VAGINAL DISCHARGE:NOTES FOR PMC STUDENTS

 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).

2)      Examination⁵

-          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.

MRCOG/MOG PRACTICE QUESTION 2

QUESTION 2

A 58 year-old woman has had a TAHBSO 3 years earlier for uterine fibroids and now complains of ‘something coming down’ her vagina. Examination reveals a vault prolapse and a moderate cystocoele.

How would you manage her? (Key word here is MANAGE; which would include history, examination, investigation, treatment)

a)      History

Clarify nature of symptoms, worse with standing/ standing, relieved by lying down

Effects on quality of life

Urinary symptoms- any incontinence, incomplete voiding, voiding difficulties (symptoms likely to be related to prolapse)

Bowel symptoms- incontinence, difficulty emptying rectum (URINARY AND BOWEL symptoms comes hand in hand)

Sexual history and desire to retain sexual function

Previous gynecological history especially on the hysterectomy/ prolapse surgery

b)      Examination

BMI

Any abdominal mass

Speculum examination; using the objective assessment of prolapse with POP-Q

Access for SUI after reducing prolapse with full bladder

Pelvic examination (the Bimanual- to assess for pelvic mass)

c)      Investigations

Relevant blood investigations eg FBC, Renal Profile, pre-operative work up

d)     Treatment options

Non-surgical options

-Pelvic floor exercise – no evidence for efficacy, used in women whom wants to avoid surgery but maintain sexual function, unlikely to be effective

- Pessaries- ring/shelf (with the ring, likely to be expelled in women with deficient perineum/perineal body. With shelf pessary, sexual intercourse may not be possible). Should be reserved for women who are unfit/decline surgery or while awaiting surgery. Need to be changed every 6-9 months.

Surgical options

-          Abdominal sacro-colpopexy- effective, evidence proven, major surgery for a relatively healthy women but may require the additional vaginal procedure if woman has anterior/posterior vaginal wall prolapse

-          Sacrospinous ligament fixation – vaginal procedure with lower morbidity and suitable for women who are unfit for laparotomy. Failure rate higher than abdominal route. Allows simultaneous vaginal wall repair.

-          Laparoscopic sacro-colpopexy may be undertaken if expertise is available

-          Colpocleisis may be offered for frail women who do not wish to retain sexual function.

-          Mesh- controversial and probably should not be mentioned in an exam answer as the only evidence for it would be anterior repair.

MRCOG/MOG PRACTICE QUESTIONS 2013

QUESTION 1.

A 65 year old otherwise healthy woman presents with incontinence of urine on coughing, sneezing and laughing.

a)What important aspects in history will influence your subsequent management? 8 marks

b)What investigations would you perform and how would you manage her?12 Marks

a)

History

-severity of incontinence and the impact on quality of life (QOL)*IMPORTANT

-other urinary symptoms; urgency, urge urinary incontinence, frequency, nocturia

-symptoms of voiding dysfunction; dribbling, hesitancy, poor stream, strain to void

-UTI symptoms; dysuria, haematuria, frequency

-Presence of bladder pain and prolapse symptoms

-Bowel symptoms- constipation, incontinence of faeces

-Past obstetric history including date of last delivery and reproductive intentions

-Fluid intake, caffeine, alcohol

-Previous treatment for incontinence including surgery

b)

Key point here is ‘healthy woman’

Investigations

Urine dipstick

Mid stream urine for culture

Bladder diary/ Frequency volume chart

Multichannel urodynamics only if conservative treatment has failed or if surgery is being considered or before surgery if there is clinical suspicion of DO/ previous surgery for SUI or anterior compartment prolapse/ symptoms of voiding dysfunction

Management include an examination (BMI, abdominal and pelvic examination; pelvic mass, palpable bladder; Check for presence of prolapse; Demonstrate SUI with moderately full bladder, 150mls)

Conservative

• Life style intervention: reduce weight, quit smoking, reduce/avoid risk factors, control medical disorders like asthma
• Application of oestrogen cream/gels-controversial, there are some evidence that has shown , reduction in all type of incontinece
• First line treatment should be supervised pelvic floor exercise/ muscle training (PFMT) lasting at least 3 months, there good evidence shown significant reduction in the incontinence esp. GSI ( 65-70%)

• Duloxetine should not be used as first line treatment or should not be routinely used as a second-line treatment for SUI. (NICE guidelines)

Surgical options if conservative treatment failed;

-          retropubic mid-urethral tape ( Subject. & Object cure rate 85-95%)

-          open colposuspension (Subject. & Object cure rate 85-95%)

-          TOT

-          Intramural bulking agents

-          Artificial urinary sphincter

Not recommended for SUI;

-          Routine use of lap colposuspension

-          Anterior colporrhapy, needle suspensions, paravaginal defect repair, MMK procedure

-          Autologous fat and PTFE as intramural bulking agents