Health Awareness blog

 

Vaginal discharge is a benign condition of the vagina. It defines as the presence of secretion from the vagina other than normal menstrual bleeding. It affects up to 17-20% of all women worldwide.

Causes:

Aetiologically, it can be divided into physiological or pathological. Physiological vaginal discharge is also known as leucorrhoea. The discharge mainly comes from vaginal epithelium and the cervix. It varies between women and stages of menstrual cycle. During premenstrual stage or at the time of ovulation, the secretion will increase. The secretion appears as mucoid and whitish in color. It is not itchy and rarely cause discomfort to the women.

Pathologically, it can be divided into infectious and non infectious. The secretion typically have offensive odor. The color may appear different from normal, example yellowish in color and the amount is excessive. It may cause itchiness.

Non infective causes are:

• Cervical ectropion
• Cervical or endocervical polyps
• Prolapsed endometrial polyps or fibroids
• Retained products of conception or other object like tampon, etc
• Vaginal trauma (e.g.: after birth, sexual abuse, etc)
• Rectovaginal fistula
• Post radiotherapy or post surgery
• Allergy causes secondary to lubricants or douching
• Underlying vaginal malignancy

 

Infective causes:

• Sexually transmitted disease like herpes genitalis, gonorrhea, Chlamydia, trichomonas, etc
• Non sexual transmitted disease like vaginal candidiasis and bacterial vaginosis
• Others; anaerobes, gram positive, gram negative

 

Evaluation of patients:

Diagnosis can be made by taking detail clinical history, do proper physical examination and investigations. If there is any suspicion of infection, swabs or specimen should be sent for microbiological conformation.

Clinical history:

• Duration and time of onset of the vaginal discharge may give some clues about the cause. Is there any relation to menses or coitus (sexual intercourse)? There are some patients come to me complaint of increase vaginal secretion just before menses or after sexual intercourse. Most of the time, there is nothing wrong about it.
• Describe the details about the secretion, the amount, consistency, odor and the color. Yellowish and offensive secretion may suggest underlying infection.
• Ask about the associated symptom to explore the severity of the symptoms to the patients. Is there any itchiness and fever that may suggest infection. Pain and swelling may give suspicion about sexual abuse or trauma. Is there any urinary symptom that may suggest underlying urinary tract infection.
• Is this is the first episode or any past similar history? If any, what have been done? Was the treatment works?
• If the patient is within reproductive age, ask detail history about sexual history. Is there any history of sexual promiscuity. Any usage of condoms or any barrier methods. This is to look for risk factors of sexual transmitted infections (STI).
• Ask about the partner’s condition. Is there any urethral or penile discharge that may strongly suggest of STIs.
• Any usage of contraceptive device like contraceptive oral pills or intrauterine device.
• How about the hygiene. Is the patient practice douching or tampon?
• Any medical disorders such as diabetes.
• Any history of vaginal disease or cancer?
• Any family history of malignancy?
• Any pap smear done before and what is the result.

 

Physical examination:

• General examination of the patient may give some clue of chronic disorder.
• Examine the abdomen and look for any mass.
• Detail external genitalia examination and look for inflammation, vesicles or abscess. Ulceration and scratch marks may suggest trauma or sexual abuse. It may also indicate itchiness or infection.
• Speculum examination is important to rule out any mass, polyps or foreign body.
• Bimanual examination is useful to elicit any pelvic tenderness or to palpate for mass. Small fibroids cannot be felt by normal abdominal examination.

 

Investigations:

• Cervical cytology smear or pap smear is useful to look for CIN (Cervical Intraepithelial Neoplasia)
• Swabs or specimens for microbiological studies. Vaginal swab can be taken from inside the vagina, endocervix or urethral meatus. Make sure to clean the genitalia before the swabs is taken to avoid contamination. Urine sample can be sent to culture and sensitivity.
• Assessment of Vaginal pH.
• Imaging study like ultrasound pelvis can be done if there is any suspicion of pelvic pathology or pelvic mass.
• Consider to check for blood sugar level in recurrent case because in some diabetic cases, it can represent with vaginal infections or vaginal candidiasis.
• Other gynaecological causes like polyps and malignancy should be rule out in persistent vaginal discharge. Consider biopsy if any lesion or mass is found.

 

Management:

 

Management is mainly depends on the causes or most possible cause. I am not going to write in detail of the management of specific causes like malignancy and polyps. For infections, antibiotics and antifungal will be given accordingly. Treatment should involve both patient and her partner. Reassurance should be given to all, especially those patients with physiological causes.

                In atrophic vaginitis (in post menopausal women), topical conjugated equine cream 0.5g cream (1/4 applicator) can be given 3 times per week. In selected cases, hormone replacement therapy can be given either oral or transdermal)

                Sometimes, the vaginal discharge is caused by IUDs or COCs. In this case, other methods can be tried. Frequent douching should be avoided and it is important to have a good hygiene practice. Local irritants, lubricants or soaps should be avoided as well as tight fitting synthetic clothings.

 

 

Reference:

1)      Lee Say Fatt. Quick Management Guide in Gynaecology. 2007. University Malaya Press.

2)      Janice et al. gynaecology in Focus. 2005. Elsevier.

Tags: atrophic vaginitis, discharge, leucorrhea, malignancy, pap smear, sexual transmitted disease, vaginal

Technorati Tags: atrophic vaginitis, discharge, leucorrhea, malignancy, pap smear, sexual transmitted disease, vaginal

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