vaginal discharge

Etiology

• hormonal (physiologic)
• infectious
  • bacterial
    • Chlamydia
    • Neisseria gonorrhoeae
    • Mycoplasma
    • Ureaplasma
    • Escherichia coli
    • group B streptococci
  • yeast: Candida albicans* (vulvovaginal candidiasis)
  • viral
    • Herpes simplex
    • papillomavirus
  • Trichomonas vaginalis*
  • Enterobius vermicularis (pinworms)
• retained foreign body
  • tampon
  • contraceptive sponge
  • diaphragm
  • cervical cap
• contact sensitivity/ allergic response
  • contraceptives: spermicides & condoms
  • deodorant in tampons
  • medications
  • douches
  • perfume in menstrual pads, toilet paper & feminine deodorant products

* normal flora of the female genital tract

History

• onset, color, consistency, odor, pruritus, last menstrual period, sexual activity, contraception, self treatment

Physical examination

• pelvic examination
  • evaluate vaginal walls for vaginitis
  • evalulate cervix for cervicitis
  • assess cervical motion tenderness

Clinical manifestations

• urinary symptoms + vaginal discharge suggests
  • Chlamydia trachomatis
  • Trichomonas vaginalis
• fishy odor suggests bacterial vaginosis
• erythema of the labia suggests Candida or contact sensitivity
• Edema of the labia suggests Candida or contact sensitivity
• grayish white vaginal discharge suggests bacterial vaginosis
• white, curdy discharge suggests Candida albicans
• grayish-yellow discharge suggests Trichomonas vaginalis
• a retained object may be visible in the vagina
• yellow exudate suggests cervicitis

Laboratory

• saline wet mount
  • many WBC suggests inflammatory process
  • Clue cells suggest bacterial vaginosis
  • motile Trichomonas may be seen
• KOH (10%) slide
  • a fishy odor of amines upon alkalinization suggests bacterial vaginosis
  • hyphae and budding forms of Candida may be visible after warming & allowing debris to disintegrate
• pH (measured with pH paper)
  • normal pH = 4.0-4.5
  • pH > 4.5 suggests bacterial vaginosis
  • pH 5-7: also consider Trichomonas vaginalis
  • pH 6.5-7.5: consider atrophic vaginitis in post-menopausal woman
• culture
  • Nickerson's media for Candida albicans
  • Tricult or Diamond's media for Trichomonas vaginalis
  • chocolate agar for Neisseria gonorrhoeae
  • Herpes simplex
  • other aerobic & anaerobic bacteria as indicated
• immunofluorescence for Chlamydia
• DNA probes for Chlamydia, Neisseria gonorrhoeae & papillomavirus
• colposcopy
  • condylomatous lesions visualized on perineum
  • no cause found in persistent or recurrent vaginitis

Management

• specific therapy for specific etiology
  • distinguish cervicitis from vaginitis (treatments differ)
• evaluate & treat sexual partner if indicated
• pharmaceutical agents
• bacterial vaginosis
  • metronidazole 250 mg PO TID or 500 mg PO BID or vaginal application BID for 7 days
  • clindamycin 300 mg PO BID or vaginal application QD for 7 days
  • ofloxacin 300-400 mg PO BID for 7 days
  • amoxicillin 250 mg PO TID for 7 days (pregnant)
  • ampicillin 500 mg PO QID for 7 days (pregnant)
• Candida albicans
  • Monistat, Terazol, Gyne-Lotrimin, Femstat, Mycostatin
    • suppository: 1 vaginally for 1-7 days
    • cream: apply daily for 7-14 days
  • Nizoral 200 mg PO BID for 14 days
  • fluconazole 150 mg PO single dose
• Trichomonas vaginalis
  • metronidazole
    • 250-500 mg PO TID for 7 days
    • 2 grams PO single dose for partner
• atrophic vaginitis
  • estrogen cream 1-4 grams vaginally for 7 days, then weekly to maintain symptom relief
• patient education
  • use of condoms to avoid transmission of infectious disease
  • loose-fitting cotton crotched underwear for recurrent yeast infection
  • avoid offending agents
  • prompt removal of contraceptive devices from vagina at earliest & safest time
  • frequent change of tampon during menses & removal before sleep
• follow-up: reculture for sexually transmitted disease

More general terms

• sign/symptom
• discharge (d/c)
• vaginal disorder

More specific terms

• leukorrhea

Additional terms

• vaginitis