Abnormal Vaginal Discharge(AVD)

Question 1

What is vaginal discharge and which hormone is it under the influence of?

Answer 1

Vaginal discharge is fluid/mucus that keeps the vagina moist, clean, lubricated and acts as a defense mechanism-normal.
Estrogen

Question 2

How are the causes of abnormal vaginal discharge grouped?

Answer 2

Infectious or Non infectious

Question 3

What are the infectious causes of vaginal discharge?

Answer 3

Vaginal :Bacterial Vaginosis, Candida Albicans and Trichomonas Vaginosis
Cervical: Neisseria gonorrhea, Chlamydia Trachomatis ,Herpes Simplex Virus

Question 4

What are the non-infectious causes of vaginal discharge? And explain them.

Answer 4

-Physiological changes: atrophic vaginitis (menopausal changes), postpartum (e.g. RPOC).
-Mechanical/chemical irritation: —Foreign Bodies, IUCD, douching, hygiene products, contact dermatitis.
-Malignancy and structural abnormalities: endometrial and cervical cancer, polyps, fistulas.
-Systemic: diabetes mellitus, psoriasis, dermatitis

Question 5

What is the approach taken for a patient with AVD?

Answer 5

-A good gynecological history, physical exam and laboratory diagnosis

Question 6

What are the Risk Factors of AVD?

Answer 6

Douching
Multiple sexual partners
Poor hygiene practices
Systemic conditions
Antibiotic/Oral contraceptive use

Question 7

What are some of the important his history taking points to pay attention to in a patient with AVD? And explain why?

Answer 7

Age, LNMP, period cycle(regularity and timing of cycle)
Hormone status(Pre- or postmenopausal)
Birth control methods.
Pregnancy
Duration (acute, chronic ,frequently recurrent)
Pruritus, dysuria(external or internal),Dyspareunia
Colour and consistency, odour
Systemic symptoms e.g. Fever, abdominal pain
Sexual history: number of partners, new partners, partner symptoms, Hx of STIs.
Hygiene practices, recent medications (systemic or otherwise).

Question 8

What kind of physical exam in a patient who presents with AVD?

Answer 8

Systemic signs of illness: fever, nutritional status, stigmata of systemic disease, abdominal pain.

Vaginal examination: discharge, herpetic vesicles, contact dermatitis, bimanual palpation may reveal cervical motion tenderness.

Speculum: visualization of cervix: strawberry cervix, collection of a sample, friability or easy bleeding, erythema of the vaginal walls/cervix.

Question 9

What is the most infectious cause of AVD?

Answer 9

Bacterial Vaginosis

Question 10

What is the causative agent of BV? And how?

Answer 10

Gardnerella Vaginalis
Occurs when there an alteration of normal vaginal flora resulting in leading to overgrowth of organisms

Question 11

What are the risk factors of BV?

Answer 11

Douching, Antibiotic use and low estrogen levels

Question 12

What are the general symtoms of BV?

Answer 12

Increased discharge-gray and milky
Fishy odor

Question 13

How do you diagnose BV?

Answer 13

Diagnosis is confirmed if 3/4 of the Amsel criteria is met.
-pH of > 4.5
-Clue cells
-Grey/white discharge that adheres to vaginal walls
-A positive whiff/amine test

Question 14

Describe the Amine /Whiff test?

Answer 14

1-2 drops of potassium hydroxide is added to a sample of infected vaginal discharge and emit a characteristic amine odor

Question 15

Treatment for BV?

Answer 15

Metronidazole.

Question 16

Which fungus causes Vulvoaginal Candidiasis?

Answer 16

Candida Albicans

Question 17

Presentation of Candida Albicans?

Answer 17

Presents with discharge, vaginal burning sensation, strong pruritus, dysuria, dyspareunia.

Question 18

What is seen on the physical exam in the case of VVC?

Answer 18

Thick, white curd like discharge (cottage cheese),Erythematous vagina and labia.

Question 19

What investigations are done in VVC and what is seen?

Answer 19

-A vaginal wet mount with potassium hydroxide(Pseudohyphae seen)
-pH-remains with the normal range

Question 20

What treatment is used in VVC?

Answer 20

-topical antifungals, cotrimazole pessaries , fluconazole
-Use topical azoles and not oral azoles in pregnant women

Question 21

Risk factors of VVC?

Answer 21

-Pregnancy
-Systemic illness(DM)
-Use of antibiotics

Question 22

What causes trichomoniasis?

Answer 22

Trichomonas Vaginalis

Question 23

How does trichomoniasis present/symptoms?

Answer 23

Foul- smelling discharge(frothy),vulvovaginal pruritus, burning sensation, dyspareunia and dysuria

Question 24

What are the signs of Trichomoniasis?

Answer 24

yellow-green purulent discharge, endocervix that easily bleeds(erythematous mucosa that easily bleeds), strawberry cervix

Question 25

What investigations are done in Trchomoniasis?

Answer 25

-Saline vaginal wet mount(Motile trophozoites with multiple flagella) -pH (>4.5), culture. If the wet mount is inconclusive do a culture

Question 26

What is the treatment for Tricho?

Answer 26

Treatment: of both partners, with metronidazole. Consider empiric treatment of other STIs. Women + their partners with TV should be told to abstain from sexual intercourse until treatment is completed and symptoms have resolved, as it is sexually transmissible.

Question 27

What is the cause of gonorrhea?

Answer 27

Neisseria gonorrhoea

Question 28

What are the signs and symptoms of Gonorrhea?

Answer 28

Presents with thin, purulent, malodorous AVD, intermenstrual bleeding, dysuria, dyspareunia. Signs: mucopurulent discharge(yellow-green, possibly blood tinged) friable cervix, vaginal bleeding, signs of PID.

Question 29

What investigations are done for gonorrhea? And when is it done?

Answer 29

NAAT, blood cultures for disseminated disease NAAT-Nucleic acid Amplification test- is A vaginal swab of the affected site is taken In the case that NAAT is unavailable or for antibiotic sensitivity testing in the case of (treatement failure, complicated infections aucg PID or DGI.

Question 30

What treatment id offered in gonorrhea?

Answer 30

Ceftriaxone + azithromycin/Doxycycline

Question 31

Which serovars of chlamydia trachomatis causes Chlamydia?

Answer 31

Serovars D-K

Question 32

What are the signs and symptoms of Chlamydia?

Answer 32

Presents with white/yellow, mucopurulent discharge, AVB, dysuria, dyspareunia, postcoital bleeding Signs: discharge, cervical friability, adnexal tenderness(PID)

Question 33

What are the investigations done in Chlamydia?

Answer 33

nucleic acid amplification test, serology, cytology and culture.

Question 34

Treatment of chlamydia?

Answer 34

Doxycycline, azithromycin.

Question 35

What is the cause of genital herpes?

Answer 35

HSV-1 and HSV-2

Question 36

How does genital herpes present?

Answer 36

-Presentation depends on the designation of the infection i.e. primary or recurrent. -Skin lesions may be present in both(Prodromal symptoms of redness, swelling , tingling, pain pruritus) -Primary Infection : white thick and/or foul-smelling vaginal discharge -May have lesions at different stages of resolution e.g. vesicles/ulcers, inflamed vaginal mucosa, cervical involvement, vaginal discharge (thick, white, cloudy and may have a pungent smell).

Question 37

What investigations are done in Genital herpes?

Answer 37

Serological test, PCR and viral culture

Question 38

Treatment for Genital Herpes?

Answer 38

Antiviral such as Acylovir

Question 39

What are the complications of AVD?

Answer 39

any woman: PID Ectopic pregnancy Tuboovarian abscess In pregnant women: Premature rupture of membranes Low birth weight Vertical transmission of infection Post partum endometritis Chorioamnionitis Post caesarean wound infection Miscarriages