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DISCHARGES VAGINAL DISCHARGE VAGINAL

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DISCHARGES VAGINAL DISCHARGE VAGINAL Powered By Docstoc
					             DISCHARGES
                                                           QUESTION 1

                                               List 8 causes of discharge in a female
Dr Jenny McCloskey
Sexual Health Clinic                           List 5 causes of discharge in a male
Royal Perth Hospital




               QUESTION                              VAGINAL DISCHARGE

 List the anatomical sites of discharge in a
   female




        VAGINAL DISCHARGE                           Gram negative intracellular
        SOURCES OF ORIGIN                                  diplococci

• Vaginal

• Cervical

• Upper genital tract




                                                                                        1
                                                             VAGINAL DISCHARGE
                 Discharge
                                                              VAGINAL CAUSES
                                                 • Physiological
                                                 • Pathological
                                                    –    Bacterial vaginosis
                                                    –    Candidiasis
                                                    –    Trichomoniasis
                                                    –    Desquammative inflammatory vaginitis
                                                    –    Foreign body
                                                    –    Atrophic vaginitis
                                                    –    Non-specific vaginitis




       VAGINAL DISCHARGE                              VAGINAL DISCHARGE
        CERVICAL CAUSES                           UPPER GENITAL TRACT CAUSES
• Physiological                                  • Associated with anaerobic infection                  &
• Pathological                                     – Gonorrhoea
  – Gonorrhoea                                     – Chlamydia
  – Chlamydia                                      – Bacterial vaginosis
  – Mucopurulent cervicitis & large area
    of exposed cervical columnar                   – Retained products of conception
    epithelium                                     – Carcinoma
  – Carcinoma




                                                             VAGINAL DISCHARGE
              QUESTION 2                                  TESTING TO ESTABLISH THE
                                                           DIAGNOSIS: sites of testing
    List the tests you would perform to          Urethra & Endocervix        gonorrhoea
                                                                             chlamydia
    establish a diagnosis of vaginal discharge
                                                 Vagina                      trichomoniasis
                                                                             bacterial vaginosis
    List the anatomical sites you would take                                 candidiasis
    samples from                                                             non-specific vaginitis
                                                                             DIV
                                                                             anaerobic overgrowth
    List the tests in order of anatomical                                    Gram negative overgrowth
    collection                                                               atrophic vaginitis


                                                 Vulva                       candidiasis




                                                                                                            2
          VAGINAL DISCHARGE
       TESTING TO ESTABLISH THE
              DIAGNOSIS                           TAKING THE MEDICAL HISTORY

• Urethra                                           •   Type of discharge
• MC&S for gonorrhoea                               •   Duration
                                                    •   Dyspareunia
  PCR for Chlamydia (+/- PCR GC)
                                                    •   Dysuria
• Vagina MC&S                                       •   Pelvic pain
• Cervix                                            •   Other symptoms
  MC&S for gonorrhoea                               •   Menstrual history
                                                    •   Symptoms in partner
  PCR for Chlamydia (+/- PCR GC)                    •   No. sexual partners, LSI
Skin fungal M&C if Candida suspected                •   PH STD’s, treatment to date allergies
Rectal & throat MC&S for gonorrhoea &               •   Missed contraception
  chlamydia




        CLINICAL EXAMINATION                         Focus on Vaginal Discharges

•   General physical examination                 • Three key tests required:
•   Genital examination
•   Pubic area
•   Lymph nodes                                    –Vaginal pH measurement
•   Vulva                                          – Gram stain slide of vaginal secretion
•   Perianal area                                  – Culture of swab , sensitivities if
•   Vagina                                           appropriate
•   Cervix
•   Pelvic examination




                 QUESTION 3                               Measuring Vaginal pH

     Write down the normal vaginal pH for a      How to take the measurement
      female post puberty, premenopause

     Write down the vaginal pH for a post
      menopausal woman

     List 3 pathological causes of an elevated
       vaginal pH

     List 3 causes of a false high vaginal pH
       reading




                                                                                                3
           Measuring Vaginal pH                         NORMAL VAGINAL pH

The normal values                                  Write down the normal vaginal pH for a
  normal vaginal pH for a female post puberty,      female post puberty, premenopause
    premenopause
                                                     3.8 – 4.7
    3.8 – 4.7
                                                   Write down the vaginal pH for a post
  post menopausal woman                             menopausal woman

     6-7                                             6-7




           VAGINAL pH PAPER                             Measuring Vaginal pH

                                                 False high pH readings
                                                 Sexual intercourse with in the last
                                                  24/24
                                                 Measuring cervical secretion instead
                                                 Touching the pH paper with your glove
                                                 Chemical products in the vagina
                                                 Patient menstruating




Diseases with an elevated vaginal                 Diseases with an normal vaginal
               pH                                               pH
Bacterial vaginosis
Trichomoniasis
Atrophic vaginitis including oestrogen
  deficiency in breast feeding women
                                                    Candidiasis
Absent lactobacillus syndrome
                                                    Non-specific vaginitis
Desquammative inflammatory vaginitis
Gram negative overgrowth                            Chlamydia
Anaerobic overgrowth                                Gonorrhoea
                                                    Group B Streptococcal overgrowth




                                                                                            4
  Focus on Vaginal Discharges                   ELEVATED VAGINAL pH & HIV

       • Three key tests required:           • Low vaginal pH hostile for the HIV virus
                                               & infected lymphocytes
         – Vaginal pH measurement
         –Gram stain slide of vaginal          -? increased vaginal pH associated
          secretion                                with increased infectivity
         – Culture of swab , sensitivities
                                               -? high pH may contribute to
         – Role for vaginal cytology
                                                  increased susceptibility to HIV




           QUESTION 4                          GRAM STAIN GENITAL SMEARS

List the laboratory features that should
be commented on on a gram stain
smear of genital discharge




 LOW POWER VAGINAL GRAM                           LABORATORY GRAM STAIN
       STAIN SMEAR                                     REPORTING
                                             Polymorphs          + ++ +++
                                             Epithelial cells    mature/ immature
                                             GNID                seen/ not seen
                                             Trichomonads        seen/ not seen
                                             Yeasts              seen/ hyphae/ not seen
                                             Clue cells          seen/ not seen
                                             Lactobacilli        + ++ +++
                                             Bacterial flora     normal- or comment
                                             Vaginal pH          normal or elevated




                                                                                          5
          The Gram Stain Slide                                    The Gram Stain Slide

Quantitation & reporting terminology                   What information can it give you?
     +            ++           +++                     Information about the cells
     Few          moderate     many                    White cells           <     3-30 >30
     Scanty       moderate     plentiful               Red cells             +     ++ ++
     <5           5-30         >30                     Epithelial cells      +     ++ +++
                                                                             mature vs immature
  Seen     Not seen
                                                       Need vaginal cytology at the moment to
  Detected Not detected                                  provide maturity and need to request
  Mature   Immature                                      maturity index in reporting




               Epithelial cells                                   The Gram Stain Slide

Presence says you touched the walls                    Information about pathogens
 of the lumen                                          Candida seen not seen


Immature forms are abnormal in                         Bacteria  faecal contamination
  oestrogenised women: parabasal                                 gram –ve contamination
  cells are indicative of a severe                               anaerobic streptococci
  vaginitis DIV, atrophic vaginitis                    GNIDseen /not seen
                                                        (urethral & endocervical smears only)




 The Gram Stain Slide Lactobacilli                         Focus on Vaginal Discharges

What information can it give you in a normally         • Three key tests required:
 oestrogenised woman?

Absent few moderate plentiful                            – Vaginal pH measurement
Absent or few is abnormal
                                                         – Gram stain slide of vaginal secretion
Moderate or many is normal
Sometimes the laboratories don’t give you this
  fundamental information
                                                         –Culture of swab ,
                                                          sensitivities if appropriate
Need active reporting from the laboratory
If lactobacilli are missing there is something wrong




                                                                                                   6
                   Cultures                                              QUESTION 5

 What information can it give you?                     Using these features write the laboratory
                                                       comments for a vaginal gram stain
 Useful for known pathogens                            smear from a patient with the following
 Misleading for some bacteria? Gp B
   streptococcal overgrowth                               Bacterial vaginosis
 Anaerobic overgrowth not reported                        Candidiasis
 Trichomoniasis often not looked for                      Atrophic vaginitis
 Need Candida speciation if refractory
   Candidiasis
                                                          Gram negative bacterial overgrowth




      LOW POWER GRAM STAIN
                                                               WHAT IS A CLUE CELL?
      OF BACTERIAL VAGINOSIS




                                                   Vaginal epithelial cells coated with large numbers of bacteria that
                                                   obscure the cell border: G. vaginalis, Mobiluncus, Bacteroides




     LABORATORY FEATURES OF                                    BACTERIAL VAGINOSIS
       BACTERIAL VAGINOSIS                                         SYMPTOMS
Polymorphs           + (occ ++)                      • None
Epithelial cells     mature
                                                     • Vaginal discharge
GNID                 not seen
                                                        – Thin/ grey/ white
Trichomonads         not seen
Yeasts               not seen                        • Odour
Clue cells           seen
Lactobacilli         + or absent                     • Odour worse after SI or during menstruation
Bacterial flora      gram variable cocco-bacilli
                                                     • Vulvar pruritis- irritation uncommon
Vaginal pH           > 4.5
                                                     • Not an inflammatory condition




                                                                                                                         7
          BACTERIAL VAGINOSIS
                                                      QUESTION 9
              DIAGNOSIS
 • 3 of 4 of AMSEL’S CRITERIA             List 5 complications associated with
 (1) Vaginal discharge                    bacterial vaginosis

 (2) Vaginal pH >4.5

 (3) Odour or positive KOH test

 (4) Clue cells on microscopy




          COMPLICATIONS OF BV                Bacterial vaginosis: treatment

 •   PID                                 • Metronidazole or tinidazole 2gm stat
 •   Post-abortal PID
 •   Post hysterectomy infections        • Metronidazole 400mg bd 7/7
 •   Preterm delivery                    • Clindamycin 2% vaginal cream 5g
 •   PROM                                      PV for 7 days
 •   Amniotic fluid infection
                                         • TOC 1 week later
 •   Chorioamnion infection
 •   Postpartum endometritis             • Absence of lactobacilli predictor of
 •   Cerebral palsy                           relapse
 •   ? Increased risk of HIV infection




      LABORATORY FEATURES OF
                                          MICROSCOPY OF CANDIDIASIS
            CANDIDIASIS
Polymorphs               + ++ +++
Epithelial cells         mature
GNID                     not seen
Trichomonads             not seen
Yeasts                   seen/ hyphae
Clue cells               not seen
Lactobacilli             ++ +++
Bacterial flora          normal
Vaginal pH               normal (4.5)




                                                                                  8
WET PREPARATION                 CANDIDIASIS




   CANDIDIASIS                  CANDIDIASIS




VULVAL DERMATITIS     CANDIDIASIS CLASSIFICATION

                    • Vulval

                    • Vaginal

                    • Vulvovaginal

                    • Recurrent ≥4 episodes /year




                                                    9
   TREATMENT OF CANDIDIASIS                             TREATMENT OF CANDIDIASIS

• POLYENES                                         • TRIAZOLES
   – Nystatin
                                                        – Fluconazole
• IMIDAZOLES
   –   Clotrimazole
   –   Miconazole                                       – Itraconazole
   –   Econazole
   –   Ketoconazole
                                                   All fungistatic causing inhibition of fungal
                                                     ergosterol synthesis
All fungistatic causing inhibition of fungal
  ergosterol synthesis




                                                        RECURRENT VULVO-VAGINAL
    DIAGNOSIS OF CANDIDIASIS
                                                              CANDIDIASIS
• Vaginal tests for vaginal involvement            •   Is it recurrent?
• Vulval tests for vulval involvement              •   Is it persistent
                                                   •   Is it a non-albicans strain?
TREATMENT
                                                   •   Is is something else such as non-
Vaginal Rx for vaginal disease
                                                       specific vaginitis or BV or genital
Vulval Rx for vulval symptoms
                                                       herpes?

Hydrocortisone if allergic component




       RECURRENT CANDIDIASIS                           What sorts of Candida are there?

• Microbiological confirmation of the diagnosis    Candida albicans
  is essential
                                                   Candida glabrata
• Determine if the infection is persistent or      Candida tropicalis
  recurrent                                        Candida parapsilosis
   – Speciation of organism if persistent
                                                   Candida kruseii
• Is there an associated non-specific vaginitis?
  Normal lactobacilli count but increased WCC




                                                                                                  10
          VULVAL CANDIDIASIS                          VULVAL CANDIDIASIS
             TREATMENT                                   TREATMENT
•   Perineal hygiene                        •   Diet or weight loss may help
                                            •   Exclude diabetes
•   Cotton or no underwear
                                            •   Prophylactic antifungal Rx with antibiotics
•   Wash and dry after SI                   •   Consider investigation & Rx of partner
•   Avoid irritants to the genital skin     •   Eat yoghurt daily
•   Try sunlight for vulval symptoms        •   Optimism
                                            •   Weekly fluconazole for 6 months




                                                        TRICHOMONIASIS
         PRURIGO NODULARIS
                                                       SYMPTOMS & SIGNS
                                                         •   Often no symptoms
                                                         •   Vaginal discharge
                                                         •   Odour with SI
                                                         •   Vaginal pH ≥4.5
                                                         •   Positive whiff test
                                                         •   Inflammation
                                                         •   Microscopic ulceration




          TRICHOMONIASIS                         LABORATORY FEATURES OF
         COMPLICATIONS & RX                         ATROPHIC VAGINITIS
• Increased pre-term delivery              Polymorphs          +++
                                           Epithelial cells           immature
                                           GNID                       not seen
• ? increased risk of HIV acquisition      Trichomonads               not seen
                                           Yeasts                     not seen
• ? more infectious if infected with HIV   Clue cells                 not seen
                                           Lactobacilli               absent
                                           Bacterial flora            diptheroids, gram -ve
• Metronidazole or tinidazole 2 gm stat    Vaginal pH                 elevated
                                           Consider vaginal cytology to assist with Dx.
                                           Low oestrogen levels




                                                                                              11
        VAGINAL INFLAMMATION                      VAGINAL INFLAMMATION




          DESQUAMMATIVE                              DESQUAMMATIVE
      INFLAMMATORY VAGINITIS                     INFLAMMATORY VAGINITIS
 • Purulent vaginal
   discharge                                                          Microscopy:
 • Elevated vaginal pH                                                •absent lactobacilli
 • Rx clindamycin 2%                                                  • PMN +++
   vaginal cream                                                      • gm +ve cocci +++
      5gm PV 2 weeks                                                  • parabasal cells
      30% relapse                                                     • no clue cells
      rate




  LABORATORY FEATURES OF
                                           Absent Lactobacillus Syndrome
 GRAM-NEGATIVE OVERGROWTH
Polymorphs         +++                  Polymorphs         +
                                        Epithelial cells   mature
Epithelial cells   mature
                                        GNID               not seen
GNID               not seen             Trichomonads       not seen
Trichomonads       not seen             Yeasts             not seen
Yeasts             not seen             Clue cells         not seen
                                        Lactobacilli       absent
Clue cells         not seen
                                        Bacterial flora    normal
Lactobacilli       +                    Vaginal pH         ≥5
Bacterial flora    gm –ve bacilli +++
Vaginal pH         elevated             Culture            No pathogens detected




                                                                                             12
     LABORATORY FEATURES OF
                                                                     QUESTION 6
        ATROPHIC VAGINITIS
Polymorphs           +++                               List the local complications that should
Epithelial cells     immature                          be looked for in a patient with a genital
GNID                 not seen                          discharge
Trichomonads         not seen
Yeasts               not seen
Clue cells           not seen
Lactobacilli         absent
Bacterial flora      diptheroids, gram -ves
Vaginal pH           elevated
Consider vaginal cytology to assist with Dx




                                                       LOCAL SIGNS & SYMPTOMS OF
                   Non-specific vaginitis
                                                              GONORRHOEA
Polymorphs              +++       sometimes <5, 5-30
Epithelial cells        mature
                                                             • SYMPTOMS
GNID                    not seen                               –   Vaginal/ rectal discharge
Trichomonads            not seen                               –   Dysuria
Yeasts                  not seen                               –   Sore throat, swelling
Clue cells              not seen                               –   Abdominal/ pelvic pain
Lactobacilli            present                              • SIGNS
Bacterial flora         normal                                 –   Discharge
Vaginal pH              ≤5                                     –   Red friable os
Culture                 No pathogens detected                  –   Cervical/ adnexal excitation
Clinical findings of erythema paramount                        –   Tenderness
                                                               –   Bartholinitis




                                                       DISSEMINATED SYMPTOMS &
                      QUESTION 7
                                                         SIGNS OF GONORRHOEA
   List the systemic complications that                     • SYMPTOMS
   should be observed for in a patient with                   –   Fever
                                                              –   Skin lesions
   a genital discharge.
                                                              –   Sore joints
                                                              –   Cardiac- SOB etc
                                                              –   Neurological- headache etc
                                                            • SIGNS
                                                              –   Skin rash
                                                              –   Arthritis
                                                              –   Endocarditis
                                                              –   Meningitis




                                                                                                   13
                                    Number of gonorrhoea notifications,                                                                                                          Number of gonorrhoea notifications by Aboriginality, WA,
                                            WA, 1990 to 2004                                                                                                                                                            01/01/2003 to 31/12/2004
                          1,600                                                                                                                                                   450
                                                                                                                                                                                                                                                                                           WA (Total)
                          1,400                                                                                                                                                   400


                          1,200                                                                                                                                                   350
Number of Notifications




                                                                                                                                                       Number of Notifications
                                                                                                                                                                                  300
                          1,000
                                                                                                                                                                                  250
                            800                                                                                                                                                                                                                                                              Aboriginal
                                                                                                                                                                                  200
                            600
                                                                                                                                                                                  150
                            400
                                                                                                                                                                                  100

                            200                                                                                                                                                   50                                                                                                     non-Aboriginal


                                0                                                                                                                                                   0
                                     1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004                                                                           Mar-03        Jun-03          Sep-03         Dec-03      Mar-04       Jun-04          Sep-04       Dec-04
                                                                                       Year                                                                                                                                                Quarter
                                                                                                                                  Data courtesy HDWA                                                                                                                                 Data courtesy HDWA
                                                                                       WA (Total)                                                                                                                         Aboriginal        non-Aboriginal      WA (Total)




                          Penicillin Resistant N. gonorrhoeae Jan - Dec 2004 WA                                                                                                         High-level Tetracycline Resistant N. gonorrhoeae (TRNG) Jan - Dec
                                                   WAGSP                                                                                                                                                         2004 WA WAGSP
                                                                                                                                                                                  50%
                           50%                                                                                                                                                                      Metropolitan                                                Non-metropolitan
                                                  Metropolitan                                               Non-metropolitan                                                     45%
                           45%
                                                                                                                                                                                  40%
                           40%

                           35%                                                                                                                                                    35%
    Proportion Resista




                                                                                                                                                             Proportion Resista




                           30%                                                                                                                                                    30%

                           25%                                                                                                                                                    25%

                           20%
                                                                                                                                                                                  20%
                           15%
                                                                                                                                                                                  15%
                           10%
                                                                                                                                                                                  10%
                           5%
                                                                                                                                                                                   5%
                           0%
                                    1998   1999     2000   2001   2002   2003   2004      1998      1999     2000   2001   2002      2003     2004
                                                                                                                                                                                   0%
                                                      Plasmid mediated (PPNG)            Chromosomally mediated (CMRNG)                                                                   1998   1999   2000     2001     2002   2003     2004   1998    1999   2000     2001    2002    2003    2004




Quinolone Resistant N. gonorrhoeae (QRNG) Jan - Dec 2004 WA WAGSP
                          50%
                                                   Metropolitan                                             Non Metropolitan                                                                                     BARTHOLINITIS
                          45%


                          40%


                          35%
   Proportion Resista




                          30%


                          25%


                          20%


                          15%


                          10%


                           5%


                           0%
                                    1998   1999     2000   2001   2002   2003   2004      1998      1999     2000   2001   2002       2003    2004

                                                                            CIP LS                  CIP R




                                                                                                                                                                                                                                                                                                          14
                              GRAM-NEGATIVE
      CERVICITIS         INTRACELLULAR DIPLOCOCCI:
                                   GNID




GONOCOCCAL TONSILLITIS    GONOCOCCAL OPTHALMIA




                                                     15
                                                     COMPLICATIONS OF
              QUESTION 8
                                                  GONORRHOEA & CHLAMYDIA
  List 5 untreated complications of           •   PID
  gonorrhoea or chlamydia.                    •   Endometritis
                                              •   Salpingitis
                                              •   Tubo-ovarian abscess
                                              •   Pelvic peritonitis
                                              •   Ectopic pregnancy
                                              •   Dyspareunia
                                              •   Infertility
                                              •   Fitz-Hugh Curtis syndrome




                                                            GONORRHOEA

                                              • Look for other infections:
                                                  – 30-50% will have another infection
                                                  – Make sure the patient is not pregnant
                                                    & that the Rx is safe to give in pregnancy
                                                  – Wherever possible give directly observed
                                                    therapy




 TREATMENT OF GONORRHOEA                            CHLAMYDIA TRACHOMATIS

• Ceftriaxone 250 mg IM or slow IV infusion   Predictors of infection
• Spectinomycin 2 gm stat if penicillin       • Age <25 years
  sensitive
                                              • Cervicitis
• 1gm azithromycin for chlamydia
                                              • Friable cervix
• TOC in 1 week and again a week later        • Multiple partners
                                              • New partners
• Always perform rectal swabs in women        • Symptomatic partners
  with gonorrhoea or who are contacts of      • Previous history of chlamydia infection
  gonorrhoea




                                                                                                 16
                                     CHLAMYDIA TRACHOMATIS                                                                                                                CHLAMYDIA TRACHOMATIS

                              • Clinical               Urethritis                                                                                              • TREATMENT
                                                       Cervicitis- contact bleeding
                                                                                                                                                                 Azithromycin 1 gm stat
                                                       Endometritis
                                                       Salpingitis                                                                                               Doxycycline 100 mg bid for 10 days
                                                       Asymptomatic                                                                                              Erythromycin 400 mg qid for 10 days

                              • Sequalae               Infertility
                                                                                                                                                               • TOC in 3 weeks and 3 months
                                                       Pelvic pain
                                                       Ectopic pregnancy
                                                       Perinatal infection




                                                                                                                                                             Number of chlamydia notifications, WA, 1993 to 2004

                                                                                                                                                           5,000

                                                                                                                                                           4,500

                                                                                                                                                           4,000
                                                                                                                                 Number of Notifications




                                                                                                                                                           3,500

                                                                                                                                                           3,000

                                                                                                                                                           2,500

                                                                                                                                                           2,000

                                                                                                                                                           1,500

                                                                                                                                                           1,000

                                                                                                                                                            500

                                                                                                                                                              0
                                                                                                                                                                   1993   1994   1995   1996   1997   1998   1999     2000   2001   2002    2003      2004
                                                                                                                                                                                                         Year
                                                                                                                                                                                                                                           Data courtesy HDWA
                                                                                                                                                                                                         WA (Total)




                            Number of chlamydia notifications by Aboriginality, WA,
                                       01/01/2003 to 31/12/2004
                          1,200

                                                                                                                   WA (Total)
                          1,000
Number of Notifications




                           800


                           600

                                                                                                              non-Aboriginal
                           400


                           200
                                                                                                                  Aboriginal


                             0
                                  Mar-03   Jun-03   Sep-03         Dec-03     Mar-04    Jun-04       Sep-04          Dec-04
                                                                                                     Data courtesy HDWA
                                                                       Quarter
                                                                                                            Data courtesy HDWA
                                                      Aboriginal       non-Aboriginal   WA (Total)




                                                                                                                                                                                                                                                                17
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