VAGINAL DISCHARGE

Vaginal discharge is one of the most common presenting complaints faced by the gynaecologists in clinical practice ,which can be caused by physiologicao or pathologica causes. The most important challenge for gynaecologist is to differentiate between pathologica and physiological causes of discharge . If a pathologica cause of discharge is suspected gynecologist needs to diagnose the exact cause for vagina discharge.

CAUSES
Physiological

2. benign conditions
3.infective discharge 4.Growth related discharge A. benign C. malignant 5.misclellenous A.Foreign body 6.vesicovaginal fistula Rectovaginal fistula Hydrosalpinx and ascitic fluid

Trauma

ETIOLOGY
Some common infective causes of pathoogical vaginal discharge are as follows Vulvovaginal candidiasis Vaginitis caused by Trichomonas vaginalis,c trachomatis,STD e,g gonorrhea Bacterial vaginosis Acute PID Post operative pelvic infection

ENIGN
Post abortal/postpartum sepsis. Various non infective causes for vaginal discharge are as follows a. Vault granulation formation b. Vesicovaginal fistula c. Rectovaginal fistula d. Neoplasia ( vulvar,vaginal,cervical,endometrial)

e.Retained tampoon

f. Chemical irritation
g. Allergic responses h. Atrophic vaginitis i.Ectropion

j. Endocervical polyp
k.Intrauterine devise l.Atrophic changes m.Physical trauma

Vulvovaginatis can be considered as one of the most common causes for pathological vagina discharge ,irritation and itching in women. Vulvovaginitis commonly results due to infammation of the vagina and vulva and is most often caused by baterial,fungal or parasitic infections.

DIAGNOSIS
Diagnostic features of various causes of vaginitis have been described in table.

Basis of Diagnosis

Bacterial Vaginosis

Vulvovaginal candidiasis

Trichomonas

Signs and symptoms

Thin,,grayish to white coloured discharge,fishy odour especially increasing after sexual intercourse.Discharge is usually homogeneious and adheres to vagina

Thick white (curd like Copious )discharge with no odour malodorous,yellow green( or discoloured ) discharge, pruritis and vaginal irritation,dysuria . Asymptomatic in many cases.

Physical examination

Normal appearance of vaginal tissue,grey white colored discharge may be adherent to walls.

Vulvar and vaginal erythema,edema and fissures,thick white discharge that adheres to the vaginal wall.

Vulvar and vaginal edema and erythema.straw berry cervix in upto 25 perent of women,frothy ,purulent discharge.

Vagina PH

Elevated (>4.5)

Normal

Elevated (>4,5)

Microscopic examination of wet mount and KOH preparations of vagina discharge

Clue cells( vaginal epithelial cells coated with coccobcili,few lactobacilli,occasio nal mobile curved rods belonging to preparations of mobiluncus species.

Pseduohyphae, Motile Mycelial tangles,or trichomonads budding yeast cells. ,many polymorphonuclear cells

Whiff test ( normal = no odour)

Positive

Negative

Can be positive

Additional tests

Amsel,s criterion is positive in nearly 90% of affected women with bacterial vaginosis

KOH microscopy/grame stain and culture

DNA probe tests sensitivity of 90% and specificity of 99.8% .Culture: sensitivity of 98% and specificity of 100%.

MONOLIAL ALBICANS

TRICHOMONAS VAGINALIS

NON SPECIFIC BACTERIAL VAGINOSIS

AMSEL DIAGNOSTIC CRITERIA

Thin ,homogenous discharge

Positive, whiff test

Presence of clue cells on microscopic examination Vaginal PH> 4.5

DIFFERENTIAL DIAGNOSIS
Various causess of vaginal discharge have been discribed in etiology part of this fragment.

MANAGEMENT
BACTERIAL VAGIONOSIS

Metronidazole? A 7 day course of oral metronidazole, 400mg TDS or vaginal metronidazole get ( metrogel) is an effective treatment.
Tinidazole : Tinidazole is an antibiotic that appears to have fewer side effects than metronidazole and is also effective in treating bacterial baginosis. Ornidazole : ornidazole 500 mg baginal tablet daily for 7 days Is also effective Tetracyclinis: Tetracycline 500mg four times a day or Doxycycin 100 mg twice daily for 7 days may also be used. Lincosamides: Vaginal clindamycin cream 2% (cleocin) or oral clindamycin 300mg daily for 7 days is also effective.

CANDIDAL INFECTION
ANTIFUNGALS: imidazoles and triazoles are presently the most extensively used antifungal drugs for treatment of VVC.Imidazols can be used in form of creams and pessaries and include butoconazole,clotrimazole and micronazole.Trizole agens include systemically acting aents such as fluconazole,which has sown to be effective in a single oral dose of 150 mg in most of te cases. Antiseptics: Boric acid suppositories are often used for the treatment of VVc. CORTICOSTEROIDS:Topical corticosteroids are commonly prescribed to alleviate symptoms such as itchiness and redness.

VAGINAL TRICHOMONIASIS
NITROMIDAZOLES: Metronidazole in the dose of 200mg TDS or 375mg BID for 7 days or a single dose of 2gm can be used.An alternative to metronidazole could be to prescribe tinidazole in the dose of 300mg BD for 7 days or secnidazole in a single dose of 1000mg daily for 2 days.

COMPLICATIONS
Some complications related to bcterial vaginosis are as follows:

Pelivic inflammatory disease

There may be an increased frequency of endometritis ,abnormal pap smears,abdominal pain,uterine bleeding and uterine or adenexal tenderness. Development of vaginal cuff cellulitis,PID and endometritis in case of an invasive gynecological procedure. Bacterial vaginosis during pregnancy can result in complications like premature labor,preterm birth,chorioamniotis,postpartum endometritis,ectopic pregnancy and post cesarean section wound infections.]

CLINICAL PEARLS
The physiological vaginal discharge is formed by sloughing spethelial cells,nomal bacteria and vaginal transudate.The quality and quantity of this physiological vaginal discharge may vary even in the same woman over different phases of menstrual cycle. In case of VVC and trichomoniasis,ideally both the partners should be treated and be advised to avoid intercoure or use a condom during the course of therapy Topical formulations of imidazole and triazole antifungals can be used during pregnancy for treatment of VVC .Topical nystatin can be recommended in te dose of 100,000 units intravaginally once daily for 2 weeks For treatment of vaginal trichomoniasis,use of metronidazole is contraindicated during pregnancy and lactation.During ealy pregnancy,vinegar douches to lower te vaginal PH,trichofuran suppositories and Betadine gel may be used.

GONORRHEA
INTRODUCTION

Gonorrhea is a STD caused by Nisseria Gonorrhea.

It is gram negative intracellular diplococcus. Incubation period of Gonoccocus is 2-5 days The disease is characterized by adhesions of the gonococci to the surface of urethera or other mucosal surfaces.

ETIOLOGY
Gonorrhea spreads through contact sith the penis,vagina,mouth or anus.Gonorrhea can also be spread from mother to baby at the time of delivery.

DIAGNOSIS
SYMPTOMS

Symptomatic women commonly experience vaginal discharge, dysuria and abdominal pain,
The infection if untreated may extend to Bartholin,s glands ,endometrium and fallopian tubes.The gonoccoci can typically ascend to the fallopian tubes at the time of mensturation or after instrumentation ( for MTP) giving rise to acute salpingitis.Lesions due to gonorrhea are summerized in figure

INVESTIGATIONS
Culture and sensitivity

DNA probes

MEDICAL MANAGEMENT
Treatment comprisis of using the following antibiotics

Ceftriaxone 125mg im or
Ciprofloxacin 500mg PO or Ofloxacin 400 mg PO Doxycyclin 100 mg BID x 7 days or

Azithromycin 1 gm PO ( single dose),

COMPLICATIONS
The infection may spread to the periuretheral tissues,resulting in formation of abcscesses and multiple discharging sinuses ( water can perinium) Acute salpingitis may be followed by PID.This may be associated with a high probability of sterility if not treated adequately Peritoneal spread occasionally occurs and may produce a perihepatic inflammation resulting in fitz-Hugs-curtis syndrome.

ATROPHIC VAGINITIS
Atrophic vaginitis is one of the most common cause of vaginal discharge in postmenopausal women.After menopause the vaginal atrophy can result due to falling estrogen levels.Dyspanurea is common complication of atrophic vaginitis. Perspeculum examination in women with vaginal atrophy may show loss of vaginal rugosity and thinning of the vaginal epithelium. This condition can be treated using topical formulations of conjugated estrogens (premarin) in the dose of 2-4g intravaginally qHS.

CHALAMYDIAL INFECTION
Chalamydia trachomatis is a grame negative aerobic intracellular pathogen which is typically coccoid or rod shaped.However it is different from other bacteria because it requires growing cells in order to remain viable.Therefore, it cannot be grown on an artificial medium because it cannot synthesize its own AtP molecules. C.trachomatis can be considered as one of the most common causes for sexually trasmitted diseases worldwide, in association with blindness and

Infertility

Chlamydia hasw a very unique life cycle which alternates between a non replicating, infectious elementary body and a replicating ,non infectious reticulate body.

DIAGNOSIS
CLINICAL PRESENTATION:

Most women wit chlamydial infection remain asymptomatic

Some women may develoip symptoms such as vainal discharge,dysuria,abdominal pain ,increased urinary frequencyureency ,urethritis and cervicitis Infection of the urethera is often associated with chlamydial infection of the cervix

Chlamydia is very destructiv to fallopian tubes.If left untreated nearly 30 percent of women with chlamydia may develop PID Pelvic infection often results in symptoms such as fever,pelvic cramping,abdominal pain or dyspareunia.

INVESTIGATIONS FOR CHLAMYDIA

1. DIRECT INMMUNOFLOURESCENCE TEST:flourescein- conjugated monoclonal antibodies can be used on smears prepared from urethral and cervical swabs for detecting chlamydial antigens. 2. ENZYME LINKED IMMUNOABSORBENT ASSAY (ELISA):can help in detecting the chlamydial antigen 3. POLYMERASE AND LIGASE CHAIN REACTIONS:newer tests such as polymerase

And ligase chain reactions,DNA probe and DNA amplification are also being used.

MEDICAL MANAGEMENT OF CHLAMYDIA

Treatment of Chalamydia involves the use of broad spectrum antibiotics,with the most commonly used antibiotic being azithromycin in a single dosage of 1 gram per orally.Alternatively doxycyclin can be used orally in the dosage of 100mg BID for 7 days. The combination of cefoxitin and ceftriaxone with doxycyclin or tetracyclin also proves to be useful Erythromycin or amoxicillin in TID or QiD dosage may also be give during pregnancy.

COMPLICATIONS
Pelivc infections can often lead to infertility or even absolute sterility.

Tubal destruction due to chlamydial infection may also result in an increased incidence of tubal pregnancy.
Chlamydial infection is associated with an increased incidence of premature births and may cause serious eye damage or pneumonia in the infant.

GENITAL HERPES
Introduction:

Genital herpes is a viral infeection caused by the herpes simplex virus (most commonly HSV II),which is transmitted through sexual contacts
ETIOLOGY: Genital herpes spreads only by direct person to person contact.The virus enters through the mucous memberane of the genital tract via microscopic tears.From there the virus traves to the nerve roots near the spinal cord and settles down permenmantly. DIAGNOSIS: SYMPTOMS The primary infection may be associated with constitutional synptoms like fever,malaise,vulvar paesthesia,itching or tingling sensation on the vulva and vagina followed by redness of skin.

Eventually, there is formation of b listers and vesicles on the vulva,vagina,cervix,perianao area or innerthigh ,which ultimatey develop into shallow and painful ulcers within a period of 2-6 weeks.They are frequently accompanied by itching and mucoid vaginal discharge. INVESTIGATIONS: CYTOLOGICAL TESTS:The blister fluid may be sent to the laboratory for culturing of virus.However it is associated with high false negative rate of 50 %.

IMMUNOLOGICAL TESTS:These tests are specific for HSV-I or HSV-II and may be able to demonstrate that a person has been infected at some point in time with the virus.
OTHER DIAGNOSTIC TESTS:These include tests such as polymerase chain reaction and rapid flourescebnt antibody screening tests.

BIOPSY: The tzank smear is a rapid,ffairly sensitive and inexpensive method for diagnosing HSV infection.Smears are preferably prepared from the vase of the lesions and stained with 1 % aqueous solution of toudine blue O for 15 seconds.positive smear is indicated by the presence of multinucleated giant cells with faceted nuclei and homegeneously stained ground glasschromatin ( tzank cells) MEDICAL MANAGEMENT: Ora antivaral medications such as acycovir (zovirax),famciclovir(famvir) or valacyclovir (valtrex) which prevent the mutipications on virus are commony used.

For the treatment of primary outbreaks,oral acyclovir is prescribed in the dosage of 200 mg five times a day for 5 days,.
Local applications of acyclovir provides local reief and accelerates the process of heaing In sever cases,acyclovir can be administered intravenously in the dosage of 5 mg/kg body weight every 8 houry for 5 days,.

The couple is advised to abstain from intercourse starting right from time of experiencing prodromal symptoms until total reepithelization of the lesions occurs. CLINICAL PERALS: PREGNANAT WOMEN WITH ACTIVE HERPETIC LESIONS MUST be preferably deiverd by caserean section. Diagnosis is usually based on cinical examination.Genital herpes is suspected when multiple painful blisters are pesent on externa genitalia.

There is still no curative medicine available for genital herpes and the anitiviral drugs onoy help in reducing the severity of symptoms and duration of outbreaks.,
Herpes can spread from one part of the body to another during an outbreak.Through handwashingg is a must during outbreaks in order to prevent the spread of infection Couples who want to minimize the risk of transmission should always use condoms if a partner is infeted.such couples much be instructed to avoid al kinds of sexual activity, including kissing during an outbreaks of herpes.

SYPHILIS
INTRODUCTION:Syphilis is an STD,caused by the spirochete Treponema palllidum.Through the route of transmission of sphyilis is almost always through sexual contact sometimes congenital syphiis can occur via transmission from mother to chhid in utero. DIAGNOSIS SYMPTOMS:

The disease is typialy characterized by three stages:Primary ,secondary and tertiary

Primary esion,also known as a chancre,often appears at the point of ontact usually the externa genitalia.The hard chancre of syphilis is a gfirm painless relative avascular,circumscribed,indurated,superficially ulcerated lesion which usually persists for about 4-6 weeks before healing spontaneously.

In most patients,a painess regiona lymphadenopathy develops within 1-2 weeks after the appearance of the chancre.As a result the regional lymph nodes often become swollen discrete,rubbery and non tender. Secondary syphiis is typically characterized by a flu -like syndrome.Lymphadenopathy and the appearance of symmetrical reddish-pink nonitchy rashes on the trunk and extremities.in moist areas of the body such as the anus and vagina,the rash often develops into flat,broad,whitish lesions known as condyloata lata.mucous patches may also appear on the genitas or in the mouth.

Other common symptoms of this stage incude feer,maiaise,sorethroat,weightloss,headache,enlarged ymph nodes,

Tertiary syphiis usually occurs 1-10 years after the initial infetion and is characterized by the formation of gummas,which are soft,tumor like balls of granuomatous infammation.other charcteristic feates of untreated tertiary syphiis incude neuropathic oint disease (charcterized by the degeneration of joint surfaces resulting in loss of proprioception),neurosyphilis and cardiovascular syphilis.

INVESTIGATIONS

DARK FIELD MICROSCOPY

NONTREPONEMAL TESTS:Kahn test,rapid plasma regain and venera disease research laboratory (VDRL) TREPONEMA TSTS:Treponema pallidum microhemagglutination assay (MHATP),fourscent treponemal antibody assary (FTA-ABS). MEDICAL MANAGEMENT Primary,secondary and eary latent staes of syphis can generally be treated with a single dose intramuscular injection of 2.4 milion units benzathine penicillin G.

CINICAL PEARS

The chancre of syphilis is often termed as hard chancre in order to distinguisxh it from soft sore caused by HEMOPHILUS DUCREYI
All of the lesions of secondary stage are infectious and harbor active treponema organisms and therefor p[atients in this stage are most contagious The rash of secondary syphilis can invovle the palms of the hands and the soles of the feet.