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SEXUAL HEALTH AND HIV > VAGINAL DISCHARGE: VAGINOSIS, CANDIDIASIS AND TRICHOMONIASIS > Flashcards

VAGINAL DISCHARGE: VAGINOSIS, CANDIDIASIS AND TRICHOMONIASIS Flashcards

1
Q

What is the normal pH of the vagina of a woman of child-bearing age?

A

3.5 - 4.5

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2
Q

What commensal organism in the vagina of a woman of child-bearing age leads to a slightly acidic environment?

A

Lactobacilli

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3
Q

What might increase the amount of a physiological vaginal discharge in a woman of child bearing age?

A

Mid way through menstrual cycle

Pregnancy

Starting COCP

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4
Q

What is the most common cause of abnormal vaginal discharge in women of childbearing age across the world?

A

Bacterial vaginosis

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5
Q

What is the prevalence of bacterial vaginosis in the UK?

A

12%

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6
Q

What organism allows for the development of bacterial vaginosis?

A

Gardnerella vaginalis creates a biofilm which allows other opportunistic bacteria to thrive

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7
Q

Other than Gardnerella vaginalis, what microorganisms are classically associated with bacterial vaginosis?

A

Bacteroides spp - eg Prevotella

Mycoplasma hominis

Mobiluncus spp

Atopobium vaginae

They are all mostly anaerobes

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8
Q

What are the risk factors for developing bacterial vaginosis?

A

Black race

IUD

Sexually active - however, not actually considered a STI as is also found in virgins

May be particularly common in lesbian women

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9
Q

What point in menstrual are symptoms of bacterial vaginosis most prominent?

A

Menstruation

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10
Q

What happens to the pH of the vagina during bacterial vaginosis?

A

Increases to between 4.5 and 7.0

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11
Q

What are the clinical features of bacterial vaginosis?

A

Offensive, fishy smelling discharge

Particularly around menstruation and sexual intercourse

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12
Q

What colour is the vaginal discharge associated with bacterial vaginosis?

A

White or yellow

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13
Q

What is the consistency of the discharge associated with bacterial vaginosis?

A

Thin, homogenous

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14
Q

What is the name of the criteria traditionally used to diagnose bacterial vaginosis? What are the criteria?

A

Amstel’s criteria

3 of the following:
Thin, white, homogenous discharge
Vaginal pH of more than 4.5
Positive whiff test (addition of potassium hydroxide results in fishy odour)
Clue cells on microscopy: stippled vaginal epithelial cells

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15
Q

What are clue cells?

A

Vaginal epithelial cells so heavily coated with bacteria that the border is obstructed.

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16
Q

How do we diagnose bacterial vaginosis nowadays in GUM clinics?

A

Gram stained vaginal smear will show large numbers of gram-positive and gram-negative cocci and rods, with a reduced or absent large gram-positive bacilli (lactobacilli). Culture is not useful.

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17
Q

How should someone with bacterial vaginosis be managed?

A

Antibiotics need to have good anti-anaerobic properties:

Metronidazole 400 mg BD for 5 days is preferred treatment

Other options:
Metronidazole 2g stat
Metronidazole gel 0.75% for 5 days
Clindamycin cream 2% for 5-7 nights

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18
Q

What is the initial cure rate of bacterial vaginosis?

A

70-80%

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19
Q

What percentage of patients with bacterial vaginosis will suffer relapse within 1 month? 3 months?

A

1 month - 30%

3 months - 50%

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20
Q

What are the obstetric complications of bacterial vaginosis?

A

Increased risk of second trimester miscarriage.

Increased risk of premature delivery.

Increased risk of cerebral palsy

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21
Q

How would the management of bacterial vaginosis differ in a pregnant lady from a non-pregnant woman?

A

It wouldn’t really, except that 2g dose should be avoided. Recent guidelines now say that metronidazole should be given throughout pregnancy.

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22
Q

What are the side effects of metronidazole?

A

GI upset

Neuropathy at high doses

Metallic taste to breast milk.

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23
Q

What are the side effects of clindamycin?

A

Pseudo-membranous colitis.

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24
Q

How can we reduce the rate of recurrence of bacterial vaginosis?

A

Regular treatment with 0.75% metronidazole gel twice a week for 6 months

25
Q

What proportion of women will experience at least one episode of vaginal candidiasis in their lifetime?

A

75%

26
Q

What is the prevalence of vaginal candidiasis in the UK?

A

25% but only a minority will be symptomatic

27
Q

What is the organism that causes vaginal candidiasis in most cases?

A

Candida albicans (accounts for more than 80%). It is a fungus.

28
Q

Which age groups are most susceptible to vaginal candidiasis and why?

A

Women of child bearing age. This is because it is oestrogen dependent so rarely seen in pre-pubescent girls or post-menopausal women.

29
Q

What are the risk factors for developing vaginal candidiasis?

A

Broad spectrum antibiotic therapy

Increased oestrogen - eg pregnancy, high dose COCP

Diabetes mellitus

Underlying dermatosis - eg eczema

Immunosuppression - eg HIV, steroids

Vaginal douching, bubble bath, shower gel

Tight clothing

30
Q

What are the clinical features of candidiasis?

A

Itching of the vagina and vulva
Soreness of the vagina and vulva
Redness of the vagina and vulva

Curdy white discharge

Fissuring

Excoriations

31
Q

What colour is the discharge associated with vaginal candidiasis?

A

White

32
Q

How is the smell of the discharge associated with vaginal candidiasis described?

A

May be ‘yeasty’ but not offensive

33
Q

What is the consistency of the discharge associated with vaginal candidiasis?

A

Curdy, like cottage cheese

34
Q

What happens to the pH of the vagina during vaginal candidiasis?

A

Increases to pH 4.5 - 7.0

35
Q

How is the diagnosis of vaginal candidiasis confirmed?

A

Microscopy and culture of vaginal fluid

36
Q

How do we manage someone found to have vaginal candidiasis?

A

One off treatments:

Topical: Clotrimazole pessary 500mg stat
Oral: Fluconazole 150 mg stat

Longer courses:

Topical: Clotrimazole 100 mg OD for 6-7 days

Patients should only be treated if they are symptomatic.

37
Q

Who should be given longer treatment courses for vaginal candidiasis?

A

Pregnant women

Predisposing factors that cannot be eliminated such as steroid therapy.

38
Q

What are the complications associated with vaginal candidiasis?

A

Rare

Women can become allergic to topical agents

Severe episodes can trigger long term vulvodynia (pain)

39
Q

How do we treat genuine recurrent candida?

A

This is uncommon and alternative diagnoses (eg herpes) should be explored.

Can be suppressed by weekly fluconazole 150 mg for 6 months.

If continues beyond this, then referral and voriconazole may be used.

40
Q

What type of organism is trichomonas vaginalis?

A

Flagellated protozoan parasite

41
Q

What is the route of transmission of trichomonas vaginalis?

A

Sexually transmitted

42
Q

What are the clinical features of trichomoniasis?

A

Redness and swelling of vulva and vagina (vulvovaginitis)

Redness sometimes extends out onto labia majora and adjacent skin

Purulent green or yellow discharge

Strawberry cervix

43
Q

What causes the cervix to appear like a strawberry in trichomoniasis?

A

Punctate haemorrhages

44
Q

What colour is the discharge associated with trichomoniasis?

A

Yellow or green

45
Q

How is the smell of the discharge associated with trichomoniasis described?

A

Can be offensive, but not always as in bacterial vaginosis

46
Q

What is the consistency of the discharge associated with trichomoniasis?

A

Thin, homogenous

47
Q

What happens to the pH of the vagina during trichomoniasis?

A

Increases to pH 4.5 - 7.0

48
Q

How is the diagnosis of trichomoniasis confirmed?

A

Microscopy of vaginal secretions mixed with saline and culture

49
Q

What medium should be used to culture trichomona vaginalis?

A

Fineberg-Whittington

50
Q

What is seen on microscopy of vaginal secretions of someone with trichomoniasis?

A

Numerous polymorphonuclear cells with moving flagellae

51
Q

How do we manage a patient with trichomoniasis?

A

Metronidazole 2g stat

OR

Metronidazole 400 mg BD for 5 days

OR

Tinidazole 2g stat

Partner notification is needed

52
Q

What are the complications of trichomoniasis?

A

PID

Risk factor for preterm birth

53
Q

How would you treat recurrent trichomoniasis?

A

Higher doses of metronidazole - 400mg TDS and then 1g PR or IV if still recurring

Arsphenamine pessaries and clotrimazole can be used

54
Q

What are the side effects and contraindications of fluconazole?

A

Deranged LFTs at high doses

Avoid in pregnancy

55
Q

What are the risk factors for presence of STIs?

A

Age under 25

No condom use

Symptoms developed after recent change of sexual partner

Multiple partners

Recurrent or persistent symptoms

56
Q

What are the less common non-infective causes of vaginal discharge?

A

Retained tampon or condom

Cervical ectropion or endocervical polyp

Chemical irritation

IUD

Allergic vaginitis

Desquamative exudative vaginitis

Atrophic vaginitis

Trauma

Fistula: recto-vaginal or vesico-vaginal

Vault granulation tissue

Neoplasia

57
Q

What is toxic shock syndrome?

A

Rare condition associated with retention of tampons or foreign bodies in the vagina. Leads to overgrowth of staphylococci producing a toxin.

58
Q

What are the clinical features of toxic shock syndrome?

A

Fever

Diarrhoea

Vomiting

Erythematous rash

Vaginal discharge

SEXUAL HEALTH AND HIV (13 decks)

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