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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
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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
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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
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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
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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)
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WET PREPARATION CANDIDIASIS
CANDIDIASIS CANDIDIASIS
VULVAL DERMATITIS CANDIDIASIS CLASSIFICATION
• Vulval
• Vaginal
• Vulvovaginal
• Recurrent ≥4 episodes /year
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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
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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
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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
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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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