Leukorrhea

1. Leukorrhea
ชัยพงศ์ ตั้งสิทธิธรรม
ทอแสง ชโยวรรณ

2. Leukorrhea
• Increased vaginal discharge
• Physiologic/Pathologic

3. Normal Vaginal Discharge
• Creamy white discharge
– Vulvar secretion
• Bartholin glands
• Sweat glands
• Sebaceous glands
• Skene glands
– Vagina
– Cervix
– Endometrial glands
– Fallopian tubes

4. Normal Vaginal Discharge
• Increased when
– Ovulation—endocervical glands
– Premenstrual phase
– Pregnancy
– Sexual excitement—Bartholin’s glands
• pH < 4.5

5. Physiological Vaginal Discharge
– Newborns
– Puberty
– Congestion of pelvic organs
– Cervical ectopian
– Contraceptives
– Vaginal douche

6. Pathological Vaginal Discharge
– Vaginitis in infancy and childhood
– Senile vaginitis (Atrophic vaginitis)
– Candidiasis
– Bacterial vaginosis
– Trichomonas vaginitis
– Mucopurulent cervicitis
– Foreign bodies
– Neoplasm
– Urinary and fecal discharge

7. Vaginitis
in infancy and childhood
• Low immunity
• Age 1-5 years
• Infection/Foreign body/Tumor
• Wet smear, Gram stain, culture, speculum
• Treatment
– Rest
– antibiotics
– estrogen

8. Atrophic vaginitis
• Postmenopause
• Decreased estrogen
– Vaginal wall thining
– Decreased acidic environment
• Yellow/Green/Bloody
• Pruritic/Painful
• Dysuria
• Dyspareunia/Postcoital bleeding
• Vaginal wall thining, colpitis macularis, patchy
ulceration, adhesive vaginitis

9. Atrophic vaginitis
• PAP smear, Gram stain, culture
• +- Cervical biopsy, Fractional curettage
• Treatment:
– Antibiotics
– estrogen (local/systemic)

11. Candidiasis
• Yeast cells/Pseudohyphae
• Inflammation and curd-like discharge
• Predisposing factors
– Diabetes
– Obesity
– Pregnancy
– Antibiotics
– Contraceptives
– Low immunity
– Premenstrual period

12. Candidiasis
• KOH preparation, Gram stain (positive)
• Subouraud’s/Nicerson’s media culture
• Treatment:
– Uncomplicated
• Clotrimazole V.P. (100) Vg suppo OD 6days
• Clotrimazole V.P. (200) Vg suppo OD 3days
• Itraconazole (400) PO stat
• Fluconazole (150) PO stat
– Complicated
• Clotrimazole V.P. (100) Vg suppo OD 14 days then Clotrimazole V.P.
(500) Vg suppo weekly for 6 months
• Repeat Fluconazole 3 days after then weekly for 6 months
• Partner?

14. Bacterial vaginosis
• Decreased amount of Lactobacilli 
Increased amount of anaerobes
• Low immunity, fatigue, frequent sexual
intercourse, vaginal douche
• Mostly asymptomatic
• Increased (foul-smelling) discharge

16. Bacterial vaginosis
• Amsel criteria (3/4)
– Gray-white discharge
– pH > 4.5
– Clue cells
– Whiff test
• Treatment:
– Metronidazole (500) 1 tab PO bid pc 7 days
– Clindamycin (300) 1 tab PO bid pc 7 days

18. Trichomonas vaginitis
• Anaerobic flagellated protozoa
• Mainly sexually transmitted
• Yellowish green/white discharge
• Itchy
• Dysuria, dyspareunia
• Vaginal mucosa inflammation
• colpitis macularis, strawberry cervix

22. Trichomonas vaginitis
• Wet smear, Gram stain to rule out gonococcal
infection
• Treatment
– Metronidazole (500) 1 tab PO bid pc 7 days
– Clotrimazole V.P. (100) Vg suppo OD 6days
• Must also treat partners, no intercourse until
resolved

23. Mucopurulent cervicitis
• Mucopurulent discharge
• Dysuria
• Vulval inflammation
• N. gonorrhoeae, C. trachomatis, HSV
• Gram stain intracellular gram negative
diplococci

24. Mucopurulent cervicitis
• Dual therapy
• Gonococcal infection
– Ceftriaxone 125 mg IM stat
• Chlamydial infection
– Doxycycline (100) 1 tab PO bid pc 7 days
– Azithromycin (1g) 1 tab PO stat
• Must also treat partners, no intercourse until
resolved

25. Foreign Bodies
• Children
• Adults—contraceptive devices, pessary,
swabs, tampons
• Purulent vaginal discharge; foul-smelling,
bloody
• Speculum; may use nasal or aural speculum
• Removal then antiseptics

26. Neoplasm
• Benign/Malignant
• Leukorrhea
• purulent, foul-smelling, bloody
if infected/malignant

27. Urinary and fecal discharge
• Urinary discharge
– Urethro-vaginal fistula
– Vesico-vaginal fistula
– Uretero-vaginal fistula
• Fecal discharge
– Recto-vaginal fistula

28. Summary
• Physiologic
• Pathologic
– Vaginitis in infancy and childhood
– Senile vaginitis (Atropic vaginitis)
– Candidiasis
– Bacterial vaginosis
– Trichomonas vaginitis
– Mucopurulent cervicitis
– Foreign bodies
– Neoplasm
– Urinary and fecal discharge

29. THANK YOU