Vaginal Discharge

1. APPROACH TO PATIENT WITH
VAGINAL DISCHARGE

2. OBJECTIVES
• Introduction
• Normal vaginal discharge
• Important history
• Symptoms and signs
• Diagnosis
• Treatment
• Case presentation

3. INTRODUCTION
• Vaginitis is the general term for disorders of the vagina
caused by infection, inflammation, or changes in the
normal vaginal flora.
• Around 90% of vaginitis is caused by infection, mainly
bacterial vaginosis, vulvovaginal candidiasis, and
trichomoniasis.
• These 3 diagnoses should be excluded in all patients
before considering other less common causes.

4. • Less common causes include:
vaginal atrophy/atrophic vaginitis, cervicitis, foreign body,
irritants and allergens, and several rarer entities, including
some systemic medical disorders.

5. NORMAL
• In reproductive aged women, normal vaginal discharge
consists of 1 to 4 mL fluid (per 24 hours), which is white or
transparent, thick or thin, and mostly odorless.
• This physiologic discharge is formed by mucoid endocervical
secretions in combination with sloughing epithelial cells,
normal vaginal flora, and vaginal transudate.
• The discharge may become more noticeable at times
(“physiological leukorrhea”), such as at midmenstrual cycle
close to the time of ovulation or during pregnancy or use of
estrogen-progestin contraceptives.

6. • Diet, sexual activity, medication, and stress can also
affect the volume and character of normal vaginal
discharge.

7. HISTORY
In a patient presenting with a complaint of ongoing vaginal
discharge, the initial history should include:
• Any new sexual partnerspartner symptomatic
• Use of new soaps or detergents
• Douching
• Contraceptive vaginal ring or IUD use
• Symptoms such as pelvic pain, itching,
quality/quantity/odour of discharge.

8. SYMPTOMS
• Change in the volume, color, or odor of vaginal
discharge
• Pruritus
• Burning
• Irritation
• Erythema
• Dyspareunia
• Spotting
• Dysuria
• Abdominal pain
• Fever

9. SYMPTOMS

10. PHYSICAL EXAMINATION
• The vulva usually appears normal in bacterial vaginosis
• whereas erythema, edema, or fissures suggest
candidiasis, trichomoniasis, or dermatitis.
• Atrophic changes are caused by hypoestrogenemia, and
suggest the possibility of atrophic vaginitis.
• Changes in vulvovaginal architecture (eg, scarring) may
be caused by a chronic inflammatory process, such as
erosive lichen planus, as well as lichen sclerosis, or
mucous membrane pemphigoid, rather than vaginitis.

11. • A foreign body (eg, retained tampon) is easily detected
and is often associated with vaginal discharge,
intermittent bleeding or spotting, and/or an unpleasant
odor due to inflammation and secondary infection.
• Removal of the foreign body is generally adequate
treatment. Antibiotics are rarely indicated.

12. • Vaginal warts are skin-colored or pink, and range from
smooth flattened papules to a verrucous, papilliform
appearance
• When extensive, they can be associated with vaginal
discharge, pruritus, bleeding, burning, tenderness, and
pain.
• Punctate hemorrhagic areas or the so-called "strawberry
cervix" are pathognomonic for trichomoniasis

13. • The presence of multifocal rounded macular
erythematous lesions (like a spotted rash or bruise),
purulent discharge, and tenderness suggests erosive
vulvovaginitis, which can be caused by trichomoniasis or
one of several noninfectious inflammatory etiologies

14. • Necrotic or inflammatory changes associated with
malignancy in the lower or upper genital tract can result
in vaginal discharge; spotting is more common in this
setting than in infectious vaginitis.
• Bimanual examination should be done to check for any
cervical motion tenderness or adnexal tenderness which
suggest PID.

15. CLINICAL SIGNS

16. CLUES FOR DIAGNOSIS
• A lack of itching makes diagnosis of vulvovaginal candidiasis
unlikely .
• Presence of inflammatory signs is more commonly associated
with vulvovaginal candidiasis.
• Lack of odor is associated with vulvovaginal candidiasis.
• Presence of a fishy odor on examination is predictive of
bacterial vaginosis.
• A lack of perceived odor makes bacterial vaginosis unlikely.

17. DIAGNOSIS
• Individual symptoms and signs, pH level, and
microscopy results often do not lead to an accurate
diagnosis of vaginitis.
• Laboratory tests perform better than standard office-
based evaluation for diagnosing causes of vaginitis, but
they do not add substantially to the treatment threshold
and are justified only in patients with recurrent or difficult-
to-diagnose from symptoms

18. CANDIDIASIS
• Candida species are the most common cause of
symptomatic vaginal discharge.
• Risk factors:
glucosuria, diabetes mellitus, pregnancy, obesity, recent
use of antibiotics, corticosteroids, or immunosuppressive
agents.

19. • Despite elimination of all predisposing factors, some
women continue to experience episodes of recurrent,
symptomatic vaginal candidiasis.
• Candidiasis is not a sexually transmitted disease.

20. DIAGNOSIS
• microscopic examination of vaginal secretions with a
10% potassium hydroxide solution thus it is helpful for
identifying hyphae and budding yeast for the diagnosis of
candidal vaginitis pseudohyphae.
• Vaginal pH is usually normal (4.0 to 4.5).
• Vaginal culture should be considered in recurrently
symptomatic women with negative microscopy and a
normal pH.

22. TREATMENT
• Candidiasis can be classified as uncomplicated or
complicated.
Patients with uncomplicated vulvovaginal candidiasis:
• Mild to moderate disease
• Fewer than four episodes of candidiasis per year
• Pseudohyphae or hyphae visible on microscopy.

23. Treatment of uncomplicated vulvovaginal candidiasis:
• Clotrimazole 100 mg vaginally tab vaginally HSx7 days
or HSx2 weeks ,, 200 mg vaginally HSx3 days or
Clotrimazole 500 mg tab vaginally single dose
• Clotrimazole 2% cream 5 g intravaginally once daily for
three days
• Nystatin 100,000 unit tab OD for 2 weeks.

24. Patients with complicated vulvovaginal candidiasis have
one or more of the following:
• Moderate to severe disease
• Four or more episodes of candidiasis per year
• Only budding yeast visible on microscopy
• Adverse host factors (e.g., pregnancy, diabetes mellitus,
immunocompromise).
• Needs an intensive, longer course of antifungals

25. • Initial regimen
Any topical agent for seven to 14 days
Fluconazole 100, 150, or 200 mg orally once daily every
third day for three doses
• Maintenance regimen
Fluconazole 100, 150, or 200 mg orally once weekly for six
months
• Pregnancy:
Any topical azole
Intravaginally once daily for seven days

26. BACTERIAL VAGINOSIS
• 37%- 64% of women presenting to sexually transmitted
disease clinics for treatment of other infections; two-
thirds of these women were assymptomatic.
• Bacterial vaginosis is associated with late miscarriages,
premature rupture of membranes, and preterm birth.
• Although there is an association with sexual activity, it is
not a sexually transmitted infection.

27. DIAGNOSIS
In clinical practice, bacterial vaginosis is diagnosed by the
presence of three out of four Amsel criteria:
• Thin, homogenous vaginal discharge
• Vaginal pH greater than 4.5
• Positive whiff test (fishy amine odor when 10 percent
potassium hydroxide solution is added)
• At least 20 percent clue cells (vaginal epithelial cells with
borders obscured by adherent coccobacilli on wet-mount
preparation or Gram stain.

29. TREATMENT
• Metronidazole (Flagyl)
500 mg orally twice daily for seven days
• Clindamycin 300 mg orally twice daily for seven days
• Metronidazole gel (Metrogel)
One full applicator (5 g) intravaginally once daily for five days
• Clindamycin 2% cream
One full applicator (5 g) intravaginally at bedtime for seven days

30. Pregnancy
• Metronidazole 500 mg orally twice daily for seven days
• Metronidazole 250 mg orally three times daily for seven
days
• Clindamycin 300 mg orally twice daily for seven days

31. TRICHIMONIASIS
• T. vaginalis accounted for up to 25% of all clinically
significant vaginal infections in the United States.
• Up to 50% of women with positive cultures for T.
vaginalis are assymptomatic.
• The most consistently described risk factors associated
with trichimoniasis are increased level of sexual activity
and multiple sexual partners

32. • Symptoms and signs of trichomoniasis are not specific,
and diagnosis by microscopy is more reliable.
• Features suggestive of trichomoniasis are :
trichomonads seen in wet mount test, leukocytes more
numerous than epithelial cells
positive whiff test
vaginal pH greater than 5.
 purulent, foul-smelling, thin discharge

34. TREATMENT
• A single 2-g dose of metronidazole is adequate.
• Metronidazole in a dosage of 500 mg twice daily for
seven days will treat bacterial vaginosis and
trichomoniasis.
• Metronidazole in a dosage of 2 to 4 g daily for seven to
14 days is recommended for metronidazole-resistant
strains

35. • Sexual partners should be treated simultaneously.
• To reduce recurrence, partners should avoid resuming
sexual intercourse until both have completed treatment
and are asymptomatic.

36. Any women with new or multiple sexual partners,
a symptomatic sexual partner, or an otherwise
unexplained cervical or vaginal discharge ,should
be tested for the presence of other sexual
transmitted infections (chlamydia and gonorrhea) ,
by culture or an alternative sensitive test.

37. CHLAMYDIA
• The most common bacterial STD in the United States.
• The prevalence of chlamydial infections has ranged from
3% in assymptomatic sexually active women to 40% in
women screened in STD clinics.
• The most common symptom is a mucopurulent
discharge associated with dysuria and lower abdominal
discomfort

38. • Diagnosis of the infection depends entirely on culture.
• screening cultures must include urethral and
cervical specimens.
Treatment:
• Azithromycin (Zithromax), 1 g (single dose)
or
• Doxycycline 100 mg orally BIDx7 days
• Other alternative , Tetracycline 500 mg orally QlDx7 days

39. In pregnancy:
• Azithromycin, 1 g (single dose)
or
• Amoxicillin, 500 mg three times daily for seven days

40. • Partners who had sexual contact with patient within 60
days before a diagnosis was made or at the onset of
symptoms , should be treated.
• Patients should also be instructed to abstain from sexual
intercourse until seven days after a single-dose regimen
or after completion of a multiple-dose regimen, and after
their partner has also completed treatment.

41. GONORRHEA
• In men, uncomplicated urethritis is the most common
manifestation, whereas in women, less than one-half of
cases produce symptoms (such as vaginal discharge
and dyspareunia).
Treatment:
• cephalosporin ( ceftriaxone, 125mg by intramuscular
injection, as a single dose or cefixime, 400mg orally, as a
single dose.
• plus either azithromycin or doxycycline
• Treat along with chlamydia as they coexist .

42. CASE PRESENTATION
• 24-year-old single female who presented with complaints
of a smelly, yellow vaginal discharge and slight dysuria
for one week.
?History

43. • Denies vulvar itching, pelvic pain, or fever
• Has had 2 sex partners over the past 6 months—did not
use condoms with these partners—on oral
contraceptives for birth control

44. • Physical Exam
• Vital signs: blood pressure 112/78, pulse 72, respiration 15,
temperature 37.3° C
• Abdominal exam NAD.
• Normal external genitalia with a few excoriations near the
introitus, but no other lesions
• Speculum exam reveals a moderate amount of frothy,
yellowish, malodorous discharge, without visible cervical
mucopus or easily induced cervical bleeding
• Bimanual examination was normal without uterine or adnexal
tenderness

45. • Whatdo you thinkthe cause?
• Do you wantto do any thingmore?

46. • Vaginal pH—6.0
• Saline wet mount of vaginal secretions—numerous
motile trichomonads and no clue cells
• KOH wet mount—negative for budding yeast and
pseudohyphae
How are you goingto treat her?

47. • metronidazole 2 g orally, and she was instructed to
abstain from sexual intercourse until her current partner
was treated.

48. REFERENCES
• Vaginal Discharge: An Approach to Diagnosis and
Management, William J. Watson, MD, CCFP Gregory DeMarchi, MD, CCFP
• Vaginosis daignosis and treatment . AFP
• Chlamydia Trachomatis Infections: Screening,
Diagnosis, and Management . AFP
• Approach to women with symptoms of vaginitis , Up-To-
Date.

49. THANK YOU