Ultimate guide to evaluation of vaginal discharge

Introduction

Vaginal discharge is a common gynaecological symptom of various aetiologies, it usually present with excessive passage of fluid (of which composition depend on the cause) per vaginum.

N.B: Vaginal epithelium is stratified squamous epithelium hence DOES NOT

secrete any fluid. The sources of vaginal discharge are: 

• Bartholins gland
• Skene's gland
• Sebaceous glands
• Sweat gands
• Transudate through vaginal epithelium
• Cervical gland and
• Endometrium.

Causes of vaginal discharge

Physiological causes:

• Premenstrual
• Periovulatory
• Sexual excitement
• Pregnancy

Pathological causes:

• A. Infection-
• Candidiasis
• Trichomoniasis
• Bacterial Vaginosis (BV)
• Chlamydial infection
• Gonococcal infection
• Genital Herpes
• Genital TB (rare)
• B. Neoplasms
• Benign
• Cervical polyp
• Florid Condylomata Accuminata
• Sloughing of submucous fibroid
• Malignancy
• Cervical Cancer (Stage II-IV)
• Carcinoma of Vagina
• Choriocarcinoma
• Carcinoma of Vulva

• C. Others:
• Vaginal fistulae (VUF, RVF)
• Secondary infection of genital ulcers or abrasion 
• Cervical entropion
• Cervical ectropion
• Cervical erosion
• Foreign body insertion, especially in children
• Uretheral prolapse (common in children).

HOW TO TAKE HISTORY OF VAGINAL DISCHARGE

Biodata

• Name
• Age
• Gravidity (if pregnant)
• Parity

Presenting complain

• Staining of under wears (common presenting complaint)
• Excessive fluid per vaginum 

Characterise the complain

• Estimate the amount of the discharge (number of sanitary pads used per day)
• Determine how well soaked the pads are
• Colour of the discharge
• Odour of the discharge (Extremely foul smelling discharge is common in Gonorrhoe/Chlamydia/PID)
• Normal discharge is odourless, whitish but can becomes yellowish.

Ask for symptoms commonly associated with vaginal discharge

• Itching (common in Candidiasis and Trichomoniasis)
• Fever
• Ask for Dysuria and Dyspareunia
• Ask for relationship of the discharge with sexual intercourse: fishy odour discharge of Bacterial Vaginosis, it worsens during unprotected sex.
• Ask for post coital bleeding (common in Trichomonas vaginalis infection)
• Ask for suprapubic pain (common in PID)
• Ask for regularity of menses (menstrual irregularities are common in PID)
• Elate onset with menstruation, ovulation and pregnancy

NB:

• Vaginal discharge after pregnancy may be due to puerperal infection or candidiasis.
• Symptoms of Trichomonas Vaginalis often begin during or after menstruation and tend to be worse for few days after subsequent period.

Ask for history of predisposing factors to identify the cause

• Vaginal douching
• Hx of Genital prolapse, vaginal fistulae
• Hx of predisposing factors to vagina candidiasis.
• Long term use ofsteroids
• Recurrent use of Antibiotics
• Use of cytotoxic drugs
• HIV/AIDS infection
• Pregnancy
• Tight clothing
• Multiple sexual partners
• Unprotected sexual intercourse
• Poor hygiene

N.B:

Classical features of pathologic discharges and causes are given in the

table below:

EXAMINATION OF VAGINAL DISCHARGE

General physical examination

• No specific sign

Abdomen

• Lower abdominal tenderness (PID)

Vaginal examination

Inspection

• Vulva often wet, scratch marks (may be present).
• Check for:
• Colour and odour
• Growth around or protruding through the intriotus
• Genital ulcers and its features
• Redness, soreness around the vulva
• Urinary/Faecal incontinence.

N.B:

Candida discharge is cheesy, curdy, whitish and thick.

Speculum examination

• Punctate haemorrhage on the cervix/ vaginal wall (STRAWBERRY APPEARANCE).
• May reveal cervical ectropion

Digital examination

• Excitation Tenderness (- PID).

INVESTIGATIONS

Wet Mount (with 2mls of N/S)

• Trichomonas vaginalis = CONE shaped, flagellated organism with terminal spikes and 4 flagellae in amoeboid motion.
• For Candida Albicans (10 - 20% KOH) = long pseudohyphae.
• Bacterial vaginosis = clue cells

Culture and sensitivity.

• Nikerson's / sabouraud's Agar = Candida albicans
• Fernberg Whitting / Diamond Agar = T. vaginalis

For bacterial vaginosis

• Gram stain
• Vaginal pH> 4.5 (normal = 3.8-4.2)
• Fishy odour with 10% KOH (SNIFF or Whiff Test).
• Homogenous, copious, Thin, Gray-like discharge.
• Clue cells (vaginal epithelium coated with bacteria especially Gadnerella Vaginalis)
• Pap smear for T. vaginalis (50-60% Sensitive)
• Monoclonal antibody to Trichomonas vaginalis

N.B: In recurrent / chronic candidiasis (= 4 episodes/year) screen for DM & HIV.

TREATMENT OF VAGINAL DISCHARGE

Base on aetiology
I. BACTERIALVAGINOSIS

• Metronidazole 500mg bd x7 days (non pregnant) / single 2g, 250mg tds (pregnant).
• Clindamycin can be used.
• N.B: in case of recurrence, treat for 10-14days.

II. TRICHOMONAS VAGINALIS: 

• As above.
• Avoid unprotected sex during treatment.
• Treat male partners.
• For persistent infection treat for 4-6 weeks.

III. CANDIDIASIS:

• Topical 
• Intravaginal clothrimazole, cotrimoxazole or other imidazoles for 3 - 7days (uncomplicated) or 10-14 days if (complicated)
• OR
• Nystatin 100,000IU (high vaginal) noctel for 14 days
• Systemic
• Fluconazole or other systemic antifungals

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