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- 2. OVERVIEW • Introduction • Differential diagnoses • History taking • Overview of each differential diagnosis • Some case scenarios
- 3. INTRODUCTION • Common presentation of women to the STI clinic • Can be physiological or pathological • Related with some common STIs
- 4. VAGINAL DISCHARGE •Secretions produced by the glands of vaginal wall and cervix that drain from the vaginal opening
- 7. Physiological • Menstrual cycle variations- Midcycle discharge • Sexual arousal • Pregnancy Other • Cervical polyps • Foreign bodies - eg, retained tampon, conception • Vulval dermatitis • Chemical irritation • IUCD use • Oral contraceptive use NON-INFECTIOUS VAGINAL DISCHARGE
- 8. Sexually transmitted infections • Chlamydia • Gonorrhoea • Herpes simplex • Trichomonasis • Vulvovaginal candidiasis Non-sexually transmitted infections • Bacterial vaginosis INFECTIOUS VAGINAL DISCHARGE
- 9. Physiological Vaginal Discharge • White or clear • Thick or thin • Mostly odorless/ slight odor • Normal vaginal discharge in reproductive aged women
- 10. HISTORY TAKING History of Presenting Complaint •Color •Odour •Presence of blood •Relationship to the menstrual cycle •Associated symptoms
- 11. Past Medical History Sexual History Obstetric History Gynaecological History Contraceptive History Menstrual History Drug History Family History Social History
- 12. NATURE OF THE DISCHARGE Clear/ white Physiological Gonnorrhoea, Pelvic inflammatory disease, Chlamydia Mucopurulent Vulvovaginal candidiasis Thick, curdy Trichomonasis Frothy, yellowish green Greyish white Bacterial vaginosis
- 13. EXAMINATION • Patient is examined in the lithotomy position • A speculum can be inserted
- 15. GONORRHOEA
- 16. CLINICAL FEATURES • Endocervical mucopurulent discharge • When complicated with PID • Dysuria • Lower abdominal pain • Post coital and intermenstrual bleeding.
- 17. GONOCOCCAL INFECTION • Pathogen – Neisseria gonorrhoeae • Intracellular Gram negative diplococci • Mainly affect endocervix • 50% of females are asymptomatic • I.P. 2-7 days • Common age of onset 15 - 24
- 18. COMPLICATIONS • Bartholin’s abscess • Pelvic inflammatory disease • Due to ascending infection • Disseminated gonococcal infections • Fever, • Septic arthritis, • Blisters near small joints • Perihepatitis, infertility • Mother to child transmission • Opthalmia neonatorum Opthalmia neonatorum
- 19. •Endocervical swab •Vulvo-vaginal swab (For NAAT and of abused children) SAMPLES
- 20. INVESTIGATIONS Microscopy of Gram stained endocervical smear for Gonorrhea • Gram negative intracellular diplococci • Rapid diagnosis Culture for Gonorrhea • Thayer Martin medium- gray colonies Nucleic acid amplification test (NAAT) • Vulvovaginal swab is used
- 21. TREATMENT •Cefexime 400mg stat •IM Ceftriaxone 250mg •Partner tracing and Epidemiological treatment to the partner •Avoid sexual relationships until both partners complete treatments
- 22. CHLAMYDIA
- 23. CLINICAL FEATURES • Purulent, mucopurulent discharge • When complicated with PID • Dysuria • Lower abdominal pain • Post coital and inter-menstrual bleeding. • Dyspareunia
- 24. Chlamydia trachomatis • Serovars D to K • Gram negative obligatory intracellular bacteria • Nearly 70% of females are asymptomatic
- 25. COMPLICATIONS • Pelvicinflammatory disease • Cause ectopic pregnancy and infertilitty • Perihepatitis • Sexually acquired reactive arthritis • In pregnancy • Pre-term births, • Post-partum infections, • Opthalmia neonatarum
- 27. INVESTIGATIONS • Microscopy (Not diagnostic nor confirmatory) • Polymorphonuclear leukocytes > 30, • under high power • In absence of intracellular diplococci • diagnosed as non gonococcal cervicitis • Nuclear amplification test (Diagnostic)
- 28. TREATMENT • Doxycyclin 100mg / bd for 7 days or azithromycin 1g stat • Azithromycin during pregnancy • Partner tracing and Epidemiological treatment to the partner • Avoid sexual relationships until both partners complete treatments
- 29. TRICHOMONASIS
- 30. CLINICAL FEATURES • Profuse frothy yellow/gray discharge with foul odor • Dysuria • Abdominal discomfort • Vulval itching • Dyspareunia • Rare – strawberry cervix (multiple hemorrhagic areas in cervix )
- 31. Trichomonas vaginalis • Cause trichomoniasis • Most common STI worldwide • Flagellated protozoa • Mainly affects vagina, urethra and para urethral glands. • 10- 50% of females are asymptomatic.
- 32. COMPLICATIONS • In pregnancy • Preterm birth • Low birth weight SAMPLES • Secretions from the posterior fornix is collected into the swab • Observe under microscope
- 33. INVESTIGATIONS Microscopy • Prepare wet smear (normal saline) • Observed for motile • Flagellated organism immediately • Staining with Giemsa Culture • Modified diamond TYM medium
- 34. TREATMENTS • Metronidazole 400mg – 500 mg / bd for 7 days • Partner tracing and epidemiological treatment to the partner • Avoid sexual relationships until both partners complete treatments
- 36. VULVOVAGINAL CANDIDIASIS • Oval budding fungus • Pathogen – 80-92% Candida albicans • Non albicans species • C.glabrata • C tropicalis • Yeast
- 37. CLINICAL FEATURES • Thick white (curd like) non offensive vaginal discharge • Vulval itching • Vulval soreness • Superficial Dyspareunia (due to the vulval irritation) • Signs – • Erythema • Fissuring • Vulval oedema
- 38. PREDISPOSING FACTORS • Diabetes mellitus • Long term steroids • Pregnancy • Prolonged antibiotic use • Immune suppression SAMPLES • Vaginal swabs from lateral fornix
- 39. INVESTIGATION Microscopy of vaginal smear •Gram stain or •wet film examination (KOH) •Hyphae and spores Culture • Sabouraud agar medium
- 40. TREATMENT • Good hygiene • Remove predisposing factors • Oral Triazoles drugs- Fluconazole 150mg stat or Itraconazole 200mg bd • Topical applications- Clotrimazole, Miconazole, Nystatin • Pessaries and clotrimazole cream intravaginally daily for 7-14 days • No epidemiological treatment for partner
- 42. Bacterial vaginosis • Non- sexually transmitted infection • Frequent cause for vaginal discharge • Anaerobic or facultative aerobic bacteria • Normal vaginal flora of lactobacilli are replaced by overgrowth of • Gardenerella vaginalis • Prevotella spp • Mycoplasma hominis • Mobiluncus spp • Vaginal PH > 4.5
- 43. CLINICAL FEATURES • Greyish white homogenous vaginal discharge • Offensive fishy odor • No vaginal inflammation PREDISPOSING FACTORS • Vaginal douching • Oral sex • Smoking • Antibiotic use • Recent change in sex partner • IUCD
- 44. INVESTIGATIONS • Microscopy • Gram stained smear of vaginal discharge • (presence of clue cells)
- 45. DIAGNOSTIC CRITERIA • Presence of clue cells on microscopic examination • clue cells are epithelial cells covered with bacteria giving a characteristic stipped appearance on examination • Yellowish grey discharge seen on naked eye examination • Vaginal pH more than 4.5 • Release of characteristic fishy odor on addition of alkali • 10% KOH For diagnosis of bacterial vaginosis at least three criteria should be present.
- 46. TREATMENTS •Metronidazole •400mg – 500 mg / bd for 7 days •Or 2g stat
- 47. Non-infective causes of vaginal discharge • Retained foreign bodies • Foul-smelling discharge • Cervical polyps • Intermenstrual bleeding
- 48. Case scenario 1 • 27 year old female, presenting with a mucopurulent vaginal discharge for 1 day, also complains of dysuria,lower abdominal pain and post coital bleeding. She has a recent history of having unprotected sex.
- 49. Case scenario 2 • 27 year old female, presenting with a profuse frothy yellow/gray discharge with foul odor for 1 day also complains of dysuria, vulval itching and dyspareunia. She has a recent history of having unprotected sex.
- 50. Case scenario 3 • 25 year old female, presenting with a thick curdy vaginal discharge for 1 day, also complains of external dysuria, vulval itching & soreness.
- 51. Case scenario 5 • 33 year old female, presenting with a creamy vaginal discharge with a fishy odor for 2 days, no vulval itching or soreness.
- 52. REFERENCES • Kumar and clark clinical medicine 9th edition • Gynaecology byTen Teachers 19th edition • Medical Microbilogy Greenwood 18th edition • www.cdc.gov
- 53. Thank you