Vaginal discharge

Question 1

What are infective causes for vaginal discharge?

Answer 1

Bacterial vaginosis
Candida
Trichomonas
Chlamydia
Gonorrhea

Question 2

What is bacterial vaginosis? What specific organisms are involved?

Answer 2

Overgrowth of anaerobic bacteria such as:
- Gardnerella vaginalis (most common)
- Prevotella species
- Mycoplasma hominis
- Mobiluncus species

This is due to pH disturbance, creating more alkaline environment for the anaerobic bacteria to multiply.

Question 3

How does bacterial vaginosis present? Diagnosis?

Answer 3

Clinical diagnosis

Vaginal discharge:
- fishy odour
- thin
- grey/white homogenous

No vulva itching or soreness.
No urinary symptoms.
No abdominal pain.
No systemic symptoms.
No abnormal bleeding.

Question 3

Risk factors for bacterial vaginosis?

Answer 3

Being sexually active
Douching
Genital hygiene
Menstruation
Copper coil

Question 4

Management of bacterial vaginosis?

Answer 4

Oral Metronidazole 400mg BD for 5-7 days (preferred)

or

Metronidazole 1 applicatorful OD for 5 days, administer via vaginal gel route at night time (allows drug to work better as pt won’t be going to the toilet frequently)

Avoid:
- vaginal douching
- bubble baths
- water-based lubricants
- harsh soaps

Question 5

What is candida?

Answer 5

Referred to as ‘thrush’.

Overgrowth of Candida yeasts in mucosa of female genital tract.
- Candida Albicans (more common)
- Candida Glabrata

Question 6

Risk factors for candida?

Answer 6

Recent abx use
Scented soaps/washes
Immunosuppression
Uncontrolled diabetes
Pregnancy

Question 7

How does candida present? Diagnosis?

Answer 7

Clinical diagnosis

Vaginal discharge:
- non-offensive (no smell)
- white
- cottage cheese like

Vulva or vaginal itching and soreness.
Dysuria
Dyspareunia (superficial)

No abdominal pain.
No systemic symptoms.
No abnormal bleeding.

Question 8

Management of candida?

Answer 8

Fluconazole (oral) or Clotrimazole (intravaginal pessary)

Vulva itching or soreness →Clotrimazole cream

Avoid:
- vaginal douching
- bubble baths
- irritant soap
- tight fit clothing
- cotton underwear

Check for diabetes if recurrent thrush.

Question 9

What is trichomoniasis?

Answer 9

A sexually transmitted infection (STI) caused by Trichomonas Vaginalis flagellated protozoan.

Lives in the urethra of men.
Lives in the urethra and vagina of women.

Question 10

What can trichomoniasis lead to?

Answer 10

In women:
- Cervicitis
- Vaginitis
- Urethritis

Question 11

How does trichomoniasis present? Diagnosis?

Answer 11

Women: high vaginal swab (posterior fornix of the vagina)
Men: urethral swab

Vaginal discharge:
- offensive (has smell)
- yellow/green
- frothy

+/- Vulva or vaginal itching and soreness.
+/- Dysuria
+/- Lower abdominal pain.

Strawberry cervix on speculum

Question 12

What is chlamydia (uncomplicated)? Which sites does it infect?

Answer 12

A sexually transmitted infection (STI) caused by Chlamydia Trachomatis, which is a Gram-negative bacteria.

It is the infection of the urogenital tract targets:
- urethra (men)
- cervix and/or urethra (women)

It can also infect conjunctiva, rectum, and naspharynx.

Question 12

Management of trichomoniasis?

Answer 12

Refer pt to genitourinary medicine (GUM) or sexual health clinic.

Metronidazole BD for 7 days

Offer full STI screen

Contact tracing

Sexual abstinence

Question 13

Risk factors for chlamydia?

Answer 13

Under age 25
Two or more sexual partners in a year
Lack of barrier protection
New sexual partners

Question 14

Who is the National Chlamydia Screening Programme for?

Answer 14

If partner has been suspected or proven chlamydia infection.

Under age 25 years should be offered annually screening or more frequently if partner changes.

Treated with chlamydia in last 3 months.

Two or more sexual partners in 12-month period.

Pts attending GUM clinics.

Women seeking termination of pregnancy (TOP)

Question 15

How does chlamydia present?

Answer 15

70% women are asymptomatic.

Purulent discharge
Post coital bleeding
Dysuria
Deep dyspareunia
Pelvic pain or tenderness

Cervical tenderness
Cervix inflamed
Contact bleeding

Question 16

Diagnosis of chlamydia?

Answer 16

Nucleic acid amplification tests (NAATs)
Women: vulvo-vaginal swab or endocervical swab
Men: first-void urine sample

Question 17

Management of chlamydia?

Answer 17

Refer pt to genitourinary medicine (GUM) or sexual health clinic.

Doxycycline BD for 7 days
or
Azithromycin 1g single dose, then take 500mg OD for 2 days.

Offer full STI screen

Contact tracing

Sexual abstinence

Chlamydia screening

Question 18

What is gonorrhoea?

Answer 18

A sexually transmitted infection caused by gram negative bacteria called Neisseria gonorrhoea.

Uncomplicated gonorrhoea infection can affect mucosal membrane urethra, endocervix, rectum, pharynx, and conjunctiva.

Question 19

Risk factors of gonorrhoea?

Answer 19

Young age 15-24 years
New sexual contact
More than one partner in the year
Lack of barrier protection
Previous STI

Question 20

How does gonorrhoea present?

Answer 20

50% women are asymptomatic.

Altered vaginal discharge
Lower abdominal pain
Intermenstrual bleeding (rare)
Dysuria
Deep dyspareunia

+/- purulent discharge frm cervix

Question 21

Diagnosis of gonorrhoea?

Answer 21

Nucleic acid amplification tests (NAATs)
Women: vulvo-vaginal swab
Men: first-void urine sample

Question 22

Management of gonorrhoea?

Answer 22

Refer pt to genitourinary medicine (GUM) or sexual health clinic.

Ceftriaxone 1g IM single dose
or
Ciprofloxacin 500mg oral single dose

Offer full STI screen

Contact tracing

Sexual abstinence

Test of cure recommended 1 week post tx

Question 23

What is pelvic inflammatory disease (PID)?

Answer 23

Inflammation or infection of the organs of the pelvis (or upper genital tract) -for e.g. uterus, fallopian tubes, ovaries, peritoneum.

Question 24

What commonly causes pelvic inflammatory disease (PID)?

Answer 24

STI: - Chlamydia Trachomatis - Neisseria Gonorrhoeae - Mycoplasma Genitalium Other infections include: - Gardnerella vaginalis - Escherichia coli - Haemophilus influenzae

Question 25

Risk factors for pelvic inflammatory disease (PID)?

Answer 25

Not using barrier contraception Multiple sexual partners Younger age Existing sexually transmitted infections Previous pelvic inflammatory disease Intrauterine device (e.g. copper coil)

Question 25

How does pelvic inflammatory disease (PID) present?

Answer 25

Pelvic or lower abdominal pain and tenderness Deep dyspareunia Abnormal vaginal bleeding (post coital bleeding, intermenstrual bleeding) Abnormal vaginal discharge +/- fever +/- n+v Febrile (fever) Adnexal tenderness Cervical excitation Contact bleeding

Question 26

How is pelvic inflammatory disease (PID) diagnosed?

Answer 26

Clinical diagnosis - Nucleic acid amplification tests (NAATs) -endocervical swab - Pregnancy test - Urine dip Consider bloods: - FBC, CRP, ESR - HIV, Hepatitis, Syphilis serology

Question 27

Management of pelvic inflammatory disease (PID)?

Answer 27

Refer pt to genitourinary medicine (GUM) or sexual health clinic. Don't wait for results to start tx. 1st line: ceftriaxone 1g IM single dose, then take doxycycline 100mg oral BD PLUS metronidazole 400mg BD for 14 days In severe cases, pts may require IV abx. Analgesia Contact tracing Sexual abstinence

Question 28

What are non-infective causes for abnormal vaginal discharge?

Answer 28

Retained foreign body -tampons, condoms Allergy/irritant -deodrant/lubricants Physiological Malignancy -vulva, vaginal, cervix, endometrium

Question 29

How does cervical cancer present?

Answer 29

Often asymptomatic in early stages. Unexplained abnormal vaginal bleeding (IMB, PCB) Unexplained persistent vaginal discharge. Pelvic pain Postmenopausal bleeding (PMB not on HRT) Cervix inflamed Contact bleeding Ulcerating or necrotic lesion on cervix

Question 30

Management of cervical cancer?

Answer 30

Suspect cancer →refer via 2ww pathway to gynaecology