Vaginal discharge

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shankar Kumar, M.B.B.S. [2] Samah ObaiahRinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords: Discharge from the vagina

Overview

Vaginal discharge is a common patient complaint that is paired with anxiety regarding sexually transmitted diseases. If a STD is detected, a search for all other STDs should be done. Advise the infected patient to inform all sexual partners of their diagnosis.Also there is normal vaginal discharge depends on periodic hormonal change

Causes

Common Causes

• Atrophic vaginitis or senile vaginitis, it as a result of estrogen deficiency lead to vaginal dryness, itching, irritation, discharge, and dyspareunia
• Bacterial vaginosisis mostally happen during the reproductive age of women characterized by a shift in the vaginal flora from the dominant Lactobacillus to a polymicrobial flora
• Cervical cancer
• Chlamydia,sexually transmitted infections.
• Foreign body vaginitis
• Gonorrhea,sexually transmitted infections
• Herpes
• Trichomoniasis,a parasitic infection typically contracted and caused by having unprotected sex
• Vaginal cancer
• Vaginal yeast infection
• Diabetes
• Drug side effect as antibiotic or steroid use as, Amoxicillin and Clavulanic Acid , Butoconazole Vaginal Cream , Clotrimazole , Combined oral contraceptive pill, Estradiol Topical , Estradiol Transdermal , Estrogen and Progestin (Oral Contraceptives) ,Estrogen Injection , Estrogen Vaginal , Etonogestrel and Ethinyl Estradiol Vaginal Ring , Glatiramer Injection ,Hormone replacement therapy (trans), Letrozole, Leuprolide , Medroxyprogesterone Injection , Metronidazole Topical ,Miconazole , Nafarelin , Natalizumab injection , Norelgestromin and ethinyl estradiol transdermal system , Ospemifene, Oxcarbazepine , Pramipexole, Progesterone, Tamoxifen , Terconazole Vaginal Cream, Vaginal Suppositories , Toremifene, Zoledronic Acid Injection

Classification

Normal vaginal discharge as in Neonatal, Pediatric, Puberty, Menstrual cycle, Pregnancy, and Menopause. -Abnormal vaginal discharge as

• Bacterial vaginosis

• Vaginal yeast infection

• Sexually transmitted diseases

• vaginal cancer

• cervical cancer

Laboratory findings

Initial tests include:

• CBC
• Urinalysis
• Urine culture
• Beta-hCG
• Gonorrhea culture
• Chlamydia culture

Other Diagnostic Studies

Type	pH	Discharge	Odor	Wet Mount
Trich	>4.5	yellow-green, copious	present	motile, flagellated
BV	>4.5	white-grey	fishy	clue cells
Candida	<4.5	white, curd-like	none	pseudo-hyphae
GC		mucopurulent	varies	PMNs
A.V.		thin, gray, watery	none	few epithelial cells

Diagnosis

Abbreviations: BP: Blood pressure, RR=Respiratory rate, HR=Heart Rate, OCP= Oral Contraceptive Pill, NAAT= Nucleic Acid Amplification Test

Treatment

'Abbreviations: QHS : Every bedtime , BID: 2 times daily, TID: Three times a day, QID: Four times a day, IM :Intramuscular

Organisms	Recommended Drugs	Alternative drugs
Candidiasis	Over-the-Counter Intravaginal Agents Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days OR Clotrimazole 2% cream 5 g intravaginally daily for 3 days OR Miconazole 2% cream 5 g intravaginally daily for 7 days OR Miconazole 4% cream 5 g intravaginally daily for 3 days OR Miconazole 100 mg vaginal suppository, one suppository daily for 7 days OR Miconazole 200 mg vaginal suppository, one suppository for 3 days OR Miconazole 1,200 mg vaginal suppository, one suppository for 1 day OR Tioconazole 6.5% ointment 5 g intravaginally in a single application Prescription Intravaginal Agents: Butoconazole 2% cream (single dose bioadhesive product), 5 g intravaginally in a single application OR Terconazole 0.4% cream 5 g intravaginally daily for 7 days OR Terconazole 0.8% cream 5 g intravaginally daily for 3 days OR Terconazole 80 mg vaginal suppository, one suppository daily for 3 days Oral Agent: Fluconazole 150 mg orally in a single dose	Nystatin 1,00,000 unit tab vaginally QHS for 2 weeks
Trichomoniasis	Metronidazole 2 g orally in a single dose OR Tinidazole 2 g orally in a single dose	Metronidazole 500 mg orally twice a day for 7 days OR Clotrimazole 2 X 100 mg vaginal tabs QHS for 7days
Bacterial Vaginosis	Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days	Tinidazole 2 g orally once daily for 2 days OR Tinidazole 1 g orally once daily for 5 days OR Clindamycin 300 mg orally twice daily for 7 days OR Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days
Neisseria gonorrhoea	Amoxicillin orally 3 gm single dose or Ampicillin orally 3.5 gm single dose or Procaine PCN G 4.8 million IM single dose PLUS Probenecid 1 gm orally single dose AND Tetracycline 500 mg orally QID for 7 days or Doxycycline 100 mg orally BID for 7 days or Ceftriaxone 250 mg IM single dose	Erythromycin 500 mg orally QID for 7 days or Tetracycline 500 mg orally QID for 7 days or Doxycycline 100 mg orally BID for 7 days or Spectinomycin 2 gm IM single dose
Chlamydia trachomatis	Tetracycline 500 mg orally QID for 7 days or Doxycycline 100 mg orally BID for 7 days	Erythromycin base 500 mg orally QID for 7 days or Erythromycin ethylsuccinate 800 mg orally QID for 7 days or Sulfamethoxazole 1gm orally BID for 10 days
Herpes Simplex	Acyclovir

Patient should be referred to a gynecologist if following are present.

• Retained foreign bodies.
• Recent instrumentation or surgery of the genital tract such as hysterosalpingography, dilation and curettage, hysteroscopy, termination of pregnancy/evacuation of retained products of conception, laparoscopy and major gynaecological surgical procedure.
• Suspected tumor of the genital tract.
• Cervical ectopy or polyps.
• Recurrent vulvovaginal candida infections.
• Pregnant woman with abnormal vaginal discharge
• Symptoms of upper genital tract infections as fever, lower abdominal pain

Treatment in pregnancy:

• Vulvovaginal Candidiasis: It frequently occurs during pregnancy. Only topical azole therapies for 7 days are recommended for use among pregnant women.

• Trichomoniasis: Metronidazole 2 g orally single dose is recommended. Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.

• Bacterial vaginosis: Treatment is recommended for all symptomatic pregnant women. Metronidazole 250-mg regimen is effective. But, Metronidazole 500 mg twice daily can be used.

Acute pharmacotherapies

Bacterial Vaginosis

• Metronidazole single dose for 7 days

Candida and Chlamydia

• Azithromycin
• Doxycycline

Gonorrhea

• Oral ciprofloxacin or IM ceftriaxone

Trichomonas

• Metronidazole single dose for 7 days
• Intravaginal clotrimazole if pregnant or unable to use Metronidazole