1. ALTERED VAGINAL
DISCHARGE
Dr.Jyoti Bhaskar MD MRCOG
Consultant
Lifecare Centre
Pushpanjali Crosslay Hospital
Lecture – 2 (2012)

2. Sources
 Management of Vaginal Discharge in Non-
Genitourinary Medicine Settings
FSRH and BASHH Guidance (February 2012)
 UK National Guideline for management of Bacterial
vaginosis 2012 BASHH Guidance
 UK National Guideline for management of
trichomoniasis vaginalis 2007 BASHH Guidance
 UK National Guideline for management of
Vulvovaginal candidiasis 2007 BASHH Guidance
 CDC Diseases characterised by Vaginal Discharge
2010 STD treatment Guideline

3. Clinician’s Office
 determined by pH,
 a potassium hydroxide (KOH) test,
 microscopic examination of fresh
samples of the discharge
1. one to two drops of 0.9% normal saline
2. second sample in 10% KOH solution

4. Microscopy
 WET FILM
1. Trichomonas or Clue cells
2. WBC in absence of these – Cervicitis
 KOH
1. fishy smell – BV or TV
2. Spores or psuedohyphae

5. Common Causes
 Infective (non-sexually transmitted)
 o Bacterial vaginosis
 o Candida
 Infective (sexually transmitted)
 o Chlamydia trachomatis
 o Neisseria gonorrhoeae
 o Trichomonas vaginalis
 o Herpes simplex virus
 Non-infective
 o Foreign bodies (e.g. retained tampons, condoms)
 o Cervical polyps and ectopy
 o Genital tract malignancy
 o Fistulae
 o Allergic reactions.
Management of Vaginal Discharge in Non-Genitourinary Medicine Settings
FSRH and BASHH Guidance (February 2012)

6. Bacterial Vaginosis

7. Bacterial vaginosis
Commonest cause of AVD in reproductive
age group
5% in asymptomatic college students to as
high as 50% in rural uganda.
UK – 12% in pregnant women,30% in
women TOP

8. Bacterial vaginosis
Gardnerella vaginalis, Mycoplasma
hominis, Bacteroides species, and
Mobiluncus species. Found at numbers
100 to 1000 times greater than found in
the healthy vagina.
In contrast, Lactobacillus bacteria are in
very low numbers or completely absent .
.

9. Risk Factors
Vaginal douching
Black Race
Recent change of partners
Smoking
STI – Chlymadia or Herpes
Described in Virgins
It is not considered a sexually transmitted disease although
it can be acquired by sexual intercourse

10. Clinical Manifestations
About 50% of women with BV do not
have symptoms
Offensive, fishy-smell which is
stronger after sexual intercourse and
menses,
Thin, milky-white or gray vaginal
discharge.
Not associated with soreness, itching
or irritation

11. Bacterial vaginosis Diagnosis
 "Amsel's criteria" if three of the following four
criteria were present
 a thin, milky white discharge that clings to the
walls of the vagina,
 presence of a fishy odor (a positive amine test)
 a vaginal pH of > 4.5,
 and the presence of "clue cells" in the vagina.
 Those with one or two criteria were classified as
having a disturbance of vaginal flora

12. Gram stained vaginal smear – Hay/Ison or
Nugent criteria ( Gold Standard)
Isolation of GV alone cannot be used to
diagnose BV
OSOM BVBlue, Pip Activity Testcard
,Affirm VP 111

13. Bacterial Vaginosis

15. Treatment
Indications:
1. Symptomatic women
2. Women undergoing surgical procedures

16. Recommended Regimens
 Metronidazole 400 mg twice daily 5-7 days
 Metronidzole 2 gm single dose
 Intravaginal metronidzole gel (0.75%) once daily
for 5 days
 Intravaginal clindamycin cream (2%) once daily
for 7 days
Alternate Regimens
 Tindazole 2G single dose,1 gm daily for 5 days
 Clindamycin 300 mg twice daily for 7 days

17. Caution
 Alcohol to be avoided
Clindamycin cream is oil based – weakens
latex condoms for 5 days after use

18. Rationale
70-80% cure rate after 4 weeks
MNZ – 2 gm dose is less effective
Intravaginal Mnz and clindamycin are
equally effective
 MNZ – has advantage as less active
against lactobacilli
No recommendation for use of probiotic
lactobacilli or lactic acid preparations

19. Special situations
 Allergy to MNZ
 Pregnancy
1. No evidence of teratogenicity with MNZ use in
first trimester.
2. Symptomatic women to be treated in the same
way.
3. Asymptomatic pregnant wn found to have BV ==
insufficient evidence
4. Additional risk factors – may benefit if Rx before
20 weeks

20. CDC recommendation
Metronidazole 500 mg orally twice a day
for 7 days
Metronidazole 250 mg orally three times
a day for 7 days
Clindamycin 300 mg orally twice a day
for 7 days
Intravaginal clindamycin cream might be
associated with adverse outcomes if used
in the latter half of pregnancy( 20 wks)

21. Special Situations
 Breast feeding
1. Avoid high dose of MNZ
2. Prudent to use intravaginal clindamycin for treatment.
 TOP
Support screening for and treating BV to reduce
subsequent endometritis and PID
 HIV
Risk factor for female to male transmission- Supress
BV or treat recurrence rapidly

22.  Sexual Partners
1. Routine screening and treatment of male
partners not indicated
2. High incidence of BV in female partners of
lesbians of BV
 Follow up
A test of cure is not required if symptoms
resolve.

23. Candidal Vaginitis

24. Candidal Vaginitis
Approximately 75% of sexually active
women suffer at least one episode of
Candida vaginitis.
10% of them have recurrent episodes.
 Saporiti AM, Rev Argent Microbiol. 2001

25. Candidal Vaginitis
 Species identified:
 C. albicans 87.5%,
 C. glabrata 8.6%
 C. krusei, C.famata, C.tropicalis &
S.cerevisiae - 3.9%
 Fluconazole resistant C. albicans were
isolated in 13.46% of the cases
 Saporiti AM, Rev Argent Microbiol. 2001

26. Predisposing factors
 C.albicans is a natural inhabitant of the
vagina.
1.Use of antibiotics
2.Uncontrolled DM, HIV/AIDS (decrease immunity)
3.During pregnancy due to increase vagina acidity &
increase glycogen content.
4.Use of oral contraceptive pills.
5.Young age at first intercourse, frequent intercourse
& oral sex.
6.Tight fitting clothes, deodorants ,vaginal
contraception have also been reported to increase
incidents.

27. Clinical Manifestations
 Symptoms –
Vulval Itch, soreness, Vaginal discharge
Superficial dyspareunia, external dysuria
 Signs –
Erythema,Fissuring,Curdy white non offensive
discharge, Oedema, excoriation
None of this is pathognomic, corroborative
evidence of laboratory must be sought.

28. Diagnosis
 Routine microscopy and culture is
standard
 Vaginal Swab from anterior fornix
1. Gram or wet film
2. Directly plated to solid fungal media.

29. Candidal Vaginitis

31. Management
 All topical and oral azole therapies give
80% cure rate
 Topical Azole therapies can cause
vulvovaginal irritation
 Sexual partners – No treatment required
for asymptomatic partners
 Follow up – Unneccessary if symptoms
resolve

32. Topical Azoles
1. Clotrimoxazole pessary- 500 mg stat,200mg x
3days,100mg x6nights, Vaginal cream(10%) 5gm stat
2. Econazole pessary 150 mg stat, 150 mg x 3 nights
3. Fenticonazole pessary –200 mg x 3days, 600 mg stat
4. Miconazole- 1.2 g stat ,100 mg x14 nights
5. Nystatin vaginal cream (100,00 u) 4g x 14 nights,pessary
1-2 x14 nights
6. Tioconazole 6.5% ointment 5 g intravaginally in a single
application
ORAL
Fluconazole 150 mg stat
Itraconazole 200mg BD x 1day

33. Pregnancy
Asymptomatic women do not need to be
treated..
No one topical imidazole is better than
other
Longer courses are needed. 7 day course
cures over 90% .
Oral therapy is contraindicated.

34. NON ALBICANS VVC
longer duration of therapy (7–14 days)
with a nonfluconazole azole drug (oral or
topical)
If recurrence occurs,600 mg of boric acid
in a gelatin capsule is recommended,
administered vaginally once daily for 2
weeks.

35. Trichomoniasis Vaginalis

36.  Flagellated Protozoan
 Vagina, urethra and
paraurethral glands
 Urinary tract is site of
sole infection in
5%,urethritis is
present in 90% of
episodes
 Exclusively Sexually
Transmitted

37. RISK FACTORS
More number of sexual partners
5 years or more of sexual activity
H/o gonorrhoea or other S.T.I.s
Early coitarche
Bad hygienic habits
Chronic asymptomatic infections can
persist for several decades

38. Clinical Manifestations
 10-50% are symptomatic
 Vulvovaginal irritation, dysuria
 70% vaginal discharge , classical discharge
(Copious, yellow-gray or green, homogeneous
or frothy, malodorous) in 10-30%
 Elevated pH level (> 4.5)
 Vulvitis and vaginits
 2% strawberry cervix
 5-15% no abnormality

39. Diagnosis
 Wet mount smear – 70% sensitive
 Culture techniques – gold standard (Diamond
TYM medium)
 FDA-cleared tests – OSOM trichomonas rapid
test, Affirm VP 111
 PCR based 100% sensitive
 Cervical cytology – 58% sensitive
Site sampled
1. Swab from posterior fornix
2. Self administered swab

40. Trichomonas vaginalis
Presence of mobile, flagellated organisms and
leukocytes on wet-mount microscopic evaluation

41. Management
 General Advice
1. Treat sexual partners together
2. Avoid intercourse till both have
completed treatment and follow up
 Screening for STI in both partners
Spontaneous cure rate in 20-25%

42. Recommended Regimens
Metronidazole 2gm orally single dose
Metronidazole 400-500 mg twice daily for
5-7 days
Alternate regimen
Tinidazole 2 gm orally single dose
Caution
Alcohol consumption to be avoided

43. Treatment failure
 Check compliance and rule out vomiting
of metronidazole
 Check possibilty of re infection
 Check partner has been treated
1. If pt’s fail to respond to first course, rpt
course of standard treatment
2. Use of antibiotics like erythromycin or
amoxy before retreating with MNZ

44. 3. Higher dose of MNZ
MNZ 400 mg TDS with MNZ 1 gm PR
daily for 7 days
MNZ 2 gm daily for 3-5 days
Higher doses of Tinidazole 2gm twice
daily for 2 weeks

45. Special situations
 Sexual Partners
Screen for full range of STI and treat for TV
 TV in children
Acquired perinatally -5%
Infection beyond first year – Sexual abuse
 HIV
Screening for TV at entry and annually
Longer teatment regimens with oral MNZ, Follow up
 Follow up
Test of cure only if remains symptomatic or symptoms
recur.

46. COMMON RTI’s

47. Syndromic approach to diagnosis
& treatment of AVD
Diagnosis

49. Dietary modification and nutritional supplementation
 Antioxidant vitamins, including A, C, and E, as well
as B complex vitamins, and vitamin D, are
recommended.
 A well-balanced diet low in fats, sugar, and refined
foods include cheese, alcohol, chocolate, soy
sauce, sugar, vinegar, fruits, and any fermented
foods
 Lactobacillus acidophilus can be taken orally in the
form of acidophilus yogurt, or in capsules or
powder. It can also be administered vaginally.

50.  Don't douche.
 Use medication as long as directed.
 Avoid sexual intercourse until treatment is
completed and you are symptom free.
 Don’t scratch infected or inflamed area; it can
cause further irritation.
 If using medication inside the vagina, use it
during the menstrual period.

51.  During an infection, use pads rather than
tampons if menstruation occurs.
 Avoid vulvovaginal irritants, including perfumed
or deodorant soaps/body washes.
 If symptoms persist after completing the
treatment, an exam is indicated. Call for an
appointment, and please use nothing in the
vagina for 48 hours prior to your examination by
doctor.

52. Conclusion
 Correct diagnosis is necessary before therapy.
 Careful history, examination, and laboratory
testing to determine the etiology of vaginal
complaints are warranted.
 Diagnosis can be accomplished by a
microscopic examination in 90% of the cases
in Clinician’s office.
 The cytologic smear is also very important.
 Complete treatment initially may help prevent
recurrent form of the disease and growth of
resistant strains.

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