Discharge

Question 1

What causes cottage cheese discharge?

Answer 1

vaginal candidiasis

Question 2

how would vaginal candidiasis present?

Answer 2

itching
white, cottage cheese discharge
pruritus
tenderness and burning sensation

Question 3

how does penile candidiasis present?

Answer 3

soreness, pruritus
redness
dull, dry and glazed plaques and papules
vulvitis: superficial dyspareunia, dysuria

Question 4

what is the pathophysiology candidiasis?

Answer 4

• fungal: Candida albicans
• transmission non-sexual
• caused by overgrowth despite being part of normal commensal flora

Question 5

what are some risk factors for candida?

Answer 5

immunosuppression, endogenous oestrogen, recent Abx, DM, mucosal breakdown, recurrent candidiasis

Question 6

how is candida investigated?

Answer 6

microscopy - detection of blastospores, pseudohyphae and neutrophils
high vaginal swab - charcoal not routine if clinical strong

*recurrent investigate for immunosuppressive conditions

Question 7

what is the management for candida?

Answer 7

• first line fluconazole
• second line clotrimazole pessary
• pregnancy → cream or pessaries
• recurrent → induction with fluconazole
• general skin care

*compliance for medication, abstinence till complete, no use of soaps, tight underwear and douching

Question 8

what causes grey-white discharge?

Answer 8

Bacterial vaginosis

Question 9

what is the pathophysiology of BV?

Answer 9

bacterial imbalance of the vagina caused by an overgrowth of anaerobic bacteria, such as Gardnerella vaginalis, and a loss of lactobacilli, the dominant bacterial species responsible for maintaining an acidic vaginal pH

Question 10

what factors could cause a pH imbalance which leads to BV?

Answer 10

• Having multiple sexual partners or a new sexual partner
• Douching
• Lack of consistent condom use
• Hormonal changes, such as those that occur in pregnancy

Question 11

what are some risk factors for BV?

Answer 11

douching, perfumed products, cunnilingus, black race, recent change in partner, smoking, presence of an STI

Question 12

how does is BV diagnosed?

Answer 12

Amsel’s criteria for diagnosis of BV - 3 of the following 4

• thin, white homogenous discharge
• clue cells on microscopy: stippled vaginal epithelial cells
  vaginal pH > 4.5
• positive whiff test (addition of potassium hydroxide results in fishy odour)

Question 13

how is BV investigated?

Answer 13

• microscopy: no lactobacilli
• pH: alkali
• high vaginal swab
• whiff test

Question 14

how is BV managed?

Answer 14

• Metronidazole or Clindamycin, which can be administered orally or intravaginally
  
  • Sex partners do not typically require treatment
  • can have a gel if cannot keep off alcohol
• washing advice - no douching, no use of soaps

Question 15

when might BV cause life threatening complications?

Answer 15

*if pregnant

• results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage

Question 16

What causes Offensive, yellow/green, frothy discharge?

Answer 16

Trichomonas vaginalis

Question 17

what is the pathophysiology of trichomonas?

Answer 17

• Flagellate protozoan
• transmission: sex

Question 18

how might trichomonas present?

Answer 18

• Vaginal discharge (thin, frothy yellow coloured)
• Strawberry cervix on speculum examination
• Vulval pruritus
• Vulvovaginitis
• Dysuria
• Dyspareunia

Question 19

how might trichomonas present in men?

Answer 19

• Urethral discharge
• Urethral irritation/itching
• Dysuria
• Balanitis

Question 20

how is trichomonas investigated?

Answer 20

• pH >4.5
• microscopy of a wet mount shows motile trophozoites

Question 21

how is trichomonas managed?

Answer 21

oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole
- avoid alcohol during tx and 72h afterwards
- - full sexual health screen
- contact tracing and partner notifications
- avoid sex until tx
- test of cure not routine

Question 22

what are some complications of trichomonas?

Answer 22

• Pelvic inflammatory disease: increases the risk of ectopic pregnancy and infertility
• Altered vaginal flora
• Prostatitis
• In pregnancy, there is an increased risk of premature rupture of membranes and preterm birth

Question 23

what presents as Copious, mucopurulent discharge, dysuria, sx 3 days after new sexual contact?

Answer 23

Gonorrhoea

Question 24

what is the pathophysiology of gonorrhoea?

Answer 24

• Neisseria gonorrhoea - gram negative intra-cellular diplococci
• primary sites: columnar epithelium lines mucous membranes
  
  • urethra, endocervix, rectum, pharynx, conjunctiva
  • urethral - mucopurulent discharge
• transmitted through sexual contact + direct inoculation of infected secretions, vertical transmission can cause ophthalmia neonatorum

Question 25

how does gonorrhoea present?

Answer 25

- rectal: proctitis leading to pain, bleeding and discharge mucopurulent dysuria Upon examination in women, discharge from the cervical os, Skene's gland or Bartholin's gland may be observed

Question 26

how is gonorrhoea investigated?

Answer 26

- Self-taken vulvovaginal swab in women or self-obtained first pass urine in men; self-obtained rectal swab; or clinician-obtained endocervical or penile swab - Microscopy revealing monomorphic Gram-negative diplococci within polymorphonuclear leukocytes - Nucleic acid amplification tests (NAAT) - Culture

Question 27

how is gonorrhoea managed?

Answer 27

Ceftriaxone as the first-line treatment. Following treatment, a test of cure after 14 days is essential to monitor disease clearance and assess the effectiveness of the chosen antibiotic regimen - avoid sex - partner notification - treat them

Question 28

how does gonorrhoea complicate?

Answer 28

- DIC: pustular lesions, joints, tendon involvement *are complication of gonococcal infection leading to systemic features (including arthritis, skin lesions and arthralgia) - transluminal spread - PID, epidiymoorchitis, prostatitis

Question 29

what presents as Colourless mucoid, watery urethral discharge, dysuria?

Answer 29

Chlamydia

Question 30

what is the pathophysiology of chlamydia?

Answer 30

- Organism: chlamydia trachomatis, obligate intracellular bacteria - **transmission**: sexual contact, peri-natal transmission in vaginal canal → neonatal conjunctivitis and pneumonia

Question 31

how does chlamydia present in women?

Answer 31

- Vaginal discharge - Proctitis - Post-coital bleeding (may indicate cervicitis) - Intermenstrual bleeding - Cervicitis on vaginal exam - PID

Question 32

how does chlamydia present in men?

Answer 32

- Urethral discharge (usually clear) - Dysuria - Proctitis - scrotal pain → epididymo-orchitis

Question 33

how is chlamydia investigated?

Answer 33

For women: a vulvovaginal swab (either self-taken or clinician-taken) or an endocervical swab analysed using NAATs For men: urine or urethral swab, analysed using the same method For suspected anal infections: an anal swab, also analysed using NAATs

Question 34

how is chlamydia managed?

Answer 34

Treatment involves a course of oral doxycycline, administered twice daily for 7 days Following treatment of rectal infections, a test of cure is usually recommended - contact tracing + partner notification - abstinence until completed tx - test of cure at 5w in case of rectal infection or pregnancy

Question 35

what are some complications of chlamydia?

Answer 35

- Pelvic inflammatory disease (PID): increases the risk of ectopic pregnancy and infertility - Epididmyo-orchitis (leading to scrotal pain and swelling) - Prostatitis - Reactive arthritis

Question 36

what does vulvovaginal swabs test for?

Answer 36

- NAAT for gonorrhoea and trachomatis - PCR for T.vaginalis

Question 37

what does high vaginal swab test for?

Answer 37

- culture - t.vaginalis - microscopy with wet mount or gram stain

Question 38

what does endocervical swabs?

Answer 38

gonorrhoea

Question 39

what are some differentials for physiological discharge?

Answer 39

- pregnancy - sexual arousal - cyclical - hormonal contraception

Question 40

what may cause pathological vaginal discharge?

Answer 40

- candidiasis - TV - BV - foreign body - post-menopausal vaginitis

Question 41

what are some pathological cervical discharge?

Answer 41

- gonorrhoea - chlamydia - herpes - non-specific genital infections - cervical ectopy