white discharge! infectious causes of leucorrhea. bacterial vaginosis, trichomonas vaginalis, candidiasis, sexually transmitted diseases,

1. LEUCORRHEA
Dr. Ravali Kethineedi
final year pg
GEMS & H –SRIKAKULAM

3. BACTERIAL VAGINOSIS
◦ Also called nonspecific vaginitis or Gardnella vaginitis
◦ Alteration of normal vaginal bacterial flora that results in loss of lactobacilli and an
overgrowth of predominantly anaerobic bacteria.
◦ Concentration of anaerobes and G. vaginalis and Mycoplasma hominis, is 100 to
1,000 times higher than in normal women.
◦ Lactobacilli are usually absent.
◦ repeated alkalinization of the vagina, which occurs with frequent sexual
intercourse or use of douches, plays a role.

4. ◦ Increased risk
⁻ pelvic inflammatory disease (PID)
⁻ postabortal PID
⁻ postoperative cuff infections after hysterectomy
⁻ and abnormal cervical cytology
⁻ Pregnant women risk for premature rupture of the membranes, preterm labor
and delivery, chorioamnionitis
⁻ postcesarean endometritis .
In women with BV who are undergoing surgical abortion or hysterectomy,
perioperative treatment with metronidazole eliminates this increased risk
• Hydrogen peroxide–producing lactobacilli disappear, it is difficult
to reestablish normal vaginal flora -recurrence of BV is common

5. A) Normal mature vaginal cells with Döderlein’s lactobacilli.
B) Clue cells with very few Döderlein’s bacilli.

6. DIAGNOSIS-
◦ A fishy vaginal odor, which is particularly noticeable following coitus
◦ vaginal discharge- gray and thinly coat the vaginal walls.
◦ The pH of these secretions is >4.5 (usually 4.7 to 5.7).
◦ Microscopy of the vaginal secretions reveals an increased number of clue cells.
• the “whiff” test -releases a fishy, amine like odor- +

7. ◦ Clinicians who are unable to perform microscopy should use alternative diagnostic
tests such as a
-pH
-amines test card
-detection of G. vaginalis ribosomal RNA
-Gram stain .
◦ Culture of G. vaginalis is not recommended as a diagnostic tool because of its lack
of specificity.

8. Bacterial vaginosis.
(A) Vaginal smear showing Döderlein’s bacilli.
(B) Clue cells suggestive of bacterial vaginosis

9. ◦ Amsel et al. established clinical criteria for diagnosing BV.

10. ◦ Nugent et al. described a Gram stain scoring system of vaginal smears to
diagnose BV

12. ◦ Ideally, treatment of BV should inhibit anaerobes but not vaginal
lactobacilli.
◦ METRONIDAZOLE-
◦ Excellent activity against anaerobes but poor activity against lactobacilli, is the
drug of choice for the treatment of BV.
◦ Avoid using alcohol during treatment with oral metronidazole and for 24 hours
◦ A dose of 500 mg administered orally twice a day for 7 days should be used.
◦ Metronidazole gel, 0.75%, one applicator (5 g) intravaginally once daily for 5
days, may also be prescribed.

13. ◦ CLINDAMYCIN
◦ Clindamycin ovules, 100 mg, intravaginally once at bedtime for 3 days
◦ Clindamycin bio adhesive cream, 2%, 100 mg intravaginally in a
single dose Clindamycin cream, 2%, one applicator full (5 g)
intravaginally at bedtime for 7 days
◦ Clindamycin, 300 mg, orally twice daily for 7 days
◦ Many clinicians prefer intravaginal treatment to avoid systemic side
effects ( GI upset , unpleasant tasete)
◦ Treatment of the male sexual partner is not recommended

14. TRICHOMONAS VAGINITIS
◦ Caused by -sexually transmitted
-flagellated parasite.
◦ The transmission rate is high (70% of men contract the disease after a
single exposure to an infected woman.)
◦ It is a anaerobe that has the ability to generate hydrogen to combine
with oxygen to create an anaerobic environment.
◦ It often accompanies BV,

16. ◦ Diagnosis –
Trichomonas vaginitis is associated with a
-profuse, purulent, malodorous vaginal discharge
-vulvar pruritus.
-The pH of the vaginal secretions >5.0.
-patchy vaginal erythema and colpitis macularis (“strawberry” cervix) -
present

17. ◦ Microscopy of the secretions
- motile trichomonads
-increased numbers of leukocytes.
-Clue cells may be present (common association with BV)
◦ The whiff test may be positive.
◦ increased risk for postoperative cuff cellulitis following hysterectomy
◦ Pregnant women with trichomonas vaginitis are at increased risk for premature
rupture of the membranes and preterm delivery.

18. TREATMENT:
◦ Metronidazole is the drug of choice for treatment of vaginal trichomoniasis.
- single-dose (2 g orally) / multidose (500 mg twice daily for 7 days) regimen
- The sexual partner should be treated.
- Metronidazole gel, although effective for the treatment of BV, should not be used for
the treatment of vaginal trichomoniasis.
- Women who do not respond to initial therapy
-treated again with metronidazole, 500 mg, twice daily for 7 days.
-If repeated treatment is not effective-treated with a single 2-g dose of
metronidazole once daily for 5 days or tinidazole, 2 g, in a single dose for 5
days.

19. -should be tested for other STDs, particularly Neisseria
gonorrhoeae and Chlamydia trachomatis.
-Serologic testing for syphilis and HIV infection should be
considered.
- Uncommon refractory cases-obtain cultures of the parasite to
determine its susceptibility to metronidazole and tinidazole.

20. VULVOVAGINAL CANDIDIASIS
◦ An estimated 75% of women experience at least one episode of vulvovaginal
candidiasis (VVC) during their lifetimes.
◦ Few are plagued with a chronic, recurrent infection.
◦ Candida albicans is responsible for 85% to 90% of vaginal yeast infections.
◦ Other species of Candida, such as C. glabrata and C. tropicalis, can cause
vulvovaginal symptoms and tend to be resistant to therapy.

21. Candida –
DIMORPHIC FUNGI
-BLASTOSPORES
which are responsible for transmission
and asymptomatic colonization
-MYCELIA
result from blastospore germination
and enhance colonization and facilitate
tissue invasion.
• The extensive areas of pruritus and inflammation often associated with minimal
invasion of the lower genital tract
• A hypersensitivity phenomenon may be responsible for the irritative symptoms
associated with VVC, especially for patients with chronic, recurrent disease.

23. ◦ Predisposing factors-
– antibiotic use
– Pregnancy
– diabetes
◦ Categorize women with VVC -uncomplicated or complicated disease
Uncomplicated Complicated
Sporadic or infrequent in occurrence Recurrent symptoms
Mild to moderate symptoms Severe symptoms
Likely- candida albicans Non albicans candida
Immunocompetent women Immunocompromised – DM, HIV

24. ◦ Diagnosis
The symptoms of VVC consist -
◦ vulvar pruritus
◦ vaginal discharge that typically resembles cottage cheese.
◦ Vaginal soreness, dyspareunia, vulvar burning
◦ External dysuria (“splash” dysuria) -micturition leads to exposure of the
inflamed vulvar and vestibular epithelium to urine.

25. ◦ The whiff test is negative.
◦ A fungal culture is recommended to confirm the diagnosis.
◦ women with a normal physical examination findings and no evidence of fungal
elements disclosed by microscopy are unlikely to have VVC and should not be
empirically treated unless a vaginal yeast culture is positive.

26. TREATMENT
1.Topically applied azole drugs
◦Symptoms usually resolve in 2 to 3 days.
◦Short-course regimens up to 3 days are recommended.
2.The oral antifungal agent
-fluconazole, used in a single 150-mg dose,
-Patients should be advised that their symptoms will persist for 2 to 3 days so
they will not expect additional treatment

27. 3.Women with complicated VVC
-150-mg dose fluconazole given 72 hours after the first dose.
-Patients with complications treated with a more prolonged topical regimen lasting
10 to 14 days.
-Adjunctive treatment with a weak topical steroid, such as 1% hydrocortisone
cream, may be helpful in relieving some of the external irritative symptoms.

28. RECURRENT VULVOVAGINAL CANDIDIASIS
◦ defined as ≥4 episodes / year
◦ Persistent irritative symptoms of the vestibule and vulva.
◦ Burning replaces itching as the prominent symptom in patients with RVVC.
◦ The diagnosis confirmed by direct microscopy of the vaginal secretions and by
fungal culture.
◦ Many of these patients have chronic atopic dermatitis or atrophic vulvovaginitis.

29. ◦ TREATMENT :
-inducing a remission of chronic symptoms with fluconazole (150 mg every 3 days
for three doses).
-Patients should be maintained on a suppressive dose of this agent (fluconazole,
150 mg weekly) for 6 months.
◦ On this regimen, 90% of women with RVVC will remain in remission.
◦ After suppressive therapy, approximately half will remain asymptomatic.
◦ Recurrence will occur in the other half and should prompt reinstitution of suppressive
therapy .

31. DESQUAMATIVE INFLAMMATORY VAGINITIS
◦ Clinical syndrome characterized by
-diffuse exudative vaginitis
-epithelial cell exfoliation
-profuse purulent vaginal discharge
◦ The cause of inflammatory vaginitis is unknown, but Gram stain findings
reveal a relative absence of normal long gram-positive bacilli (lactobacilli) and
their replacement with gram-positive cocci, usually streptococci.
◦ .

32. ◦ Vaginal erythema is present, and there may be an associated vulvar erythema,
vulvovaginal ecchymotic spots, and colpitis macularis.
◦ The pH of the vaginal secretions is >4.5 in these patients .
◦ TREATMENT:
◦ 2% clindamycin cream treatment of choice

33. ATROPHIC VAGINITIS
◦ Deficency of oestrogen.
◦ Women undergoing menopause
◦ secondary to surgical removal of the ovaries,
◦ Develop inflammatory vaginitis, accompanied by an increased, purulent vaginal
discharge.
◦ They may have dyspareunia and postcoital bleeding resulting from atrophy of the
vaginal and vulvar epithelium.

34. ◦ Examination reveals
-atrophy of the external genitalia, along with a loss of the vaginal rugae.
-The vaginal mucosa friable .
-predominance of parabasal epithelial cells
TREATMENT:
◦ Atrophic vaginitis is treated with topical estrogen vaginal cream.
-Use of 1 g of conjugated estrogen cream intravaginally each day for 1 to
2 weeks generally provides relief.
-Maintenance estrogen therapy, either topical or systemic, should be
considered to prevent recurrence of this disorder

35. SEXUALLY TRANSMITTED DISEASES
◦ STD ASSOCIATED WITH WHITE DISCHARGE
- GENITAL ULCERS-
genital herpes
granuloma inguinale (donovanosis),
lymphogranuloma venereum (LGV),
chancroid and
syphilis
- STD ASSOCIATED VAGINITIS
Gonococcal
Chlamydia
Trichomonas

37. -

38. GONOCOCCAL
VULVOVAGINITIS
◦ Gram-negative intracellular diplococcus -Neisseria gonorrhoea.
◦ The vaginal squamous epithelium is resistant to gonococcal infection.
◦ The gonococci attack the columnar epithelium of glands of Skene, Bartholin,
urethra and its glands, cervix and fallopian tubes.
◦ It ascends in a piggy-back fashion attached to the sperms to reach the fallopian
tubes.

39. Signs and symptoms-
◦ Urinary frequency ,dysuria
◦ dyspareunia, rectal discomfort,
◦ vaginal discharge
◦ pruritus .
◦ Examination –
◦ swollen, painful external genitalia,
◦purulent vaginal discharge
◦erythema surrounding external urinary meatus,
◦opening of the Bartholin’s ducts, vaginitis , endocervicitis.
◦ Late clinical findings: Bartholinitis, Bartholin’s abscess, Bartholin’s cyst, tubo-
ovarian abscess, pyosalpinx, hydrosalpinx and blocked tubes.
◦ End result of chronic pelvic infection - chronic pelvic pain, dysmenorrhoea,
menorrhagia, infertility with fixed retroversion and at times dyspareunia.

40. ◦ DIAGNOSIS
◦ Gram staining of smear prepared from any suspicious discharge.
◦ Culture -Thayer–Martin medium, and McLeod chocolate agar.
◦ Complement fixation tests and PCR staining..
◦ NAAT from urine, endocervical discharge—95% sensitive
◦ Laproscopy- gonococcal and chlamydial infection showing Fitz-Hugh Curtis
syndrome

41. ◦ Treatment –
◦ Injecting cefoxitin 2.0 g IM plus probenecid 1.0 g orally
◦ followed by 14 days treatment with oral cap. Doxycycline100 mg bid for 14 days
or oral cap.
◦ Tetracycline 250 mg qid for 14 days.
Treat the male partner as well

42. CHLAMYDIA
◦ Chlamydial infection is common in young.
◦ transmitted by vaginal and rectal intercourse.
◦ caused by -Chlamydia trachomatis -Gram-negative bacterium,
◦ asymptomatic mostly- vaginal discharge, dysuria and frequency of micturition,
cervicitis.
◦ During pregnancy, abortion, preterm labour and intrauterine growth retardation
(IUGR) may occur.
◦ The cervix is the first site of infection but may spread upwards to develop PID and
spread to the partner and neonate.
◦ it may cause salpingitis and infertility,

43. ◦ Diagnosis
◦ Immunofluorescence tests on smears prepared from urethral and cervical secretion
◦ IgM can be detected -recent infection.
◦ Enzyme-linked immunosorbent assay (ELISA)
◦ Chlamydia is cultured from the cervical tissue in 5–15% of asymptomatic women.
◦ PCR- fast, highly sensitive and specific -‘gold standard’ in the laboratory diagnosis.
◦ Urine for PCR is simple.

44. ◦ Treatment-
◦ Tetracycline 500 mg and clindamycin 500 mg for 14 days are found
effective.
◦ The combination of cefoxitin and ceftriaxone with doxycycline (100 mg bid
for 14 days) or tetracycline is also useful.
◦ During pregnancy, erythromycin or amoxicillin tid or qid is given for 7 days.
◦ Contact tracing, avoidance of sex or barrier contraceptive is necessary to
avoid recurrence.

45. References-
◦ Berek and novacks
◦ Shaws gynaecology

46. THANK YOU