Vaginal
Discharge
Vaginal
discharge is a common presenting symptom in any physician’s office. Vaginal
discharge may be physiological or pathological. Although abnormal vaginal
discharge often prompts women to seek screening for sexually transmitted infections
(STIs), vaginal discharge is poorly predictive of the presence of an STI.1Clinicians
need to be aware of emerging epidemiological data, the different presentations
of vaginal discharge, and how to approach their management so that the symptom
can be treated according to its aetiology.2
Vaginal
discharge is a common gynaecological condition among women of childbearing age
that frequently requires care. It derives from physiological secretion of
cervical and Bartholin’s glands and desquamation of vaginal epithelial cells
resulting from bacterial action in the vagina.3The
amount of mucus produced by the cervical glands varies throughout the menstrual
cycle. Vaginal discharge that suddenly differs in colour, odour, or
consistency, or significantly increases or decreases in amount, may indicate an
underlying problem like an infection.4 Increased amount of vaginal
discharge can be due to emotional stress, ovulation, pregnancy or sexual
excitement.
Aetilogy
Physiological
Discharge
Many
women have what they perceive as an abnormal vaginal discharge at some point in
their lives, but usually it is just a normal physiological discharge. This is a
white or clear, non-offensive discharge that varies with the menstrual cycle. The
quality and quantity of vaginal discharge may alter in the same woman in cycles
and over time. Factors that can influence physiological discharge are:-
1) Age
-
Prepubertal
-
Reproductive
-
Pregnancy
-
Hormonal contraceptions
-
Menopause
2) Local
facors
-
Semen
-
Personal hygiene and
habits
-
Menstruation
Pathological Discharge
Pathological
vaginal discharge can be further divided by specific age groups which are
prepubertal group, reproductive group and menopause group.
Common
causes of pathological vaginal discharge for each age group are:-
Prepubertal
|
Reproductive
|
Menopause
|
Nonspecific bacterial vaginitis
|
Foreign bodies (ex: IUCD, tampon,
condom)
|
Cervical or endometrial carcinoma
|
Foreign bodies
|
Allergic to local irritant
|
Actropic vaginitis
|
Sexual abuse
|
Infections
|
FB (ex: vaginal pessary)
|
Common
causes of infections:-
-
Candidiasis: Acute
vulvovaginal candidiasis / recurrent vulvovaginal candidiasis
-
Bacterial vaginosis
-
Trichomoniasis
-
Chlamydia trachomatis
-
Neisseria gonorrhoea
-
Pelvic inflammatory
disease
Principles of management
1) History5
-
Characteristics of the
discharge - Onset, duration, colour, odour, consistency.
-
Any associated symptoms
- Itch, dyspareunia, abdominal pain, abnormal vaginal bleeding or pyrexia is
more likely to indicate sexually transmitted infection.
-
Sexual history - Is
patient at increased risk of sexually transmitted infection (age <25 years,
new sexual partner or more than one sexual partner in past year, previous sexually
transmitted infection)
-
Contraceptive use
-
Pregnancy
-
Concurrent medications
and previous treatments
-
Medical conditions such
as diabetes, immunocompromised state.
-
Non-infective causes of
discharge such as allergic reaction, known cervical ectopy or polyps, genital
tract malignancy, foreign body (such as tampons).
-
Abdominal palpation for
tenderness or mass.
-
Inspect the vulva for
discharge, erythema, ulcers, other lesions or skin changes.
-
Bimanual pelvic
examination for adnexal or uterine tenderness or mass, and for cervical motion
tenderness (this can indicate pelvic inflammatory disease).
-
Speculum examination to
inspect vaginal walls, cervix, and characteristics of discharge.
-
Take endocervical swabs
if there is risk of sexually transmitted.
-
High vaginal swabs are
of limited diagnostic value except in pregnancy, post-instrumentation, failed
treatment, recurrent symptoms, or to confirm candidiasis.
Bacterial Vaginosis
Bacterial
vaginosis is the most common cause of infective vaginal discharge. It causes
profuse and fishy smelling discharge without itch or soreness. This condition
is characterised by an overgrowth of anaerobic bacteria and occurs and remits
spontaneously. Asymptomatic bacterial vaginosis in non-pregnant women does not
require treatment. The condition is associated with poor pregnancy outcomes,
endometritis after miscarriage, and pelvic inflammatory disease. Antibiotics
are the mainstay of therapy for bacterial vaginosis. Medications include
metronidazole, clindamycin, and metronidazole vaginal gel.
Vulvovaginal Candidiasis
The
prevalence of asymptomatic carriage of Candida in women is 10%. Symptoms are
vulval itch and soreness and thick white non-offensive discharge. There is no
evidence that combined oral contraceptives cause candidiasis. Asymptomatic
vulvovaginal candidiasis does not need treatment. Vulvovaginal candidiasis can
be acute or recurrent. Recurrent vulvovaginal candidiasis diagnosed when there are
4 or more episodes of VVC in 1 year.
Chlamydia Trachomatis
Chlamydia
trachomatis is the most common sexually transmitted infection caused by a
bacterium. Chlamydia can cause a purulent vaginal discharge, but it is
asymptomatic in 80% of women. It was thought that 10-40% of untreated
chlamydial infections will result in pelvic inflammatory disease. This has
recently been challenged by a large observational study, which reported that
only 5.6% of women developed this disease,6 and by a small prospective
study that reported an even lower rate of 1%.7 Chlamydia is treated
with either single dose of Azithromycin or twice daily dose of Doxycycline.
Neisseria gonorrhoea
Neisseria
gonorrhoea may present with a purulent vaginal discharge but is asymptomatic in
up to 50% of women. Major symptoms include vaginal discharge, dysuria,
intermenstrual bleeding, dyspareunia and mild lower abdominal pain. The true
prevalence and epidemiology in the general community is not known. Gonorrhoea
may be complicated by pelvic inflammatory disease.Culture is the most common
diagnostic test for gonorrhoea, followed by the deoxyribonucleic acid (DNA)
probe, and then the polymerase chain reaction (PCR) assay and ligand chain
reaction (LCR).
Trichomonasvaginalis
Trichomonasvaginalis
can cause an offensive yellow vaginal discharge, which is often profuse and
frothy, along with associated symptoms of vulval itch and soreness, dysuria,
and superficial dyspareunia, but many patients are asymptomatic. The true
prevalence and epidemiology in the general community is not known. Usually an
oral antibiotic called metronidazole (Flagyl) is given to treat trichomoniasis.
Persistent Vaginal Discharge
It
would be difficult to proceed further for women who complain of persistent
vaginal discharge with repeated negative STI screen results. When minimal discharge
is evident, it is worth discussing again personal hygiene practices and
douching, the basis for physiological discharge, and inquiring whether there
are psychosexual difficulties as a result of the patient's continued symptoms.
If
use of spermicides and lubricants are contributing to symptoms, alternative
contraception choices should be discussed. An extensive cervical ectropion can
cause heavy mucoid discharge. After the menopause, atrophic vaginal changes may
predispose women to infective vaginitis. Intravaginal oestrogen replacement,
with pessaries or cream, gradually improves the condition of the vaginal
epithelium and reduces the susceptibility to infection.
Underlying
gynaecological disease must be considered in all women with unexplained
persistent vaginal discharge. Gynaecological neoplasms, such as benign
endocervical and endometrial polyps, can present with vaginal discharge, and malignancy
needs to be excluded.
Conclusion
Many
women self-diagnose and self-treat episodes of vaginal infection with over the
counter treatments. Some women may subsequently present with history of
recurrence and never having had this diagnosis confirmed by any microbiological
tests. It is important to confirm the diagnosis and to ensure a full sexual
health screen has been done to exclude concurrent infection. Management of
vaginal discharge requires an empathic approach with reassurance and psychological
support as necessary.
Reference
1. Vaginal discharge—causes, diagnosis, and treatment
BMJ
2004; 328 doi: http://dx.doi.org/10.1136/bmj.328.7451.1306 (Published 27 May
2004)
2. Vaginal discharge
BMJ.
2007 December 1; 335(7630): 1147–1151. doi:
10.1136/bmj.39378.633287.80 PMCID:
PMC2099568 Clinical Review
3. Pathological Vaginal Discharge among Pregnant Women: Pattern of Occurrence and Association in a
Population-Based SurveyTânia Maria M. V. da Fonseca,1 Juraci A. Cesar,2 Raúl A. Mendoza-Sassi,2
and Elisabeth B. Schmidt3
4. Source: Vaginal discharge | University of Maryland Medical Centerhttp://umm.edu/health/medical
/ency/articles/vaginal-discharge#ixzz2foJJk45j
5. Abnormal vaginal discharge
BMJ 2013; 347 doi:
http://dx.doi.org/10.1136/bmj.f4975 (Published 13 August 2013)
6. Low N, Egger M, Sterne JA, Harbord R, Ibrahim F, Lindblom B, et al. Incidence of severe
reproductive tract complications associated with diagnosed genital chlamydial infection: the Uppsala
women's cohort study. Sex Transm Infect 2006;82:212-8.
7. Morré SA, van den Brule AJC, Rozendaal L, Boeke AJ, Voorhorst FJ, de Blok S, et al. The natural
course of asymptomatic Chlamydia trachomatis infections: 45% clearance and no development of
clinical PID after one-year follow up. Int J STD AIDS 2002;13(suppl 2):12-8.
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