Vaginal Discharge/Vaginitis – Basics, Clinical Manifestations, Diagnosis, Treatment
- Physiologic or normal vaginal discharge (also referred to as leukorrhea) generally consists of cervical mucus and desquamated epithelial cells.
- Usually, the term vaginal discharge is used in conjunction with a vaginal infection. Such infections are characterized by the following:
- Abnormal color of discharge, caused by increased concentration of polymorphonuclear leukocytes
- Increased volume of discharge
- Vaginal malodor, and/or
- Vulvar pruritus, irritation, burning, or dysuria
APPROACH TO THE PATIENT
- Physicians should inquire about the characteristics of the discharge (color, odor, etc.) and the presence of other local or systemic symptoms. Previous similar symptoms and a complete sexual history can aid in the diagnosis.
- Examination of the vaginal fluid, using the following tests, can diagnose most cases:
- Measuring pH, using pH paper that reads from 4.0 to 6.0
- Detecting an amine (“fishy”) odor, which is released upon alkalinizing vaginal fluid by adding one drop of KOH (10%) solution
- Searching for clue cells (vaginal epithelial cells that are so overladen with adherent bacteria that the cell border is obscured) and for trichomonads and white blood cells in a saline preparation under the microscope
- Examining a KOH preparation under the microscope for hyphae and mycelia of Candida
- Investigation of vaginal discharge in sexually active adult women should involve the collection of both endocervical and high vaginal swabs. High vaginal swabs should be placed in transport medium to prevent drying and to allow the survival of anaerobes.
- Harvesting of endocervical cells from the squamocolumnar junction is required for chlamydial culture, detection of chlamydial antigen, or chlamydial DNA by polymerase chain reaction.
- It is convenient to divide specimens into those requiring a full culture and those requiring a screening culture. A screening culture will include selective plates forNeisseria gonorrhoeae, Candida spp, and beta-haemolytic streptococci, and microscopy for Trichomonas vaginalis and bacterial vaginosis.
- Physiologic discharge accounted for 10% of women attending a private practice with vaginal complaints.
- Three etiologies account for over 90% of cases of vaginitis:
- Trichomonas (T. vaginalis) (25%)
- Candida (25%)
- Bacterial vaginosis (40%)
- Bacterial vaginosis is associated with multiple sexual partners and recent intercourse with a new partner. The prevalence and concentrations ofGardnerella vaginalis, Mycoplasma hominis, and several anaerobic bacteria are greater in vaginal fluid of women with bacterial vaginosis than in that of women without this syndrome. It is diagnosed when three out of four of the following are present:
- Abnormal, thin, homogeneous vaginal discharge
- Vaginal pH > 4.5
- Positive amine test
- Presence of clue cells
- Vaginal discharge may be the presenting manifestation of genital herpes and occasionally reflects mucopurulent cervicitis or pelvic inflammatory disease caused by gonorrhea or chlamydial infection.
- Vaginitis may be an early and prominent feature of toxic shock syndrome.
Bacterial vaginosis is the most common cause of vulvovaginal symptoms in most clinical settings; it is closely followed in frequency by vulvovaginal candidiasis. Trichomoniasis is much less common in most settings in developed countries.
- Although the clinical signs and symptoms are often nonspecific, certain features can suggest the diagnosis of candidal vaginitis:
- Vulvar pruritus and burning
- Abnormal vaginal discharge; only 25% have the “typical” thick, curdy discharge.
- Burning on urination at the urethral orifice
- Vaginal erythema; white or yellow adherent plaques (in 40%)
- Findings and characteristics of the vaginal discharge:
- Symptomatic trichomoniasis: characteristically produces a profuse, yellow, purulent, homogeneous vaginal discharge and vulvar irritation
- Vulvovaginal candidiasis: The vaginal discharge typically is white and scant and sometimes takes the form of white thrushlike plaques or cottage cheese-like curds adhering loosely to the vaginal mucosa.
- Trichomonas vaginalis usually manifests with malodorous vaginal discharge (often yellow), vulvar erythema and itching, dysuria or urinary frequency (in 30% to 50% of cases), and dyspareunia. These manifestations, however, do not clearly distinguish trichomoniasis from other types of infectious vaginitis.
- Detection of motile trichomonas by microscopy of wet preparations of vaginal or prostatic secretions has been the conventional means of diagnosis:
- For a wet preparation, vaginal fluid is added to a drop of saline on a slide, and covered with a coverslip. Wet preparations are checked for the presence of T. vaginalis, yeast cells, pus cells, epithelial cells, and clue cells.
- Clue cells are vaginal epithelial cells covered with numerous, short coccobacilli. In addition, lactobacilli will be absent or reduced in number when clue cells are present. If clue cells are seen on the wet preparation, a confirmatory Gram stain is made.
- The relative numbers of epithelial and pus cells can be helpful.
- Culture for T. vaginalis will yield few additional positives.
- Wet preparations provide an immediate diagnosis. Its sensitivity for the detection of T. vaginalis is only about 60% in routine evaluations of vaginal secretions (up to 70% to 80% among symptomatic patients). Direct immunofluorescent antibody staining is more sensitive (up to 90%) than wet-mount examinations. Culture of the parasite is the most sensitive means of detection; however, the facilities for culture are not generally available, and detection of the organism takes 3 to 7 days.
- The diagnosis of vulvovaginal candidiasis involves the demonstration of fungi by microscopic examination of vaginal fluid in saline or 10% KOH or by Gram stain. Culture does identify C. albicans in some women with symptoms and signs of vulvovaginal candidiasis in conjunction with negative results upon microscopic examination, but it also commonly detects coincidental colonization in women without such symptoms or signs. The pH of vaginal secretions is usually 4.5, and no amine odor is produced when vaginal secretions are mixed with 10% KOH.
- For vaginal trichomoniasis, a single 2-g oral dose of metronidazole is the treatment of choice, and is as effective as more prolonged regimens.
- The standard regimen for the treatment of bacterial vaginosis has been metronidazole (500 mg orally, twice daily for 7 days). Clindamycin (300 mg orally, twice daily for 7 days) is also effective. Intravaginal treatment with 2% clindamycin cream (one applicator each night for 7 nights) or 0.75% metronidazole gel (one applicator twice daily for 5 days) is also effective.
- In most circumstances, therapy for candidal vaginal infection is indicated only if the patient is symptomatic or has signs of vulvovaginitis.
- Intravaginal products, many of which are available over the counter, are the treatments of choice. They should be applied at bedtime.
- Clotrimazole, 1% vaginal cream, 5 g for 7 to 14 days; 100-mg vaginal tablet, single tablet for 7 days or two tablets for 3 days; or 500-mg vaginal tablet, single application
- Miconazole, 2% vaginal cream, 5 g for 7 days; 200-mg vaginal suppository for 3 days; or 100-mg vaginal suppository for 7 days
- Butoconazole, 2% vaginal cream, 5 g for 3 days
- Terconazole, 80-mg vaginal suppository for 3 days
- In pregnancy, intravaginal clotrimazole, miconazole, or terconazole may be used for symptomatic women, but their use should be deferred until the second trimester.
- The newer azoles, fluconazole and itraconazole, can be used as a single oral dose, but they are more expensive than older treatments. For azole-resistant Candida strains, nystatin and boric acid can be used, but these products are not first-line treatments.
- About 10% of women will have another, or several, attacks of Candida vaginitis after what should be an appropriate treatment course. The definition of “recurrent candidiasis” is four or more episodes per year.
- Vaginal trichomoniasis and bacterial vaginosis early in pregnancy are independent predictors of premature onset of labor.
- The full significance of bacterial vaginosis is gradually unfolding, and is currently recognized as a risk factor in the following:
- Bacterial infection of the upper genital tract
- Endometritis following caesarean section
- Neonatal sepsis
- Preterm labor/late miscarriage
- Vaginal cuff cellulitis following abdominal hysterectomy
Recurrent or chronic vulvovaginal candidiasis develops with increased frequency among women with systemic illnesses, such as diabetes mellitus or HIV infection.
- Prevention suggestions for vaginal infections:
- Practice safe sex.
- Limit the number of sex partners.
- Treat infected partners, as indicated.
- Weekly oral fluconazole has been found effective in preventing vulvovaginal candidiasis among patients with advanced HIV infection, but this approach is rarely needed and should be based on selective criteria.
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