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Altered vaginal discharge (2)


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  • 1. ALTERED VAGINAL DISCHARGE Dr.Jyoti Bhaskar MD MRCOG Consultant Lifecare Centre Pushpanjali Crosslay Hospital Lecture – 2 (2012)
  • 2. Sources  Management of Vaginal Discharge in Non- Genitourinary Medicine Settings FSRH and BASHH Guidance (February 2012)  UK National Guideline for management of Bacterial vaginosis 2012 BASHH Guidance  UK National Guideline for management of trichomoniasis vaginalis 2007 BASHH Guidance  UK National Guideline for management of Vulvovaginal candidiasis 2007 BASHH Guidance  CDC Diseases characterised by Vaginal Discharge 2010 STD treatment Guideline
  • 3. Clinician’s Office  determined by pH,  a potassium hydroxide (KOH) test,  microscopic examination of fresh samples of the discharge 1. one to two drops of 0.9% normal saline 2. second sample in 10% KOH solution
  • 4. Microscopy  WET FILM 1. Trichomonas or Clue cells 2. WBC in absence of these – Cervicitis  KOH 1. fishy smell – BV or TV 2. Spores or psuedohyphae
  • 5. Common Causes  Infective (non-sexually transmitted)  o Bacterial vaginosis  o Candida  Infective (sexually transmitted)  o Chlamydia trachomatis  o Neisseria gonorrhoeae  o Trichomonas vaginalis  o Herpes simplex virus  Non-infective  o Foreign bodies (e.g. retained tampons, condoms)  o Cervical polyps and ectopy  o Genital tract malignancy  o Fistulae  o Allergic reactions. Management of Vaginal Discharge in Non-Genitourinary Medicine Settings FSRH and BASHH Guidance (February 2012)
  • 6. Bacterial Vaginosis
  • 7. Bacterial vaginosis Commonest cause of AVD in reproductive age group 5% in asymptomatic college students to as high as 50% in rural uganda. UK – 12% in pregnant women,30% in women TOP
  • 8. Bacterial vaginosis Gardnerella vaginalis, Mycoplasma hominis, Bacteroides species, and Mobiluncus species. Found at numbers 100 to 1000 times greater than found in the healthy vagina. In contrast, Lactobacillus bacteria are in very low numbers or completely absent . .
  • 9. Risk Factors Vaginal douching Black Race Recent change of partners Smoking STI – Chlymadia or Herpes Described in Virgins It is not considered a sexually transmitted disease although it can be acquired by sexual intercourse
  • 10. Clinical Manifestations About 50% of women with BV do not have symptoms Offensive, fishy-smell which is stronger after sexual intercourse and menses, Thin, milky-white or gray vaginal discharge. Not associated with soreness, itching or irritation
  • 11. Bacterial vaginosis Diagnosis  "Amsel's criteria" if three of the following four criteria were present  a thin, milky white discharge that clings to the walls of the vagina,  presence of a fishy odor (a positive amine test)  a vaginal pH of > 4.5,  and the presence of "clue cells" in the vagina.  Those with one or two criteria were classified as having a disturbance of vaginal flora
  • 12. Gram stained vaginal smear – Hay/Ison or Nugent criteria ( Gold Standard) Isolation of GV alone cannot be used to diagnose BV OSOM BVBlue, Pip Activity Testcard ,Affirm VP 111
  • 13. Bacterial Vaginosis
  • 14. Treatment Indications: 1. Symptomatic women 2. Women undergoing surgical procedures
  • 15. Recommended Regimens  Metronidazole 400 mg twice daily 5-7 days  Metronidzole 2 gm single dose  Intravaginal metronidzole gel (0.75%) once daily for 5 days  Intravaginal clindamycin cream (2%) once daily for 7 days Alternate Regimens  Tindazole 2G single dose,1 gm daily for 5 days  Clindamycin 300 mg twice daily for 7 days
  • 16. Caution  Alcohol to be avoided Clindamycin cream is oil based – weakens latex condoms for 5 days after use
  • 17. Rationale 70-80% cure rate after 4 weeks MNZ – 2 gm dose is less effective Intravaginal Mnz and clindamycin are equally effective  MNZ – has advantage as less active against lactobacilli No recommendation for use of probiotic lactobacilli or lactic acid preparations
  • 18. Special situations  Allergy to MNZ  Pregnancy 1. No evidence of teratogenicity with MNZ use in first trimester. 2. Symptomatic women to be treated in the same way. 3. Asymptomatic pregnant wn found to have BV == insufficient evidence 4. Additional risk factors – may benefit if Rx before 20 weeks
  • 19. CDC recommendation Metronidazole 500 mg orally twice a day for 7 days Metronidazole 250 mg orally three times a day for 7 days Clindamycin 300 mg orally twice a day for 7 days Intravaginal clindamycin cream might be associated with adverse outcomes if used in the latter half of pregnancy( 20 wks)
  • 20. Special Situations  Breast feeding 1. Avoid high dose of MNZ 2. Prudent to use intravaginal clindamycin for treatment.  TOP Support screening for and treating BV to reduce subsequent endometritis and PID  HIV Risk factor for female to male transmission- Supress BV or treat recurrence rapidly
  • 21.  Sexual Partners 1. Routine screening and treatment of male partners not indicated 2. High incidence of BV in female partners of lesbians of BV  Follow up A test of cure is not required if symptoms resolve.
  • 22. Candidal Vaginitis
  • 23. Candidal Vaginitis Approximately 75% of sexually active women suffer at least one episode of Candida vaginitis. 10% of them have recurrent episodes.  Saporiti AM, Rev Argent Microbiol. 2001
  • 24. Candidal Vaginitis  Species identified:  C. albicans 87.5%,  C. glabrata 8.6%  C. krusei, C.famata, C.tropicalis & S.cerevisiae - 3.9%  Fluconazole resistant C. albicans were isolated in 13.46% of the cases  Saporiti AM, Rev Argent Microbiol. 2001
  • 25. Predisposing factors  C.albicans is a natural inhabitant of the vagina. 1.Use of antibiotics 2.Uncontrolled DM, HIV/AIDS (decrease immunity) 3.During pregnancy due to increase vagina acidity & increase glycogen content. 4.Use of oral contraceptive pills. 5.Young age at first intercourse, frequent intercourse & oral sex. 6.Tight fitting clothes, deodorants ,vaginal contraception have also been reported to increase incidents.
  • 26. Clinical Manifestations  Symptoms – Vulval Itch, soreness, Vaginal discharge Superficial dyspareunia, external dysuria  Signs – Erythema,Fissuring,Curdy white non offensive discharge, Oedema, excoriation None of this is pathognomic, corroborative evidence of laboratory must be sought.
  • 27. Diagnosis  Routine microscopy and culture is standard  Vaginal Swab from anterior fornix 1. Gram or wet film 2. Directly plated to solid fungal media.
  • 28. Candidal Vaginitis
  • 29. Management  All topical and oral azole therapies give 80% cure rate  Topical Azole therapies can cause vulvovaginal irritation  Sexual partners – No treatment required for asymptomatic partners  Follow up – Unneccessary if symptoms resolve
  • 30. Topical Azoles 1. Clotrimoxazole pessary- 500 mg stat,200mg x 3days,100mg x6nights, Vaginal cream(10%) 5gm stat 2. Econazole pessary 150 mg stat, 150 mg x 3 nights 3. Fenticonazole pessary –200 mg x 3days, 600 mg stat 4. Miconazole- 1.2 g stat ,100 mg x14 nights 5. Nystatin vaginal cream (100,00 u) 4g x 14 nights,pessary 1-2 x14 nights 6. Tioconazole 6.5% ointment 5 g intravaginally in a single application ORAL Fluconazole 150 mg stat Itraconazole 200mg BD x 1day
  • 31. Pregnancy Asymptomatic women do not need to be treated.. No one topical imidazole is better than other Longer courses are needed. 7 day course cures over 90% . Oral therapy is contraindicated.
  • 32. NON ALBICANS VVC longer duration of therapy (7–14 days) with a nonfluconazole azole drug (oral or topical) If recurrence occurs,600 mg of boric acid in a gelatin capsule is recommended, administered vaginally once daily for 2 weeks.
  • 33. Trichomoniasis Vaginalis
  • 34.  Flagellated Protozoan  Vagina, urethra and paraurethral glands  Urinary tract is site of sole infection in 5%,urethritis is present in 90% of episodes  Exclusively Sexually Transmitted
  • 35. RISK FACTORS More number of sexual partners 5 years or more of sexual activity H/o gonorrhoea or other S.T.I.s Early coitarche Bad hygienic habits Chronic asymptomatic infections can persist for several decades
  • 36. Clinical Manifestations  10-50% are symptomatic  Vulvovaginal irritation, dysuria  70% vaginal discharge , classical discharge (Copious, yellow-gray or green, homogeneous or frothy, malodorous) in 10-30%  Elevated pH level (> 4.5)  Vulvitis and vaginits  2% strawberry cervix  5-15% no abnormality
  • 37. Diagnosis  Wet mount smear – 70% sensitive  Culture techniques – gold standard (Diamond TYM medium)  FDA-cleared tests – OSOM trichomonas rapid test, Affirm VP 111  PCR based 100% sensitive  Cervical cytology – 58% sensitive Site sampled 1. Swab from posterior fornix 2. Self administered swab
  • 38. Trichomonas vaginalis Presence of mobile, flagellated organisms and leukocytes on wet-mount microscopic evaluation
  • 39. Management  General Advice 1. Treat sexual partners together 2. Avoid intercourse till both have completed treatment and follow up  Screening for STI in both partners Spontaneous cure rate in 20-25%
  • 40. Recommended Regimens Metronidazole 2gm orally single dose Metronidazole 400-500 mg twice daily for 5-7 days Alternate regimen Tinidazole 2 gm orally single dose Caution Alcohol consumption to be avoided
  • 41. Treatment failure  Check compliance and rule out vomiting of metronidazole  Check possibilty of re infection  Check partner has been treated 1. If pt’s fail to respond to first course, rpt course of standard treatment 2. Use of antibiotics like erythromycin or amoxy before retreating with MNZ
  • 42. 3. Higher dose of MNZ MNZ 400 mg TDS with MNZ 1 gm PR daily for 7 days MNZ 2 gm daily for 3-5 days Higher doses of Tinidazole 2gm twice daily for 2 weeks
  • 43. Special situations  Sexual Partners Screen for full range of STI and treat for TV  TV in children Acquired perinatally -5% Infection beyond first year – Sexual abuse  HIV Screening for TV at entry and annually Longer teatment regimens with oral MNZ, Follow up  Follow up Test of cure only if remains symptomatic or symptoms recur.
  • 44. COMMON RTI’s
  • 45. Syndromic approach to diagnosis & treatment of AVD Diagnosis
  • 46. Dietary modification and nutritional supplementation  Antioxidant vitamins, including A, C, and E, as well as B complex vitamins, and vitamin D, are recommended.  A well-balanced diet low in fats, sugar, and refined foods include cheese, alcohol, chocolate, soy sauce, sugar, vinegar, fruits, and any fermented foods  Lactobacillus acidophilus can be taken orally in the form of acidophilus yogurt, or in capsules or powder. It can also be administered vaginally.
  • 47.  Don't douche.  Use medication as long as directed.  Avoid sexual intercourse until treatment is completed and you are symptom free.  Don’t scratch infected or inflamed area; it can cause further irritation.  If using medication inside the vagina, use it during the menstrual period.
  • 48.  During an infection, use pads rather than tampons if menstruation occurs.  Avoid vulvovaginal irritants, including perfumed or deodorant soaps/body washes.  If symptoms persist after completing the treatment, an exam is indicated. Call for an appointment, and please use nothing in the vagina for 48 hours prior to your examination by doctor.
  • 49. Conclusion  Correct diagnosis is necessary before therapy.  Careful history, examination, and laboratory testing to determine the etiology of vaginal complaints are warranted.  Diagnosis can be accomplished by a microscopic examination in 90% of the cases in Clinician’s office.  The cytologic smear is also very important.  Complete treatment initially may help prevent recurrent form of the disease and growth of resistant strains.
  • 50. THANK YOU
  • 51. ADDRESS 35 , Defence Enclave, Opp. Preet Vihar Petrol Pump, Metro pillar no. 88, Vikas Marg , Delhi – 110092 CONTACT US 011-22414049, 42401339 WEBSITE : E-MAIL ID &