Vaginal Discharge: Symptoms and Diagnosis

Approach to Vaginal Discharge

• This presentation focuses on the approach to vaginal discharge, including anatomy, symptoms, diagnosis, and different causes

Anatomy

• The Vagina is a fibromuscular tube connecting the vestibulum and uterus
• The Vagina has anterior, posterior, and lateral walls and is separated by the cervix with 4 fornices (posterior, anterior, Lateral)
• The Vulva includes the labia minora (rich in sebaceous glands) and labia majora (eccrine, apocrine, and sebaceous glands)
• The Vestibule contains major and minor vestibular glands

Micro Anatomy and Physiology

• The Vagina includes a mucosa layer of squamous epithelium with cells rich in glycogen
• Vaginal bacteria (Lactobacilli) break down glycogen to produce lactic acid, increasing glycogen after ovulation
• The vagina has an acidic protective environment with a pH less than 4.5 influenced by oestrogen
• The vagina includes longitudinal and circular smooth muscle layers
• Vaginal discharge changes through life stages and the menstrual cycle
• Physiologically, vaginal discharge is asymptomatic, without pruritis, pain, burning, irritation, or erythema, and can be colourless or yellowish, odour can be subjective

Presenting Symptoms

• Change in vaginal discharge can be a presenting symptom
• Offensive smell, and change in colour can be symptoms of vaginal discharge
• Itching, and burning of the vagina are both common
• Vaginal discharge can involve the vulva and external genitalia
• Contact bleeding during sexual intercourse can be a symptom
• Pain during urination or intercourse can be related to vaginal discharge

History

• Details on the main complaint, when it started, duration, and associated symptoms must be taken
• Preceding events, changes in diet, pregnancy, sexual activity, systemic illness or antibiotic use are relevant
• A new medication or contraception can sometimes cause vaginal discharge
• Previous episodes, gynaecological and general history are good to know

Examination

• Quick assessment of whether the patient is stable or unstable, acute or chronically ill / well is important
• Take Vitals, including temperature, pulse, BP, urine dipstix, and do a pretest
• Perform a general system assessment of the abdomen; examine via inspection and palpitation for masses, tenderness, and guarding
• Vaginal examination requires consent, privacy, and patient comfort; inspect the vulva and vagina for inflammation, discharge.

Vaginal Examination

• A speculum should be gently inserted with lubrication
• Cervix examined for discharge, masses, and contact bleeding

Cervicitis

• Cervicitis is inflammation of the cervix, and can be caused by gonorrhea, trichomonas, and candida

Bimanual Examination

• During the exam, palpate the labia majora for masses
• Digital vaginal examination and palpation of the cervix are performed
• Check for masses and whether the cervical os is open
• Assess for motion tenderness to indicate pelvic peritoneum inflammation and fullness in the pouch of douglass

Differential Diagnosis

• The most common cause in general is Bacterial Vaginosis (40-50%)
• Candida vulvovaginitis accounts for 20-25%
• Trichomoniasis accounts for (15-20%)
• Common causes in sexually active persons include Chlamydia and Gonorrhoea
• Hypoestrogenic females can have vulvovaginal atrophy

Genital Tract Infections and Discharges Differential Diagnosis

• Vaginal Candida is thick, white, or green discharge accompanied by itching, burning, and erythema
• It is associated with antibiotic therapy, diabetes mellitus, immune deficiency states, pregnancy, and contraceptive use
• Diagnose based on clinical appearance and microscopy with potassium hydroxide wet preparation showing thread-like pseudo-hyphae.
• Bacterial Vaginosis: white, grey discharge with odour and minimal itching
• Diagnosis using potassium hydroxide "whiff test" and microscopy to detect clue cells (AMSEL CRITERIA)
• Trichomonas: yellow-green frothy discharge with burning odour and erythema, especially in the upper vagina and cervix
• Diagnosis via wet mount with sodium chloride showing mobile protozoa
• Chlamydia / Gonorrhoea are non-specific vaginal discharges that can be asymptomatic, or occasionally cause discomfort with or without erythema
• Diagnosis using polymerase chain reaction on urine or cervical swabs
• Diagnose mixed bacterial infection through clinical appearance and culture of specific bacteria
• This is a yellow-brown malodorous discharge associated with neoplasms, trauma, foreign bodies, pelvic inflammatory disease, or retained products of conception

Special Investigations

• Wet mount smear must be done via microscopy
• Speculum, clear glass slide, and a drop of saline and KOH (10%) are needed
• An Amine test can be done (whiff test)
• A microscopy at 10x magnification can show lacto/doderlein bacilli, trichomonas, clue cells, candida, or ferning pattern

Special Investigations

• Swabs for MCS are not routine
• Chlamydia can be diagnosed using NAAT (nucleic acid amplification test)
• HVS and Endocervical swab are used for Gonorrhoea
• General Special Investigations include testing for HIV and Syphilis as well as cervical cancer screening
• Ultrasound of the Uterus and Adnexa to check for masses can be done

Bacterial Vaginosis

• Bacterial Vaginosis is not an STI, but polymicrobial
• Bacterial Vaginosis is a type of overgrowth of anaerobic organisms where Lactobacilli are replaced or destroyed
• Triggers for Bacterial Vaginosis can include antibiotics, chemicals, oestrogenic environment, and sexual activity
• Diagnosis can be done according to the Amsel Criteria for Diagnosis of Bacterial Vaginosis (3 of 4) based on: homogenous non-clumping vaginal discharge, amine odour, vaginal Ph above 4.5

Candidiasis

• Candidiasis is linked to commensal yeast-like Fungi, where the vagina is colonized with 80-92% Candida that can spread to the vulva / perianal area
• Symptoms of Candidiasis include itching red, curdy thick discharge
• Causes can include medical conditions, decreased immunity, antibiotic use, changes in oestrogen and chemicals

Trichomonas Vaginalis

• Trichomonas Vaginalis is a sexually transmitted infection caused by a protozoal parasite (unicellular flagellated organism)
• It can be diagnosed on the Saline side of the wetmount

Gonorrhoea

• Gonorrhoea is a sexually transmitted infection, it causes Muco-purulent discharge with cervicitis
• It is composed of Neisseria Gonorrhoea bacteria (gram neg diplococcus)
• It spreads to the internal genital organs
• Diagnosed via swab from discharge or endocervical canal and use of a charcoal transport medium

Chlamydia Trachomatis

• Chlamydia Trachomatis are a Sexually transmitted intracellular parasite
• This can be asymptomatic, with high prevalence of contact bleeding
• Can cause Purulent discharge, Cervicitis, dysuria, ascending pelvic infection
• Diagnosis requires a clinical visit, PCR test with urine, or NAAT Swab

Mixed Bacterial Infection

• Mixed bacterial infections are when the Discharge has a secondary source following a preceding event
• Symptom Overview includes a Tender abdomen, masses, guarding – peritonism
• Vaginal assessment may indicate an open Os, discharge, necrotic material, cervical motion tenderness, retained products
• Mixed bacterial infections cause ascending infection (Pelvic and tubo-ovarian complexes) and can be due to a a foreign material
• The infection can cause systemic involvement – acute abdomen, systemic response, sepsis and septic shock and a need to find the source

Conclusion

• Vaginal discharge is common, but it can cause anxiety and fear
• Vaginal discharge can progress from a physiological state to a severe sepsis state
• To diagnose the condition, take a thorough history and clinical examination with side room investigations