Obstetrics & Gynaecology
Question 49 of 180
A 27 year old woman presents to the Emergency Department complaining of vaginal discomfort and discharge. She describes a foul smelling profuse vaginal discharge associated with vulval itching. She has no past medical history. She reports recent unprotected sexual intercourse with a new partner. On examination you note an offensive smelling, yellow-green frothy discharge and vulvitis. Speculum exam demonstrates a 'strawberry cervix'. What is the recommended treatment for this patient?
Answer:
The patient has features of trichomoniasis. The recommended treatment is oral metronidazole 400 mg bd 5 - 7 days.Vaginal Discharge
Obstetrics & Gynaecology / Sexual Health
Last Updated: 12th February 2021
Normal physiological vaginal discharge is a white or clear, non-offensive discharge that can vary over time. Abnormal vaginal discharge is characterised by a change of colour, consistency, volume, and/or odour, and may be associated with symptoms such as itch, soreness, dysuria, pelvic pain, or intermenstrual or postcoital bleeding. It is most commonly caused by infection; however, there can be non-infective causes.
Causes of abnormal vaginal discharge
- Vaginal infections
- Bacterial vaginosis
- Vulvovaginal candidiasis
- Trichomoniasis
- Endocervical infections
- Cervicitis caused by chlamydia or gonorrhoea
- Pelvic inflammatory disease caused by chlamydia or gonorrhoea
- Non-infective causes:
- A retained foreign body, such as a tampon, condom, or vaginal sponge.
- Inflammation due to allergy or irritation caused by substances such as deodorants, lubricants, and disinfectants.
- Tumours of the vulva, vagina, cervix, and endometrium.
- Atrophic vaginitis in postmenopausal women.
- Cervical ectopy or polyps.
- Fistulae.
- Recent childbirth (with perineal, vaginal lacerations, or episiotomy) or vaginal surgery — vaginal discharge may result from granulation tissue or from a surgical site infection.
Vaginal infections
| Vaginal Discharge | Bacterial vaginosis | Trichomoniasis | Vaginal candidiasis |
|---|---|---|---|
| Cause | Overgrowth of anaerobic bacteria esp. Gardnerella vaginalis | STI caused by the flagellated protozoan Trichomonas vaginalis | Superficial fungal infection with Candida albicans |
| Discharge | Fishy-smelling, thin, grey/white homogeneous discharge | Offensive smelling yellow/green frothy discharge | White, odourless, curdy discharge |
| Associated symptoms | No soreness, itching or irritation | Vulval itching or soreness, dysuria, lower abdominal pain, superficial dyspareunia | Vulval itching, soreness and irritation, superficial dyspareunia, dysuria |
| On examination | Thin white/grey homogeneous discharge coating of the vaginal walls and vulva with fishy odour; no inflammation | Offensive smelling, yellow-green, frothy discharge; vulvitis and vaginitis; strawberry cervicitis | White, odourless, curdy discharge; erythema; vaginal fissuring and/or oedema; vulval excoriations |
| Investigations | Vaginal pH & high vaginal swab | Vaginal pH & high vaginal swab | High vaginal swab & Speciated fungal culture |
| Treatment | Oral metronidazole 400 mg bd 5 - 7 days | Oral metronidazole 400 mg bd 5 - 7 days | Intravaginal antifungal cream or pessary or oral antifungal +/- topical imidazole |
Bacterial vaginosis
- Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge. It is caused by an overgrowth of anaerobic bacteria, particularly Gardnerella vaginalis. The exact trigger for bacterial vaginosis (BV) is unknown, but symptoms are thought to appear when the vaginal pH raises, creating an alkaline environment which favours the growth of normal and abnormal bacteria.
- Approximately 50% of women with bacterial vaginosis (BV) are asymptomatic. When symptoms are present, BV is characterized by a fishy-smelling, thin, grey/white homogeneous discharge that is not associated with itching or soreness.
- Perform a speculum examination (except in a pregnant woman with a low-lying placenta) to visualise the cervix and vagina to look for characteristic signs of BV. BV is characterised by a thin, white/grey, homogeneous coating of the vaginal walls and vulva that has a fishy odour. BV is not usually associated with soreness, itching, or irritation. Test the pH of the vaginal discharge to help distinguish between BV and other causes for symptoms; a pH greater than 4.5 is suggestive of the diagnosis of BV. Take a high vaginal swab (or use a self-taken low vaginal swab) for Gram staining and to exclude other causes of symptoms.
- If the woman is asymptomatic, treatment is not usually required, unless she is undergoing termination of pregnancy. If the woman is symptomatic, advise that, where possible, she should reduce exposure to contributing factors, such as vaginal douching and the use of antiseptics, bubble baths, or shampoos in the bath. Prescribe oral metronidazole 400 mg twice a day for 5 to 7 days. If the woman prefers topical treatment or cannot tolerate oral metronidazole, prescribe intravaginal metronidazole gel 0.75% once a day for 5 days (off-label for women aged younger than 18 years) or intravaginal clindamycin cream 2% once a day for 7 days.
- Women with bacterial vaginosis (BV) are at increased risk of acquiring sexually transmitted infections (STIs). BV is also associated with several obstetric complications.
Trichomoniasis
- Trichomoniasis is a sexually transmitted infection caused by the flagellated protozoan Trichomonas vaginalis. Vertical transmission can occur from an infected mother to baby during vaginal delivery.
- Up to 50% of women are asymptomatic. If symptoms are present, the commonest symptom is a vaginal discharge, classically a frothy yellow-green offensive smelling discharge. Associated symptoms include vulval itching and soreness, dysuria or dyspareunia.
- Perform a speculum examination (except in a pregnant woman with a low-lying placenta) to visualize the cervix and vagina to look for characteristic signs of trichomoniasis. Trichomoniasis, when symptomatic, is characterised by a yellow-green, frothy discharge with an offensive odour. Inflammation of the vulva and vagina, or more rarely a strawberry appearance of the cervix (cervicitis), may be observed on pelvic examination. Take a high vaginal swab from the posterior fornix (or use a self-taken low vaginal swab) for Gram staining and to exclude other causes of symptoms. Test the pH of the vaginal discharge to help distinguish between trichomoniasis and other causes for symptoms; a pH greater than 4.5 is suggestive of the diagnosis of trichomoniasis.
- If trichomoniasis is suspected, refer the woman to a genito-urinary medicine (GUM) clinic or other local specialist sexual health service for confirmation of the diagnosis and for treatment. To treat the infection prescribe oral metronidazole 400–500 mg twice a day for 5–7 days, or metronidazole 2 g as a single oral dose, or tinidazole 2 g as a single oral dose. Treat current partner(s) simultaneously, and also treat any partner(s) from within the 4-week period prior to presentation. Offer screening for other STIs (if not already done). Advise sexual abstinence for at least one week and until the person and partner(s) have completed treatment and follow up.
- Trichomoniasis in women may be associated with perinatal complications (preterm delivery and/or low birthweight infant), predisposition to maternal postpartum sepsis, facilitation of HIV transmission, pelvic inflammatory disease, alterations to the normal vaginal flora, increasing susceptibility to bacterial vaginosis, increased risk of cervical cancer, especially in women co-infected with human papilloma virus, infertility.
Vulvovaginal candidiasis
- Vulvovaginal candidiasis is a symptomatic inflammation of the vagina and/or vulva caused by a superficial fungal infection, usually with Candida albicans. Vulvovaginal candidiasis is very common in women of reproductive age. Risk factors include oestrogen exposure, immunocompromised state, poorly controlled diabetes mellitus, treatment with broad spectrum antibiotics, local irritants, sexual behaviours, contraception, hormone replacement therapy.
- Symptoms of vulvovaginal candidiasis include:
- Vulval itching (often the defining symptom).
- Vulval soreness and irritation.
- Vaginal discharge (usually white, 'cheese-like', and non-malodorous).
- Superficial dyspareunia.
- Dysuria (pain or discomfort during urination).
- Signs of severe vulvovaginal candidiasis include:
- Erythema — usually localised to the vagina and vulva, but may extend to the labia majora and perineum.
- Vaginal fissuring and/or oedema.
- Excoriation of the vulva.
- Investigations are not routinely recommended if the history indicates acute, uncomplicated vulvovaginal candidiasis. Consider the need for investigations (based on clinical features and clinical judgement) to confirm the diagnosis and/or exclude an alternative diagnosis. For example, consider:
- Vaginal pH testing (to differentiate between types of vaginal infection)
- High vaginal swab ( for supporting the diagnosis when this is uncertain, in women with severe or recurrent symptoms, or if there is treatment failure)
- Speciated fungal culture of vaginal secretions (to identify the species type if there is unexplained treatment failure or recurrent infection)
- Prescribe antifungal treatment. For most women, prescribe an initial course of an intravaginal antifungal cream or pessary (clotrimazole, econazole, miconazole, or fenticonazole) or an oral antifungal (fluconazole or itraconazole). If there are vulval symptoms, consider prescribing a topical imidazole in addition to an oral or intravaginal antifungal. Options include clotrimazole or ketoconazole. Give advice on self-care.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
