Vaginal discharge

Published on 10/03/2015 by admin

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Chapter 41 VAGINAL DISCHARGE

Vaginal discharge is a common complaint of women and can either be physiologic or pathologic. Physiologic discharge is usually white or clear and thin and may have a mild odor. Accompanying symptoms such as itching, burning sensation, and redness should not be present. A woman’s vaginal discharge can change with the menstrual cycle. In addition, vaginal discharge may change as a woman ages and during pregnancy.

Pathologic vaginal discharge has many different possible causes. In the United States, the two most common causes are bacterial vaginosis and candidal vaginitis. Other causes include sexually transmitted diseases, especially infections with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis.

The appropriate diagnosis of vaginal discharge is very important in order to prevent potential complications. Both bacterial vaginosis and T. vaginalis infection can increase the risk of preterm labor. In addition, chlamydia and gonorrhea can lead to pelvic inflammatory disease, which can result in infertility.

Medications That Can Affect Vaginal Discharge

Antibiotics (increases risk for candidiasis)

Antiseptics (may cause chemical irritation or allergic vaginitis)

Corticosteroids (increases risk for candidiasis)

Lubricants (may cause chemical irritation or allergic vaginitis)

Oral contraceptives (increase risk for candidiasis and may affect discharge as a result of estrogen effect)

Over-the-counter vaginal creams (may cause chemical irritation or allergic vaginitis)

Spermicides (may cause chemical irritation or allergic vaginitis)

Key Historical Features

✓ Duration, color, consistency, amount, and odor of discharge

✓ Associated symptoms, such as burning sensation, itching, bleeding, pelvic or abdominal pain, lesions, dysuria, or painful sexual intercourse

✓ Relation to menstrual cycle

✓ History of infertility

✓ History of gynecologic surgery

✓ History of sexually transmitted diseases or vaginitis

✓ History of abnormal Pap smear results

✓ Sexual history

✓ History of pelvic radiation therapy (which increases risk for fistula)

✓ Most recent menstrual period

✓ Use of tampons

✓ Contraceptive used (condoms, intrauterine device)

✓ Menopausal status

✓ Medical history

• History of diabetes or symptoms of diabetes (which increases risk of candidal infections)

• History of human immunodeficiency virus (HIV) infection

• History of inflammatory bowel disease (IBD) or symptoms of IBD (which increases risk for fistula)

✓ Obstetric history, including history of obstetric trauma (increases risk for fistula)

✓ Surgical history

✓ Medications, including over-the-counter medications

Key Physical Findings

✓ Vital signs, especially assessment for the presence of fever

✓ External genital examination

• Examination of the vulva, which may appear erythematous with candidal or T. vaginalis infection

• Examination for satellite lesions, which may be seen with candidal infection

• Examination for ulcerative lesions, which may be seen with herpes simplex

✓ Speculum examination

• Examination of the vagina, which may appear erythematous with candidal or T. vaginalis infection

• Inspection for foreign bodies or neoplastic lesions

• Examination for “strawberry” cervix (punctate hemorrhages), which may be seen with T. vaginalis infection

✓ Appearance of discharge

• Frothy, thin, yellow/green discharge, which is consistent with T. vaginalis infection

• Thick white discharge, which is consistent with candidal infection

• Thin, grayish-white discharge, which is consistent with bacterial vaginosis

• Mucopurulent or purulent cervical discharge, which is suggestive of chlamydia, gonorrhea, or herpes simplex

• Mucopurulent or purulent urethral discharge, which is suggestive of chlamydia or gonorrhea

• Thin, clear, or bloody discharge, which is suggestive of atrophic vaginitis

✓ Odor of discharge

• Fishy odor, which is suggestive of bacterial vaginosis

• Foul odor, which may be caused by T. vaginalis or by anaerobic infections as a result of forgotten foreign bodies

✓ Bimanual examination to evaluate for cervical motion or uterine or adnexal tenderness, which is suggestive of pelvic inflammatory disease

Suggested Work-Up

Microscopy includes the following tests:

Wet-mount preparation of cervical discharge	To detect trichomonads (trichomonas) or clue cells (bacterial vaginosis), polymorphonuclear leukocytes (a ratio of polymorphonuclear leukocytes to epithelial cells greater than 1:1 is seen with T. vaginalis infection, gonorrhea, chlamydia, and herpes simplex), or round parabasal cells (which are seen with atrophic vaginitis)
Potassium hydroxide (KOH) preparation	To detect candidal infections (pseudohyphae or budding yeast)
Whiff test	To detect bacterial vaginosis (fishy odor with KOH)
Measurement of pH	A pH greater than 4 could indicate bacterial vaginosis or T. vaginalis infection (normal vaginal pH is 3.8 to 4.2)
Pap smear	To evaluate for cervical dysplasia
Endocervical swab or urine nucleic acid amplification test for Chlamydia organisms and N. gonorrhoeae (endocervical swab or urine)	To detect infections by these organisms

Additional Work-Up

Urine pregnancy test	If pregnancy is suspected
Sabouraud medium or Nickerson agar culture	To evaluate for candidal infections if the diagnosis is unclear
Diamond medium culture or polymerase chain reaction (PCR) testing	To evaluate for T. vaginalis infection if the diagnosis is suspected and wet-mount test is negative
Gram stain of cervical discharge	For the presence of intracellular gram-negative diplococci, which indicates gonorrhea, if an immediate diagnosis is needed
Viral culture of herpetic lesions	If herpes simplex infection is suspected
Biopsy	To evaluate lesions that appear to be neoplastic
Colposcopy	To evaluate suspicious lesions on the cervix
Thayer-Martin agar culture of cervical discharge	To evaluate for gonorrhea
HIV test	If the patient is at risk for HIV infection
Chlamydia culture of cervical discharge	If chlamydial infection is suspected

FURTHER READING

Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician. 2000;62:1095-1104.

Fox KK, Behets F. Vaginal discharge: how to pinpoint the cause. Postgrad Med. 1995;989:87-104.

Henn EW, Kruger TF, Siebert TI. Vaginal discharge reviewed: the adult pre-menopausal female. S Afr Fam Pract. 2005;47(2):30-31.

Mitchell H. Vaginal discharge—causes, diagnosis, and treatment. BMJ. 2004;328:1306-1308.

Owen MK, Clenney TL. Management of vaginitis. Am Fam Physician. 2004;70:2125-2132.

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