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Persistent or recurrent vaginal discharge
This document discusses the causes, diagnosis, and treatment of persistent or recurrent vaginal discharge. It outlines various infectious and non-infectious causes including bacterial vaginosis, candidal vaginitis, and trichomonal vaginitis. The document provides details on symptoms, signs, and tests for diagnosis. It recommends treatments for each condition such as oral and topical antifungal and antibiotic regimens. Factors that can predispose women to recurrent infections are also identified, including multiple sexual partners, STIs, and lack of barrier contraception.
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Persistent or recurrent vaginal discharge
- 1. Persistent or recurrent vaginaldischarge Aboubakr Elnashar Benha University Hospital, Egypt Aboubakr Elnashar
- 2. Causes of persistenceor recurrence I. Wrong diagnosis of the cause II. Wrong or inadequate treatment Type Dose Duration III. Persistence of predisposing factors Aboubakr Elnashar
- 3. I. Diagnosis Causes ofvaginal discharge Non-infective Physiological: pregnancy, ovulation, s stimulation Cervical ectopy Foreign bodies, such as retained tampon Vulval dermatitis Non-sexually transmitted infection Bacterial vaginosis (BV) Candidal vaginitis (CV) Sexually transmitted infection Trichomonal vaginitis (TV) Chlamydia trachomatis (CT) Neisseria gonorrhoeae (NG) Aboubakr Elnashar
- 4. 1. Symptoms TVCVBV Offensivenon offensiveDischarge: Offensive fishysmelling Vulval itching / irritation Vulval itching soreness DysuriaSuperficial dyspareunia Rarely low abdominal discomfortAboubakr Elnashar
- 5. 2. Signs TVCVBV Vulval erythemaVulvalerythema Vaginitisfissuring,oedemaAbsence of vaginitis 70%: frothy 30%: yellow Curdy (non offensive) Discharge: Thin white homogenous coating walls of vagina and vestibule 2% “strawberry” cervix Satellite skin lesions Aboubakr Elnashar
- 6. TVCVBV >4.5<4.5>4.5pH NoneNonePresentWhiff test Leukocytes; motile trichomonads seen in 80% Leukocytes, epithelial cells;yeast, mycelia or pseudomycelia seen in 80% Clue cells; rare leukocytes; lactobacilli outnumbered by profuse mixed flora, including Gram positivecocci and coccobacilli Microsc opy 3. Tests Aboubakr Elnashar
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- 8. II. Treatment Bacterial vaginosisCDC, 2010 Recommended regimen Metronidazole (Flagyl) 500 mg orally twice daily for seven days Alternative regimen Tinidazole (Fasigyn) 2 g orally for two days or 1 g for five days Clindamycin 300 mg orally twice daily for seven days Pregnancy* Metronidazole 500 mg orally twice daily for seven days Aboubakr Elnashar
- 9. Recurrent BV: European(IUSTI/WHO)Guideline, 2011 Most patients will have recurrences within 3 to 12 months, whatever treatment has been used. Suppressive regimens Metronidazole vaginal gel (Metrogel) weekly for 16 weeks Aboubakr Elnashar
- 10. Vulvovaginal candidiasis, uncomplicatedCDC, 2010 Miconazole 4% cream 5 g intravaginally once daily for three days Miconazole vaginal suppository 100-mg vaginal suppository once daily for seven days 200-mg vaginal suppository once daily for three days 1,200-mg vaginal suppository in a single dose Nystatin vaginal tablet 100,000-unit vaginal tablet once daily for 14 days Tioconazole 6.5% ointment 5 g intravaginally in a single dose Terconazole 0.4% cream 5 g intravaginally once daily for seven days Terconazole 0.8% cream 5 g intravaginally once daily for three days Terconazole vaginal suppository 80-mg vaginal suppository once daily for three days Fluconazole (Diflucan) 150 mg orally in a single dose Aboubakr Elnashar
- 11. Vulvovaginal candidiasis CDC,2010 Recurrent: 4 or more episodes/Y. Non albicans: 30% of cases. Culture: confirm diagnosis & to identify non-albicans. Initial regimen Any topical agent 7-14 days or Fluconazole 100, 150, or 200 mg orally once daily every 3rd day for 3 doses Maintenance regimen Fluconazole 100, 150, or 200 mg orally once weekly for 6 months Aboubakr Elnashar
- 12. Non-albicans VVC 1.First linetherapy: Nystatin (Nysert, Mycostatin, Nystan) pessaries once or twice nightly for 14 d. 2.2nd line: 600 mg boric acid in gelatin capsule vaginally once daily for 14 d. 3.The final resort: Amphotericin B (Fungizone) 50 mg supp for 14 d 4. If non-albicans continues to recur, Maintenance regimen: Nystatin vaginally /w Aboubakr Elnashar
- 13. Trichomoniasis: CDC, 2010 Recommendedregimen Metronidazole 2 g orally in a single dose Tinidazole 2 g orally in a single dose Alternative regimen Metronidazole 500 mg orally twice daily for seven days Pregnancy* Metronidazole 2 g orally in a single dose Aboubakr Elnashar
- 14. Persistent / recurrentTV: European (IUSTI/WHO)Guideline, 2011 {re-infection ±drug resistance} Check compliance and exclude vomiting of metronidazole. re-infection from new or untreated partners 1. Repeat course of standard treatment. Aboubakr Elnashar
- 15. 2. If thisfails: HVS or empirical treatment with erythromycin or amoxycillin {reduce B-haemolytic streptococci before retreating with metronidazole as some organisms present in the vagina may interact and reduce effectiveness of metronidazole}. 3. Metronidazole 2 to 4 g daily for 7-14 days for metronidazole- resistant strains. Aboubakr Elnashar
- 16. III. Avoiding predisposingfactors TVCVB V •multiple s partners, •other ST infections •lack of barrier contraceptive •smoking •antibiotics •diet high in refined sugars •uncontrolled DM •Douching •local irritants, perfumed products •tight-fitting synthetic clothing •vaginal douching •smoking, •IUCD •new/multiple s partners •unprotected SI •higher doses of spermicide nonoxynol-9 •shower gels, antiseptic agents and shampoo in the bath Aboubakr Elnashar
- 17.