By Josephine Adiotomre ST1 GPVTS Jan 2010 VAGINAL DISCHARGE and STI’s
Causes of vaginal discharge • Physiological vs. Pathological • Infective (Non-STI) - Bacterial vaginosis - Candida albicans • Infective (STI) - Trichonomasvaginalis - Chlamydia trachomatis - Neisseria Gonorrhoea • Non –infective - foreign body - Cervical polpys/ectopy - Genital tract malignancy - Fistula - Allergic reactions
Do you have any vaginal discharge? • Abnormal discharge = a change in colour, consistency, volume or odour. • May be associated with: • Itch • Soreness • Dysuria • Pelvic pain • IMB • PCB
CASE 1 • A 28 year old female presents with a thin, white, offensive (“fishy”) discharge. Not associated with any itch or pain. • O/E profuse thin, white discharge coating vagina. There is no vulva inflammation or cervicitis. • Same partner for 5 years • pH using dipstick is high • What is the diagnosis? • What is the treatment? • What does the following image show?
Bacterial Vaginosis • Most common cause of infective vaginal discharge • 12% of women will get BV at some point in their life • “Nosis” not “Nitis” = no inflammation/itch • Overgrowth of anaerobes replacing lactobacilli = ↑ vaginal pH (>4.5) • Most common anaerobe is gardnerellavaginalis
BV • Associated with early age of first sex and multiple sexual partners • More common with termination of pregnancy, IUCD, PID • Pregnancy – mid-trimester miscarrgiage, PROM, preterm delivery, post partum endometritis
BV Diagnosis and Treatment • Amsel’s criteria to diagnose BV (3/4 must be present): • White discharge • pH > 4.5 • Fishy odour (Whiff test – 10% KOH) • Clue cells (vaginal epithelial cells surrounded by bacteria) • May occur and remit spontaneously. • Treat with metronidazole 400mg BD 5/7 • Or single 2g dose metronidazole (improved compliance, may be less effective at 4 weeks FU) • Or Clindamycin 2% cream PV nocte 7/7. • Stop strong soaps
CASE 2 • A 34 year old lady presents with a 3 day history of a thick white non-offensive discharge. She also complains of itching and soreness of the vulva. • She has a regular partner of 3 years. They use condoms regularly. She has had no other partners. • Otherwise well in herself. • Her smears are up to date.
Candida • Commensal in 10-20% of asymptomatic women • 2nd most common cause of infective vaginal discharge • Candida albicans (80-95%) vs. Candida glabrata (5%) • Occurs commonly when the vagina is exposed to oestrogen • Characterised thick curd-like, white, non-offensive discharge +/- vulva itch or soreness, superficial dyspareunia, dysuria • Consider DM, immunosupression, antibiotics and corticosteriod, contraceptive treatment • Dx – clinical impression, HVS (lateral wall)
Candida Treatment • If symptomatic • Single clotrimazole 500mg pessary or 200mg nightly/3 days or 100mg nightly for 6 days • Efficacy depends on total dose not duration of treatment • A single high dose is as effective as divided doses and may improve compliance • Systemic imadazoles not licensed in pregnancy/breastfeeding • Latex condoms, diaphragms and cervical caps may be damaged by some antifungals
CASE 3 • 30 year old woman with fishy, frothy, profuse greenish discharge with soreness and itching. • Her cervix had the following appearance. What is the term for this? • What is the diagnosis?
Trichonomas vaginalis • Flagellated protozoan • Causes a vaginitis = itching/soreness/dysuria • 10-15% asymptomatic • Strawberry cervix = punctate mucosal haemorrahges. (2% of cases) • Confirm HVS (posterior fornix) or wet film • Co-exists often with gonorrhoea Associated with: pre-term delivery - low birth weight
Trichonomas vaginalis • Tx – PO metronidazole 400mg BD 5-7 days • Or metronidazole 2g PO single dose • Contact tracing and partner notification • Treat all sexual partners of the previous 6 months • Advise to refrain from intercourse till partner treated
CASE 4 • 23 year old female with PCB 3 weeks duration. Increased yellow vaginal discharge. Also c/o lower abdo pain and deep dysparunia. • O/E – apyrexic. Suprapubic tenderness, mild guarding, no rebound. • Speculum exam – yellow discharge • Bimanual examination – cervical excitation, uterine tenderness, no adnexal masses, bilateral adnexal tenderness • What is you DD? • What tests would you do immediately in the surgery?
Pregancy test negative • Urine dip – leucocytes +2 • What is the most likely diagnosis? • What are the 2 most common causes? • When would you start Tx?
Chlamydia Trachomatis • Most common bacterial STI in the UK • Most common in under 25’s (1 in 10) • 80% women and 50% men asymptomatic • Can present with: • Vaginal discharge (due to cervicitis) • Abnormal bleeding (PCB, IMB) • Lower abdo pain • Deep dyspareunia • Dysuria • Screening/contact tracing • Triple swabs – endocervical x2, 1 HVS • Urine samples and NAAT
Complications of Chlamydia • PID (10-30%) • Ectopic, infertility and chronic pelvic pain • Fitz-Hugh-Curtis syndrome • Reiter’s syndrome – arthritis, conjunctivitis, urethrtis • Epididymo-orchitis • In pregnancy – PROM, LBW, postp-partum endometritis • In the neonate – conjuctivitis, pneumonia
Chlamydia Trichomonas Treatment • Doxycycline 100mg BD 7 days (CI pregnancy) • Or Azithromycin 1g PO single dose (used off license in pregnancy) • Contact tracing and partner notification • Screen for other STIs • No need for test of cure
Neisseria Gonorrhoeaae • 2nd most common bacterial STI in UK • Gram staining shows gram negative intracellular diplococci • Affects endocervical cells • Discharge due to cervicitis not vaginitis • 95% men symtomatic with urethral GC • 50% women asymptomatic for cervical, pharyngeal and rectal GC • Dx – endocervical, urethral, rectal and pharyngeal swabs
Neisseria Gonorrhoeaea Treatment • Ceftriaxone 250mg IM as a single dose • Or Cefixime 400mg oral as a single dose • Or Spectinomycin 2g IM as a single dose • All the above can be used in pregnancy • >20% strains now resistant to ciprofloxacin • Screen for other STI’s • Contact tracing and partner notification • Abstain from intercourse till treatment complete for patient and partner • No TOC needed if settles except pharngeal infection
Complications of GC • 15% of infections result in PID • Bartholin’s abscess • If disseminated may result in fever, pustular rash, septic arthritis and migratory polyarthralgia • Chorioamnionitis • Postpartum endometritis • On the fetus: PROM, pre-term delivery • On the new born: opthalmianeonatarum (40-50%)
Pelvic Inflammatory Disease • Infection and inflammation of the upper genital tract • Incidence ↑ 3X over last 25 years • Most common causes are Chlamydial and GC infection • In the absence of Tx 10-15% with Chlamydia will develop PID (40% of cases) • 15% of GC infection results in PID (20-30% of cases) • Early Dx and Tx helps prevent serious long term complications • What are the risk factors for PID?
PID Risk Factor • Age <25 • Previous STIs/PID • New or multiple sexual partners • Uterine instrumentation (IUDs – first 20 days) • Postpartum endometritis • Protective – pregnancy, sterilization, COCP, barrier contraceptive
Signs and symptoms of PID • Lower abdo pain • Abnormal vaginal discharge • Deep dyspareunia • Abnormal vaginal bleeding • Systemic symptoms - Fever >38, lethargy, N+V • Bilateral lower abdo tenderness • Cervical excitation • Adnexal tenderness
Investigations for PID • Triple swabs • FBC, CRP (lack specificity) • Pelvic USS – tubo-ovarian abscess • Laparoscopy – GOLD STANDARD
Treatment of PID • Negative swabs do not exclude PID • If suspected treat immediately with ABX • Outpatient(mild/moderate) vs. Inpatient(severe) • Bed rest, regular analgesia, antiemetic • Contact tracing and partner notification • Avoidance of sexual intercourse (condoms otherwise) and tampons during treatment • Verbal and written information • Screening for other STIs • Review 72 hours after initial diagnosis
Referral To Secondary Care • Unable to exclude a surgical emergency (ectopic, appendicitis, pelvic peritonitis) • Severe symptoms • Possible tubo-ovarian abscess on examination • Unable to tolerate oral TX due to vomiting • Not responding after 72 hours of PO Tx • Patient is pregnant
Outpatient Treatment For PID • PO ofloxacin 400mg BD and PO metronidazole 400mg BD, 14 days • Or IM ceftiaxone 250mg single dose, then, PO doxycycline 100mg BD and PO metronidazole for 14 days • Avoid ofloxacin in those at high risk of GC (clinically severe disease, partner with GC, any sexual contact abroad). • Metronidazole can be tolerated in those who can’t tolerate it
Complications of PID • Re-occurence (25%) • Infertility – 1 episode=12%, 2=35%, 3=75% • Chronic PID • Ectopic pregnancy • Chronic pelvic pain • Tubo-ovarian abscess (30%) • Fitz-Hugh-Curtis (10-20% with PID)
What to tell patients about...? • Metronidazole • ABX and COCP • Diagnosis of a STI
TREAT OR REFER • Treat in primary care : • -BV/candida • -Chlamydia • -PID • Refer to GUM: • -GC – may not survive in medium for >2 hours, bacterial resistance • - TV – need to get sample to lab by 6 hours to see live virus • 30-40% turn up at GUM if referred
References • Oxford Handbook of O+G • Oxford Handbook of Clinical Specialities • InnovAiT – vol 2, issue 9, Sept 2009 • DFSRH course book 2009 • DRCOG course book 2009 • RCOG website
THANKS FOR LISTENING ANY QUESTIONS?