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vaginal discharge

Etiology: 1) hormonal (physiologic) 2) infectious a) bacterial 1] Chlamydia 2] Neisseria gonorrhoeae 3] Mycoplasma 4] Ureaplasma 5] Escherichia coli 6] group B streptococci b) yeast: Candida albicans* (vulvovaginal candidiasis) c) viral 1] Herpes simplex 2] papillomavirus d) Trichomonas vaginalis* e) Enterobius vermicularis (pinworms) 3) retained foreign body a) tampon b) contraceptive sponge c) diaphragm d) cervical cap 4) contact sensitivity/ allergic response a) contraceptives: spermicides & condoms b) deodorant in tampons c) medications d) douches e) perfume in menstrual pads, toilet paper & feminine deodorant products * normal flora of the female genital tract History: - onset, color, consistency, odor, pruritus, last menstrual period, sexual activity, contraception, self treatment Physical examination: - pelvic examination - evaluate vaginal walls for vaginitis - evalulate cervix for cervicitis - assess cervical motion tenderness Clinical manifestations: 1) urinary symptoms + vaginal discharge suggests a) Chlamydia trachomatis b) Trichomonas vaginalis [2] 2) fishy odor suggests bacterial vaginosis 3) erythema of the labia suggests Candida or contact sensitivity 4) Edema of the labia suggests Candida or contact sensitivity 5) grayish white vaginal discharge suggests bacterial vaginosis 6) white, curdy discharge suggests Candida albicans 7) grayish-yellow discharge suggests Trichomonas vaginalis 8) a retained object may be visible in the vagina 9) yellow exudate suggests cervicitis Laboratory: 1) saline wet mount a) many WBC suggests inflammatory process b) Clue cells suggest bacterial vaginosis c) motile Trichomonas may be seen 2) KOH (10%) slide a) a fishy odor of amines upon alkalinization suggests bacterial vaginosis b) hyphae and budding forms of Candida may be visible after warming & allowing debris to disintegrate 3) pH (measured with pH paper) a) normal pH = 4.0-4.5 b) pH > 4.5 suggests bacterial vaginosis c) pH 5-7: also consider Trichomonas vaginalis d) pH 6.5-7.5: consider atrophic vaginitis in post-menopausal woman 4) culture a) Nickerson's media for Candida albicans b) Tricult or Diamond's media for Trichomonas vaginalis c) chocolate agar for Neisseria gonorrhoeae d) Herpes simplex e) other aerobic & anaerobic bacteria as indicated 5) immunofluorescence for Chlamydia 6) DNA probes for Chlamydia, Neisseria gonorrhoeae & papillomavirus 7) colposcopy a) condylomatous lesions visualized on perineum b) no cause found in persistent or recurrent vaginitis Management: 1) specific therapy for specific etiology - distinguish cervicitis from vaginitis (treatments differ) 2) evaluate & treat sexual partner if indicated 3) pharmaceutical agents 1) bacterial vaginosis - metronidazole 250 mg PO TID or 500 mg PO BID or vaginal application BID for 7 days - clindamycin 300 mg PO BID or vaginal application QD for 7 days - ofloxacin 300-400 mg PO BID for 7 days - amoxicillin 250 mg PO TID for 7 days (pregnant) - ampicillin 500 mg PO QID for 7 days (pregnant) 2) Candida albicans - Monistat, Terazol, Gyne-Lotrimin, Femstat, Mycostatin - suppository: 1 vaginally for 1-7 days - cream: apply daily for 7-14 days - Nizoral 200 mg PO BID for 14 days - fluconazole 150 mg PO single dose 3) Trichomonas vaginalis - metronidazole - 250-500 mg PO TID for 7 days - 2 grams PO single dose for partner 4) atrophic vaginitis - estrogen cream 1-4 grams vaginally for 7 days, then weekly to maintain symptom relief 4) patient education - use of condoms to avoid transmission of infectious disease - loose-fitting cotton crotched underwear for recurrent yeast infection - avoid offending agents - prompt removal of contraceptive devices from vagina at earliest & safest time - frequent change of tampon during menses & removal before sleep 5) follow-up: reculture for sexually transmitted disease

Related

vaginitis

Specific

leukorrhea

General

sign/symptom discharge (d/c) vaginal disorder

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 392-394
  2. Medical Knowledge Self Assessment Program (MKSAP) 14, American College of Physicians, Philadelphia 2006