Presentation on theme: "CASE Mrs Ford is a 29 years old lady who has been complaining of vaginal discharge for the past 3 days. Otherwise she is asymptomatic. Her PMH includes."— Presentation transcript:
1CASEMrs Ford is a 29 years old lady who has been complaining of vaginal discharge for the past 3 days. Otherwise she is asymptomatic. Her PMH includes bronchial asthma. Her cycles are normally regular with no issues. She has been with her current partner for few months. ON examination there was no significant findings.What do you want to know more?What is your differential?What investigations would you like to do, if any?What are the treatment options?What is your plan if this is a recurrent problem?Can you suggest any preventive measures?
2Causes Foreign bodies, e.g. retained tampon Vulval dermatitis Non-infective:PhysiologicalCervical polyps and ectopyForeign bodies, e.g. retained tamponVulval dermatitisErosive lichen planusGenital tract malignancyFistulaeNon-sexually transmitted infection:Bacterial vaginosisCandidaSexually transmitted infection:Chlamydia trachomatisNeisseria gonorrhoeaeTrichomonas vaginalis
3Assessment A full clinical and sexual history Nature of the discharge: odour, onset, duration, colour.Associated symptoms: itch, dyspareunia, dysuria, abdominal pain, abnormal bleeding, pyrexia.Medications: antibiotics, steroidsPMH: DM, immunocompromised state.Investigations: Triple swaps, vaginal pH testing (Candida and bacterial vaginosis can be diagnosed clinically and treated without sampling)
4Bacterial Vaginosis May be asymptomatic (in up to 50% of women) Thin, profuse and fishy smelling discharge without itch or sorenessAssociated with poor pregnancy outcomes, endometritis after miscarriage, and pelvic inflammatory diseaseAsymptomatic bacterial vaginosis in non-pregnant women does not require treatment.Routine: oral metronidazole for 5-7 days or stat 2gm dose. Alternatively topical metronidazole or oral clindamycin or topical clindamycin.70-80 % cure rate but commonly recurs
5CandidiasisThick, white, non-offensive discharge which is associated with vulval itch and soreness.May cause mild dyspareunia and external dysuriaExamination may be normal or there may be erythema, oedema and fissuringpH is less than 4.5Asymptomatic vulvovaginal candidiasis does not need treatment.Vaginal imidazole: clotrimazole, econazole, miconazole or fluconazole 150 mg orally (avoid in pregnancy)80-95 % cure rate.
6Infective (STD) vaginal discharge Can present with vaginal discharge but may also be asymptomatic.Associated with an increased risk of HIV transmission.May be complicated by PID.Trichomonas vaginalis:Offensive yellow vaginal discharge, which is often profuse and frothy, with vulval itch and soreness, dysuria, abdominal pain and superficial dyspareuniaIs associated with preterm deliveryChlamydia trachomatis:Copious purulent vaginal discharge, but it is asymptomatic in 80% of womenDiagnosis is confirmed on swabbingNeisseria gonorrhoeae:Purulent vaginal discharge but is asymptomatic in up to 50% of womenMild symptoms include slight discharge, dysuria, intermenstrual bleeding
7Treatment (infective STD discharge) Refer to the GUM clinic (unless your practice has the appropriate expertise).Chlamydia trachomatis; doxycyclin or azithromycinGonorrhoea; cefixime or ceftriaxoneTrichomonas vaginalis; metronidazolePatients will be fully screened for concurrent STDs and treated as appropriate.Partners will need to be identified, screened and treated too.
8Recurrent dischargeEnsure pathology hasn't been missed (e.g. an STD in the case of a patient being treated for bacterial vaginosis).Explore personal hygiene (douches, perfumed products and tight synthetic clothing)If the patient has coil in situ, consider alternative.Think of diabetes, immunosuppression or antibiotic administration.Consider the 'silent' complaint: depression, anxiety or psychosexual dysfunction.Post-menopausal atrophic changes may predispose women to recurrent vaginitis.