Based on gynecology by ten teachers

1. Vaginal Discharge
By Maira Shahid & Syed Sami Haider
Roll # 234 & 239
Clinical Group G3

2. References
– Obstetrics and Gynecology, Elmar Skala. BRS.
Lippincot Williams and Wilkins.
– www.emedicine.com

3. Out Line
• Background & Terminology
• Normal Vaginal Ecosystem
• Clinical approach
• Common Causes
1. Bacterial vaginosis
2. Candida vaginitis
3. Trichomonas vaginitis
• Uncommon Causes

4. Background & Terminology

5. Background & Terminology
Vaginal discharge s the most common gynaecologic condition
encountered by physicians in the office .
I. Pathophysiology : Disturbance of the normal vaginal pH
and estrogen levels can alter the vaginal flora, leading to
overgrowth of pathogens. Factors that alter vaginal
environment include feminine hygiene products,
contraceptives, vaginal medications, antibiotics, STDs,
sexual intercourse, and stress.
II. Frequency : Difficult to determine. 5-15% of visits.
III. Mortality/Morbidity :
o chronic irritation, excoriation, and scarring.
o STD
o PID
o increased risk of premature rupture of the membranes,
preterm labour, and preterm delivery.

6. Background & Terminology
IV. Terminology
i. Vaginitis : significant inflammatory response in
vaginal wall. Accompanied by high number of
leukocytes in vaginal fluid. Found with candida
and trichomonas infections.
ii. Vaginosis : minimal inflammatory response
with few leukocytes in vaginal wall. Associated
with increase in bacterial concentrations.
iii. Leukorrhoea : a non-infective, non-bloodstained
physiological vaginal discharge.

7. Normal Vaginal Ecosystem

8. Normal Vaginal Ecosystem
I. Characteristics :
A dynamic equilibrium exist between the intact
stratified epithilium, normal colonizing
microorganisms, and local secretory ( hormonal)
and cellular immune factors.
Vaginal pH is low ( 3.8- 4.2)
i. Estrogen increases vaginal epithilial glycogen.
ii. Glycogen is metabolized by lactobacilli into lactic acid
iii. pH is acidic and is unfavorable for pathogens

9. Normal Vaginal Ecosystem
II. Normal Flora :
i. Lactobacilli :
• Found in 96% of women
• Concentrations 105 to 108 / ml.
• Protective effect by interfering with adherence to
epithilial cells
i. Facultative organisms :
• Diphtheroids – streptococci – E.coli – ureapalasma
urealyticum – mycoplasma hominis
i. Anaerobic organisms :
• Peptostreptococci – bacteroid - fusobacterium

10. Normal Vaginal Ecosystem
III. Normal secretions
i. Composition and Derivation :
o water as transudate from vaginal wall
o desquamated epithelial cells
o cervical mucus this is 90% water
o uterine and tubal secretions (e.g. incl. blood when
menstruating)
o a few leucocytes / polymorphs
i. Variable dependent on multiple factors :
o Age
o Timing of Menstrual Cycle
o Sexual arousal
o Contraceptive use
o Douching

11. Clinical Approach

12. Clinical approach
I. History:
o Source of discharge must be determined. Perineal discharge could
originate from vagina, cervix, urinary tract and rectum
o Ascertain the following attributes of the discharge: quantity, duration,
colour, consistency and odour.
o Symptoms include : itching or burning . External Dysuria, Dyspareunia
o Obtain history of the following:
• Prior similar episodes
• Sexually transmitted infection
• Sexual activities
• Birth control method
• Last menstrual period
• Douching practice
• Antibiotic use
• General medical history
• Systemic symptoms such as lower abdominal pain, fever, chills, nausea,
and vomiting.

13. Clinical approach
II. Physical Exam :
o Appearance of discharge.
o Erythema and edema of vaginal mucosa
o pH levels
II. Diagnostic Tools:
o pH : Nitrazine paper
o Wet prep: microscopic examination of discharge ( clue
cells of BV)
o KOH prep: dissolves cellular debris leaving
pseudohyphae of candida.
o Whiff test: Fishy odor of BV
o Culture

14. Common Causes

15. Common Causes
I. Normal discharge (30%)
II. Bacterial Vaginosis (23-50%)
III. Candida Vulvovaginitis (20-25%)
IV. Trichomonas vaginitis (5-15%)
V. Mixed infection or Sexually Transmitted
Disease (20%)

16. Common Causes
I. Bacterial Vaginosis
i. Most common cause of vaginal complain. Up to 50% are
asymptomatic.
ii. Increase in anaerobic organisms.
iii. Diagnosis: Amsel's criteria
• Gray, homogeneous discharge adherent to walls
• pH > 4.5
• Fishy odor with KOH
• Clue cells on wet prep
i. Treatment:
• Symptomatic gynecologic and obstetric patients.
• Selected asymptomatic gynecologic patients ( e.g. undergoing
surgery)
• Selected asymptomatic obstetric patient (e.g. SROM or preterm
labor)

17. Common Causes
I. Bacterial Vaginosis
v. Medication: CDC 1998
1. Oral: metronidazole 500mg bid for 7 days, or
clindamycine 300mg bid for 7 days.
2. Vaginal: metronidazole gel 0.75% bid for 5 days, or
clindamycine cream 2% for 7 days.
NO TREATMENT OF SEXUAL PARTNER IS NEEDED

18. • Homogeneous
discharge adhering to
vaginal walls.
• Discharge in cervix

19. • Clue cell on wet prep

20. WWhhiiffff TTeesstt
The vaginal discharge of patients with BV has a
characteristic fishy odor due to increased activity of
anaerobic species. Addition of KOH will augment this
odor.

21. Common Causes
II. Candida Vaginitis:
i. 2nd most common. C. albicans, C. tropicalis, C. glabrata
are all causative agents.
ii. Risk factors include:
1. Altered immune status
2. Increased glucose levels
3. Decreased lactobacilli concentrations.
i. Diagnosis :
1. Itching and burning. vulvar burning, dyspareunia, and vulvar
dysuria
2. Clinically, vulvar erythema and edema with satellite lesions
(discrete pustulopapular lesions)
3. Whitish discharge varying from thin to crud consistency.
cottage cheese–like .
4. Vaginal pH is usually normal.
5. KOH prep : psudohyphea ( 100% specific)

22. Common Causes
II. Candida Vaginitis:
1. Management : CDC, 1998.
1. Vaginal antifungal creams : butaconazole,
clotrimazole, miconazole for 7- 14 d.
2. Oral antifungal : fluconazole in a single 150 mg dose.
NO TREATMENT OF SEXUAL PARTNER IS NEEDED

23. the Whitish discharge of candidiasis varying from
thin to crud consistency. Cottage cheese–like .

24. Common Causes
III. Trichomonas Vaginitis :
i. Protozoa. Most common cause of vaginitis world wide.
• Humans are the only host
• Sexually transmitted
i. Diagnosis :
• Vulvar erythema and edema
• A profuse, malodorous, forthy, yellowish discharge.
• Trichomonas cervicitis with red, punctuated lesions
( strawberry patches).
• Vaginal pH > 4.5
• Wet prep: detects 70%
• Culture: is most sensitive.

25. Common Causes
I. Trichomonas Vaginitis :
iii. Management : CDC, 1998
Metronidazole 500 mg PO bid for 7 days
TREATMENT OF SEXUAL PARTNER IS NEEDED

26. • Flagellated protozoa :
Trichomonas
• Trichomonas as it
appears on wet prep

27. Uncommon Causes

28. Uncommon Causes
• Atrophic vaginitis
• Infectious Cervicitis
– Neisseria gonorrhoeae
– Chlamydia trachomatis
– Herpes Simplex Virus
• Vaginitis or Vulvitis
– Vaginal or vulvar trauma
– Irritant Contact Dermatitis
– Vulvar Vestibulitis
– Malignancy
• Cervical polyp and malignancy.

29. Uncommon Causes
I. Atrophic Vaginitis:
1. Etiology: Extremely low estrogen production.
Vulvovaginal atrophy is considered a natural process
after estrogen withdrawal; atrophic vaginitis, however,
is not.
2. Clinical : The most common symptom is vaginal
spotting . vaginal soreness, postcoital burning,
dyspareunia, burning leukorrhea also present.
3. Exam: The vagina is noted to be thin, with occasional
petechia and diffuse redness with few or no vaginal
folds. Vaginal pH 5-7.
4. Treatment : Topical estrogen for 1-2 weeks
symptomatically.

30. Uncommon Causes
III. Vulvar Vestibulitis:
Unknown etiology. Many theories present including candida, HPV,
previous surgery, chemical irritants
Freidrich’s criteria
1. severe pain upon touching the vestibule or attempted vaginal
entry,
2. tenderness to pressure localized within the vulvar vestibule,
and
3. physical findings confined to vestibular erythema of various
degrees.
Clinical:
1. young, sexually active
2. Usual symptoms include pain, soreness, burning.
3. pain usually is not considered constant; it is elicited by any
attempt to enter the vagina
4. Irritating vaginal discharge
5. pelvic examination typically reveals no physical findings.
Treatment :
Symptomatic with life style modification

31. Uncommon Causes
II. STD :
Were discussed in previous
presentation.
Chlamydia
Gonorrhea

32. Uncommon Causes: Chlamydia
• Symptoms: 70% show no symptoms; abnormal vaginal
discharge &/or bleeding, abnormal cramping, abdominal pain,
fever, painful urination.
• Incubation: 1 to 4 weeks
• Organism: Chlamydia trachomatis & Ureplasma urealyticum,
Infectivity: people can infect other when they have
symptoms & some times when they do not, the partner is
infected in approximately 33% of the sexual contacts with an
infected partner.
• Treatment: antibiotics
• If Untreated: pelvic inflammatory disease, ectopic
pregnancies, sterility
• Prevention: limit the number of sexual partner & use
condoms & spermicides

33. Uncommon Causes: Gonorrhea
• Symptoms: foul smelling vaginal discharge &/or bleeding,
abnormal cramping &/or painful urination;
• Incubation: 2 to 7 days
• Infectivity: people can infect others when they have
symptoms & some times when they do not; women are more
easily infected by men than vice versa; the partner is infected
in approximately 25% of the sexual contacts with an infected
partner
• Treatment: antibiotics
• If Untreated: pelvic inflammatory disease, ectopic
pregnancies, sterility, arthritis, heart problems, blindness
• Prevention: limit number of sexual partners & use condoms &
sperimicides

34. Uncommon Causes
IV. Tumors :
• Must be ruled out
• Include:
1. Vaginal cancer
2. Cervical cancer

35. Uncommon Causes
I. Cervical Cancer:
1. 3rd most common female reproductive malignancy
(20%)
2. Risk factors include : age > 45 years, HPV 16-18,
multiple sexual partners, smoking.
3. Clinically, vaginal bleeding with discharge.
However, early stages are asymptomatic
4. Screening by PAP smear. Definite diagnosis by
biopsy.
5. Surgical staging is not needed.
6. Management : surgical according to clinical stage.