lecture for medical students

1. VAGINAL
DISCHARGE
DR.TARIG MAHMOUD
MD SUDAN
HAIL UNIVERSITY KSA

2. TWO TYPE
Physiological

3. 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.

4. 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

5. 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

6. SIGNS 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.

7. Diagnosis
 direct microscopy[budding yeast]
 Vaginal swap and culture
Treatment
 Avoid 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

8. 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.

9. 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.

10. TRICHOMONAS VAGINALIS
 Flagellated protozoon
 Affect vagina, urethra ,Para urethral
gland
 Transmitted sexually

11. SIGNS AND SYMPTOMS
 Vaginal discharge[froth ,yellow or green
offensive]
 Vulval soreness and itching
 Dysuria and abdominal discomfort
 strawberry cervix
 Asymptomatic

12. DIAGNOSIS
 Direct microscopy observation of wet
smear
 Culture
TREATMENT
 Metronidazol
 Treat the partner

13. 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 Gardnerella
vaginalis, Mycoplasma hominis, Bacteroides
spp. and Mobilincus spp.

14. 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.

15. COMPLICATION
 Post termination endometritis In
pregnancy
 Late miscarriage
 Preterm labour
 Preterm prelabour rupture of the
membrane
 Postpartum endometritis

16. 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.

17. HAY/ISON CRITERIA :
 Grade1. Normal: Lactobacillus
predominate.
 Grade2. Intermediate: Lactobacillus seen
with the presence of Gardnerella andor
Mobiluncus spp.
 Grade3. Bacterial vaginosis: Lactobacilli
absent or markedly reduced with
predominance of Gardnerella andor
Mobiluncus spp.

18. 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

19. TREATMENT
 Metronidazole 2 gm single dose or 400mg BD
for 7days
 Clindamycin 300 mg twice daily or a topical
vaginal cream

20. 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.

21. 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.

22. 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.

23. 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

24. 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.

25. 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.

26. PREGNANCY AND GONORRHOEA
 In pregnancy, it is safe to use the
penicillins and cephalosporins, but
tetracycline and ciprofloxacin/ofloxacin
should be avoided.

27. 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.

28. SIGNS AND SYMPTOMS
 Asymptomatic
 Vaginal discharge and lower abdominal
pain
 Postcoital bleeding
 Intermenstrual bleeding
 Mucopurulent cervical discharge with
contact bleeding
 Dysuria with urethral discharge

29. 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

30. 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.

31. 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.

32. 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.

33. 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.

34. VAGINAL SWABS

35. 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

36. 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

37.  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.

39. 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

40. Thank you for attention