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Management of Vaginal Discharge

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Management of Vaginal Discharge VAGINAL DISCHARGE MANAGEMENT OF VAGINAL DISCHARGE Vaginal discharge may be entirely normal, or a sign of infection. In either case, it is a relatively common presentation in general practice and deserves some attention. The normal anatomy, physiology and microbial ecology of the vagina are age- dependent as are the sources of vaginal infections. In the neonatal period, the vagina is influenced by maternal oestrogen and has a stratified squamous epithe- lium. Later, and until puberty, the vagina is lined by cuboidal cells and the pH is around 7.0. Following puberty, oestrogen causes a change to stratified squa- mous epithelium. The predominant microbial flora at this age are lactobacilli such as L. crispatus and L. jensenii, which produce lactic acid, and the pH falls to 4.0 - 4.5. The other vaginal flora include diphtheroids, β-haemolytic strepto- cocci, coliforms and coagulase-negative staphylococci.1 VAGINAL DISCHARGE IN PRE-PUBERTAL GIRLS Vaginal symptoms including a discharge in pre-pubertal girls ought to be investi- A A HOOSEN gated microbiologically as the sexually transmitted (ST) pathogens Neisseria gon- 2 MSc, MB ChB, MMed, FCPath orrhoeae and Chlamydia trachomatis may be isolated. Chief Specialist and Head Other non-ST pathogens include β-haemolytic streptococci Group A (S. pyo- Department of Microbiological Pathology genes), Shigella flexneri and Enterobius vermicularis. MEDUNSA Professor Anwar Hoosen is currently Head of VAGINAL DISCHARGES IN POST-PUBERTAL WOMEN the NHLS’s Microbiology Laboratory for the Vaginal infection is one of the top 25 reasons for women to consult doctors in the Northern Branch. He has conducted numerous USA. The 3 most common types of vaginal infections include bacterial vaginosis, clinical trials and has a research interest in trichomoniasis and candidiasis and these may or may not be associated with cer- vical infection. Other vaginal syndromes are due to chemical toxins or physical infectious diseases with special emphasis on agents (Fig. 1). sexually transmitted infections. He is a recipi- ent of the NRFs grant for research in sexually VAGINAL DISCHARGE IN POSTMENOPAUSAL WOMEN transmitted diseases and is also the principal In this age group, the vaginal epithelium becomes thin along with an increase in investigator for a phase III vaginal microbicide pH. Besides ST pathogens, a number of chronic vulvovaginal syndromes occur. An important one is desquamative inflammatory vaginitis, a syndrome associated study to be conducted at GaRankuwa and with purulent vaginal discharge, vaginal cell exfoliation, increase in pH and Soshanguve. Gram-positive cocci being observed in vaginal fluid. This syndrome responds to 2% clindamycin cream intravaginally.3 VAGINAL DISCHARGE IN ADULT WOMEN Of the 3 common infective causes of vaginal discharge, bacterial vaginosis is the commonest. However, in certain populations trichomoniasis may be as common. Yeast infections also occur commonly and host factors ranging from genetic to acquired such as pregnancy, diabetes mellitus, use of corticosteroids, immunosup- pressive therapy and systemic antimicrobials may predispose to colonisation and infection. A summary of the symptoms, signs and diagnostic features of common vaginal infections in adult women is presented in Table I. 72 CME February 2004 Vol.22 No.2 VAGINAL DISCHARGE Vaginal symptoms including Bacterial vaginosis BV was previously considered to be a discharge in pre-pubertal Bacterial vaginosis (BV) is the result of merely an inconvenience for women. girls ought to be investigat- overgrowth of the resident vaginal However, there is increasing evidence linking BV with adverse outcomes in ed microbiologically as the flora, which comprises Gardnerella vaginalis, Mobiluncus, Bacteroides, pregnancy, such as chorioamnionitis, sexually transmitted (ST) and Prevotella species and preterm labour, prematurity and post- 4,5 pathogens Neisseria gonor- Mycoplasma hominis. There is simul- partum fever. rhoeae and Chlamydia tra- taneous loss of the normal resident lac- chomatis may be isolated. tobacilli of the vagina. There is no The diagnosis of BV is made using inflammation of the vaginal epithelium bedside tests fulfilling at least 3 of the and therefore BV represents a change following criteria: Of the 3 common infective in the vaginal ecosystem. The cause •presence of grey, white homoge- causes of vaginal dis- for this overgrowth is unknown. It is nous discharge charge, bacterial vaginosis felt that normal vaginal lactobacilli are • positive amine test (addition of 1 drop of 10% KOH to 1 drop of is the commonest. hydrogen peroxide (H2O2)-producing and this restricts proliferation of the vaginal secretions releasing a char- However, in certain popu- organisms associated with BV. A loss acteristic fishy odour) lations trichomoniasis may • vaginal pH > 4.5 and presence of in H2O2-producing lactobacilli leads to be as common. Yeast the development of BV. clue cells on microscopic examina- infections also occur com- tion of vaginal secretions or by per- monly and host factors The bacterial overgrowth in BV results formance of a Gram stain on vagi- in production of amines by anaerobes nal secretions and using a scoring ranging from genetic to 6 and when potassium hydroxide is system proposed by Nugent et al. acquired such as pregnan- added to the vaginal fluid, a typical A score of 7 is diagnostic of BV; 3 cy, diabetes mellitus, use of fishy odour is produced. The bacterial is negative and 4 - 6 indicates an corticosteroids, immunosup- amines together with organic acids indeterminate diagnosis. Cultures pressive therapy and sys- such as acetic and succinic are cyto- of G. vaginalis do not offer any temic antimicrobials may toxic leading to exfoliation of vaginal advantage for diagnosis, as they are positive in nearly 60 - 70% of predispose to colonisation epithelial cells. G. vaginalis adheres to exfoliated epithelial cells and this women without infection. and infection. creates shaggy-looking clue cells, which are a characteristic feature of Ampicillin has been used with some BV. success. However, the drug of choice VAGINAL DISCHARGE PHYSIOLOGICAL PATHOLOGICAL •Sexual arousal • Pregnancy INFECTIOUS NON-INFECTIOUS • Pre-menses • Detergents e.g. Nonoxynol 9 •Foreign bodies e.g. cervical caps • Viral antiseptics e.g. Policresulin Vaginal causes •Traditional herbal preparations e.g. Snuff •Tumours e.g. carcinoma of the cervix Cervical causes •Trichomoniasis • Bacterial vaginosis • Candidiasis Endocervicitis / Ectocervicitis mucopurulent cervicitis • Neisseria gonorrhoeae • Herpes simplex virus • Chlamydia trachomatis •Trichomoniasis • Herpes simplex virus Fig. 1. Overview of the aetiology of vaginal discharge in adult women. February 2004 Vol.22 No.2 CME 73 VAGINAL DISCHARGE Table I. Diagnostic features of vaginal discharge in adult women Normal Candidiasis Trichomoniasis Bacterial vaginosis Microbiology Mainly lactobacilli Candida albicans Trichomonas Associated with L. jensenii, L. crispatus C. glabrata vaginalis Gardnerella vaginalis, Mycoplasma hominis, Mobiluncus species Bacteroides and Prevotella Symptoms None Vulval itching and Purulent Malodorous discharge irritation discharge Discharge characteristics • amount Scant/none Scanty to moderate Profuse Moderate • colour Clear White Yellow Grey/milky • consistency Non-homogenous Curd-like, adherent Frothy Homogenous, non-adherent Vaginal epithelium Normal Erythema Erythema No inflammation pH Usually < 4.5 > 4.5 > 5.0 > 4.5 Amine/whiff test with 10% KOH Negative Negative May be positive Positive Microscopy Normal epithelial cells, Leucocytes, epithelial Leucocytes, motile Clue cells, mixed flora lactobacilli cells, ovoid budding trichomonads predominantly Gram- yeast and mycelia variable bacilli including curved rods is metronidazole (Table II). The major- tozoan destroys epithelial cells by Treatment of trichomonal infection is ity of studies have shown better direct contact. with metronidazole or tinidazole. response and fewer recurrences with Metronidazole is the commonest multiple-dose therapy, rather than a The clinical features of infection range nitroimidazole currently used for thera- single 2 g dose. from asymptomatic to profuse malodor- py. Oral therapy is preferred because ous vaginal discharge. The character- there is concurrent infection of the ure- The treatment of asymptomatic BV is istic feature is a frothy greenish-yellow, thra and periurethral glands. Single- recommended in pregnancy especially purulent discharge. The vaginal walls dose therapy of 2 g oral metronida- in women with poor obstetric histories. are erythematous and in severe infec- zole has shown cure rates of greater tion, punctuate haemorrhages on the than 90% and is preferred as it Trichomoniasis ectocervix give the cervix a strawberry ensures compliance. Disadvantages Trichomoniasis is a sexually transmit- appearance. Untreated trichomoniasis of the single-dose regimen are nausea, ted infection (STI). The prevalence of in pregnancy may predispose to pre- a metallic taste in the mouth, disulfi- trichomoniasis in South African women mature rupture of membranes. ram-like effect with alcohol and also ranges from 5% to 49% in the differ- the need to treat sexual partners simul- ent groups studied. Higher preva- Diagnosis is by demonstration of the taneously. Treatment in early pregnan- lences appear to occur in pregnant organism by wet smear microscopy or cy is a problem because of the safety women. Being an STI, trichomoniasis staining techniques such as acridine of metronidazole,
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