budding yeast]
Vaginal swap and culture
TreatmentAvoid local irritant soaps, perfumes and
synthetic underwear.
Topical or systemic imidazoles
[clotrimazole,econazole & miconazole.]
nystatin cream or pessary
There is no evidence to treat the asymptomatic male partner
RECURRENT INFECTION
Recurrent infection is defined as at least four
episodes of infection per year
Commonly treated by fluconazole 150 mg given
in three doses orally every 72 hours followed by
a maintenance dose of 150 mg weekly for six
months.
PREGNANCY AND CANDIDA
There is no evidence of any adverse effects
in pregnancy to either the mother or the
baby if treated with topical imidazoles.
The oral imidazoles are contraindicated in
pregnancy.
TRICHOMONAS VAGINALIS
Flagellated protozoon
Affect vagina, urethra ,Para urethral
gland
Transmitted sexually
SIGNS AND SYMPTOMS
Vaginal discharge[froth ,yellow or green
offensive]
Vulval soreness and itching
Dysuria and abdominal discomfort
strawberry cervix
Asymptomatic
D IAGNOSIS
Direct microscopy observation of wet
smear
Culture
TREATMENT
Metronidazol
Treat the partner
BACTERIAL VAGINOSIS
This condition is due to an imbalance in the vaginal micro flora, although the exact mechanisms which result in this change remain uncertain.
It occurs due to the growth and increase in anaerobic species with simultaneous reduction in the lactobacilli in the vaginal flora causing an increase in the vaginal pH making it more alkaline .
The common species involved are Gardnerellavaginalis, Mycoplasma hominis, Bacteroidesspp. and Mobilincus spp.
SIGNS AND SYMPTOMS
1. Asymptomatic carriers
2. Fishy odorous vaginal discharge.
3. More prominent during and following
menstruation
4. Creamy or grayish-white vaginal
discharge commonly adherent to the
wall of the vagina.
COMPLICATION
Post termination endometritis In
pregnancy
Late miscarriage
Preterm labour
Preterm prelabour rupture of the
membrane
Postpartum endometritis
DIAGONOSTIC FEATURES
AMSEL CRITERIA:
1.Presence of clue cells on microscopic
examination
2.Creamy greyish white discharge which is
seen on naked eye examination.
3.Vaginal pH of more than 4.5.
4.Released of a characteristics fishy odour
on addition on alkali 10 per potassium
hydroxide.
There should be at least three criteria for
diagnosis.
HAY/ISON CRITERIA :
Grade1. Normal: Lactobacillus
predominate.
Grade2. Intermediate: Lactobacillus seen
with the presence of Gardnerella and\or
Mobiluncus spp.
Grade3. Bacterial vaginosis: Lactobacilli
absent or markedly reduced with
predominance of Gardnerella and\or
Mobiluncus spp.
NUGENT CRITERIA:
Based on the proportion of anaerobic
species giving a quantitive score between
0 and 10.
Less than 4: Normal
4 to 6: Intermediate
More than 6: Bacterial vaginosis
TREATMENT
Metronidazole 2 gm single dose or 400mg BD
for 7days
Clindamycin 300 mg twice daily or a topical
vaginal cream
PREGNANCY AND BACTERIAL VAGINOSIS
Presence of bacterial vaginosis in the first
trimester can lead to late second trimester
miscarriages and preterm labour.
a previous history of second trimester loss or
preterm delivery should have a vaginal swab
performed in early pregnancy and if bacterial
vaginosis is detected, it should be actively
treated.
GONORRHOEA
Nesseria gonorrhoea is a sexually
transmitted disease caused by the
Gram-negative diplococci.
It infects the mucous membranes of the
endocervical and urethral mucosa.
It can also infect the rectal and the
oropharyngeal mucous membrane
during anal and oral intercourse.
SIGNS AND SYMPTOMS
Asymptomatic
Increased vaginal discharge with lower abdominal/pelvic pain
Dysuria with urethral discharge
Proctitis with rectal bleeding, discharge and pain
Endocervical mucopurulent discharge and contact bleeding
Mucopurulent urethral discharge
Pelvic tenderness with cervical excitation.
DIAGNOSTIC TESTS
Endocervical swabs should be taken
Gram staining: visualization of Gram-
negative intercellular diplococci .
Culture medium using an agar medium
containing antimicrobials to reduce
growth of other organisms.
Nucleic acid amplification tests (NAATs)
Nucleic acid hybridization tests
TREATMENT
It is more important to screen both
partners and refer them to a
genitourinary medicine (GUM) clinic.
Contact tracing should be encouraged if
there is exposure to multiple partners.
They should be counseled regarding the
long-term implications of the infections
leading to chronic pelvic pain, tubal
infection and subfertility.
ANTIBIOTIC TREATMENT
Cephalosporins are the mainstay of treatment.
1. Single oral dose of cefixime 400 mg
2. Single intramuscular dose of ceftriaxone 250 mg
Single intramuscular dose of spectinomycin 2 g
Single oral dose of ciprofloxacin 500 mg or ofloxacin 400 mg
Ampicillin 2 g or amoxycillin 1 g with probenecid 2 gm as a single oral dose.
PREGNANCY AND GONORRHOEA
In pregnancy, it is safe to use the
penicillins and cephalosporins, but
tetracycline and ciprofloxacin/ofloxacin
should be avoided.
GENITOURINARY CHLAMYDIA
Chlamydia is an obligate intercellular
bacterium affecting the columnar
epithelium of the genital tract.
It causes one of the most common
sexually transmitted infections.
SIGNS AND SYMPTOMS
Asymptomatic
Vaginal discharge and lower abdominal
pain
Postcoital bleeding
Intermenstrual bleeding
Mucopurulent cervical discharge with
contact bleeding
Dysuria with urethral discharge
COMPLICATIONS
1.Pelvic inflammatory disease
Ectopic pregnancy
Infertility
Chronic pelvic pain
2.Perihepatitis: Fitz-Hugh-Curtis syndrome
3.Neonatal conjunctivitis and pneumonia
4.Adult conjunctivitis
5. Reiter’s syndrome: reactive arthritis
DIAGNOSTIC TESTS
1. Nucleic acid amplification technique:>90
per cent sensitive, should replace the old
enzyme immunoassays .
2. Real-time polymerase chain reaction
3.Culture is expensive with limited
availability. It is only around 60 per cent
sensitive, hence not routinely
recommended.
SCREENING AND APPORTUNISTIC
TESTING
1.Partners of patients diagnosed or
suspected with infection
2.History of chlamydia in the last year
3.Patients attending GUM clinics
4.Patients with two or more partners within
12months
5.Women undergoing termination of
pregnancy
6.History of the other sexually transmitted
infection and HIV.
TREATMENT
refer them to a genitourinary medicine
(GUM) clinic
Contact tracing should be encouraged if
there is exposure to multiple partners
General advice avoid intercourse, before
treatment of both partners is complete.
ANTIBIOTIC TREATMENT
1. Doxycycline 100mg orally twice a day x
7days
2.Azithromycin 1g orally in a single dose
3. Erythromycin 500mg orally four times a
day x 7days
4.Amoxicillin 500mg three times a day x
7days
5.Ofloxacin 200mg orally twice a day x
7days.
VAGINAL SWABS
PRE-PROCEDURE:
Consultation (medical history, explain
procedure & counsel)
Gain consent & offer a chaperone.
Prepare: Empty bladder, provide privacy,
dorsal position, position light, attend
hand hygiene & apply gloves / eye
protection
PROCEDURE
Inspect the labia, external meatus & vulva; Insert speculum
High Vaginal Swab(HVS): Swab, make smear on glass slide & place in charcoal medium.
Endo Cervical Swab(ECS): Pap smear first (if required), then clean mucous from cervix & take ECS PCR swab & place in tube. If pus/ inflammation of cervix, take ECS for culture, smear on glass slide & place in charcoal medium
Low Vaginal Swab & Rectal swab(LVS):
May be self-obtained by the woman if
asymptomatic.
LVS: Insert swab 1-2 cm into vagina & place
into transport tube (use charcoal medium
tube for culture & a separate thin plastic/
wire shaft swab if PCR).
Rectal: Around/inside rectum just past
external sphincter & place into charcoal
tube.
POST PROCEDURE
Provide privacy for redressing.
Offer tissues as required.
Document: Procedure, consent, persons
attending examination (e.g. chaperone,
family), swab details (swab site, date,
time, patient details- but sticker or hand
write on glass slides)
Send specimens to pathology
Thank you for attention