Vaginal Discharge

Question 1

How does the vagina keep itself free from pathogens?

Answer 1

the epithelium of the vagina contains glycogen which is broken down by enzymes and bacteria (lactobacilli) into acids - maintaining low vaginal pH creating an inhospitable environment for pathogens

Question 2

What are specific questions you may ask a pt with suspected vaginal discharge?

Answer 2

Discharge - strong odour should be referred
Age - rare in premenarchal girls, women over 60
Pruritus -

Question 3

What are symptoms of vaginal thrush?

Answer 3

itch (pruritus), burning, discomfort in vaginal area; vaginal discharge may be watery or thicker and may be think, curdy and cream-coloured.
Dysuria (pain on urination) can also occur
shouldnt have any odour

Question 4

If the discharge is grey-white and has a fishy odour, what type of bacterial infection is it?

Answer 4

bacterial vaginosis

Question 5

if the discharge is green-yellow and has a fishy odour, what type of bacterial infection is it?

Answer 5

trichomoniasis

Question 6

Is vaginal itching prominent in thrush or bacterial vaginosis or trichomoniasis?

Answer 6

Vaginal itching is prominent only in thrush

Question 7

Is the onset of thrush sudden or gradual? Which would you refer?

Answer 7

suffen

if gradual - refer

Question 8

When to refer patients with vaginal thrush?

Answer 8

1. Yellow/green or white vaginal discharge -may indicate bacterial vaginosis, chlamydia, gonorrhoea
2. More than 2 attacks in previous 6 months
3. First occurrence of symptoms
4. Pregnancy or suspected pregnancy
5. Previous hx of sexually transmitted disease
6. pt under 16 or over 60 years
7. Abnormal or irregular vaginal bleeding
8. Blood stain in vaginal discharge
9. Vaginal sores, ulcer, blisters
10. Lower abdominal pain or dysuria
11. No improvement within 7 days of tx
12. diabetic pts - poorly controlled diabetes?

Question 9

what tx is used for bacterial vaginosis and trichomoniasis?

Answer 9

Metronidazole 400mg BD for 5-7 days

Question 10

what is trichomoniasis?

Answer 10

protozoan infection

Question 11

Which pts are likely to get thrush?

Answer 11

Medicine-induced thrush - antibiotics, diabetes - poorly controlled diabetes - hyperglycaemia can enhance production of protein surface receptors on C.albicans organisms, pregnancy - hormonal changes, chemical mechanical irritants - can alter the vaginal pH

Question 12

What tx is used for vaginal discharge?

Answer 12

imdazoles (clotrimazole, miconazole) - pessary and cream, fluconazole capsule

Question 13

what are the side effects of imidazoles and when should you apply it? Can it be given in pregnancy? Any drug interactions?

Answer 13

vaginal irritation and apply at night

yes for pregnancy but pt must be referred
no drug interactions

Question 14

what are the side effects of fluconazole and any drug interactions to avoid? Can it be given in pregnancy?

Answer 14

GI disturbances
anticoagulants, ciclosporin, rifampicin, phenytoin, tacrolimus but relate to multiple use of fluconazole

AVOID in pregnancy

Question 15

how do you administer pessaries?

Answer 15

use at night
place the pessary into the applicator firmly
lie on your back with knees drawn towards chest and insert the applicator as deeply as is comfortable
slowly press the plunger until it stops, remove and dispose of the applicator

Question 16

Any recommendations to patients that have thrush?

Answer 16

• Do not use tight clothing like jeans, nylon underwear or tights, avoid deodorants or perfumes
• Yogurt is thought to help as it produces lactic acid which inhibits growth of candida
• Treatment of a sexual partner with cream to apply to penis is recommended

Question 17

when should symptoms be resolved?

Answer 17

should disappear within 3 days of treatment - if not improvement within 7 days - REFER

Oral preps can take 12-24 hours to provide symptomatic relief