Doctor, Ive got a discharge

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Doctor, Ive got a discharge

• Dr Rajakumar
• Consultant GU Medicine

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Bacterial Vaginosis

• Gardnerella vaginalis
• Bacteroids

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Bacterial Vaginosis (BV)
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Bacterial Vaginosis

• Overgrowth of anaerobic organisms
• Replacement of lactobacilli
• Increasing vaginal pH
• Offensive, fishy discharge without soreness,
  itch or irritation
• Asymptomatic/chance finding
• O/E thin, white, homogenous discharge coating the
  walls of the vagina

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Amsels Criteria diagnostic gold standard

• 3 of 4 of the following must be present
• ?Thin, white homogenous discharge
• ?Clue cells on microscopy
• ?Vaginal pH . 4.5
• ?Fishy odour on adding alkali
• Clue cells epithelial cells heavily coated with
  bacilli
• Always screen for other infections, co-infection
  common

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Management

• Treat women who are not pregnant if they are
  symptomatic
• Treat women who are pregnant if they are
  symptomatic or have hx of idiopathic pre term
  birth 2nd trimester loss
• Treat women before undergoing minor procedures
  (eg TOP, IUCD, DC) or post partum

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Medication

• Oral Metronidazole 400mg BD 7 days
• Single dose 2g (Inc compliance, less effect)
• Topical Metronidazole 5g of 0.75 vaginal gel
  nocte for 5 days
• Topical Clindamycin 2 cream nocte 5 days
• Not during pregnancy topical rx whilst
  breastfeeding

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Candidiasis

• Yeast infection candida albicans
• cottage cheese discharge (non
  offensive)/pruritis/sore vulva
• Pain on intercourse/dysuria
• RFs DM, pregnancy, immunosuppression,
  steroids, broad spectrum antibiotics,
  chemo/radiotherapy, tight synthetic underwear,
  hormone replacement

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Diagnosis

• On history and examination
• HVS not necessary if typical
• HVS recommended if requested or ?STI in diagnosis
  if in doubt
• Recurrent infection is rare and is defined as gt4
  episodes in the last year

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VULVITIS
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Treatment

• Pessary or oral (SE/choice)
• Fluconazole 150mg single capsule gt16y
• Clotrimazole pessary 500mg nocte x1
• Ecostatin-1 150mg pessary nocte x1
• Miconazole 1.2g ovule nocte x1
• No need to treat male partner

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RECURRENT THRUSH

• Careful history of microbiological confirmation
• Urine for glucose
• TFT
• FBC
• ?antibiotic/steroid use or immunodeficiant
• Try 1 week course of antifungal oral as induction
  and fortnightly single dose topical/oral for 3 to
  6 months and stop
• If no response speciation and sensitivity testing

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Trichomoniasis

• Flagellated proazoan
• Infection of vaginal/urethra
• Women-frothy yellow discharge (offensive),
  itching/dysuria vulvitis/vaginitis (common)(
• Men usually asymptomatic, urethral discharge,
  dysuria, frequency
• Examination may be normal (strawberry cervix)
• SEXUALLY TRANSMITTED

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Trichomonas Vaginalis
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Investigation

• Women HVS for culture
• Men urethral or first void culture
• Screen for co-existing STI
• Refer to GU Med if
• Diagnosis uncertain/contact tracing/screening

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Treatment

• Oral Metranidazole 400mg BD 5-7/7
• Single dose Metronidazole 2g
• Treat partners simultaneously (sexual abstinance
  during treatment)
• Pregnant/breast feeing avoid single high dose
  treatment, in early pregnancy Clotrimazole
  pessaries reduce symptoms

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Treatment failure

• Repeat courseof Metronidazole (higher dose)
• Repeat HVS
• Consider Erythromycin/Amoxycillin
• Consider referral to GU Med or if pregnant/breast
  feeing OG
• Culture and resistance testing
• Treatment with IV and topical

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Cervicitis

• Most commonly due to chlamydia or gonorrhoea
• Screen for both
• PID is a complication

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Gonococcal epididymo-orchitis
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Mucopurulent cervicitis
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Chlamydia trachomatis

• Assumptomatic in gt80 of women and gt50 of men
• Most common cause of PID
• Preventable cause of infertility and ectopic
  pregnancy
• Most commonly diagnosed STI in GU Med clinics in
  the UK
• Number of diagnoses increasing
• Females highest incidence 16-19years
• Males highest incidence 20-24 years

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Diagnosing chlamydia

• Possible symptoms include purulent discharge, PCB
  or IMB, dysuria or with PID lower abdo pain and
  dyspareunia
• Exam purulent discharge, cervicitis /- contact
  bleeding
• Which test PCR, not EIA culture medico-legal
  purpose
• Which specimen
• Cervical/HVS/urethral/urine

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Management (simple)

• Screen for other STI (consent)
• Notify partners (last 6/12 or most recent)
• FU telephone follow-up by HA
• Re-test if symptoms persist/possible
  reinfection/after treatment if pregnant
• REFERRAL TO GUM RECOMMENDED

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Antibiotics

• PO Azithromycin 1g single dose
• PO Ofloxacin 200mg bd 7 days (more expensive)
• Pregnant/breast feeding d/w obs or GUM
• Erythromycin or Amoxycillin recommended

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Again advise

• Sexual abstinence until woman and partner treated
  (7/7 if single dose)
• Prevention measures

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Gonorrhoea

• Neisseria gonorrhoeae
• Outbreaks
• Commonly co-exists with other pathogens
• Men get urethral discharge in gt80 cases
• Women lt50 mucopurulent discharge
• Infection may lead to PID, bartholins abscess,
  miscarriage, pre-term labout, neonatal ophthalmia

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Gonorrhoea
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Diagnosis

• Women endocervical swabs for gonococcus culture
  and sensitivities
• Men urethal swab
• Transport only on appropriate media, rapid
  decrease in viability of sample d/w local lab
• Screen for other STIs

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Antibiotics

• Cefixime 400mg oral stag
• Ceftriaxone 250mg IM stat
• IM Cefoxitin with Probenecid
• Ciprofloxacin 500mg po if beta lactam allergy
  do not use in pregnancy
• Check local sensitivities

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Rarer causes of vaginal discharge

• Cervical ectropion
• Chemical vaginitis
• Foreign body eg retained tampon (remove rx with
  Metronidazole)
• IUCD
• Cervical polyp
• Fistula
• Tumour vaginal.cervical

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Complications of gonorrhoea and chlamydia
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Ophthalmia Neonatum
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Gonococcal epididymo-orchitis
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Gonococcal arthritis
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Pelvic Inflammatory Disease
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Fitz-Hugh Curtis Syndrome
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Confidentiality

• NHS Trusts and Primary Care Trusts
• (Sexually Transmitted Diseases) Directions 2000
• Updates NHS Trusts (Venereal Diseases) Directions
  1991
• Applicable only to England

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Confidentiality

• Every NHS trust and Primary Care Trust shall
  take all necessary steps to secure that any
  information capable of identifying an individual
  obtained by any of their members or employees
  with respect to persons examined or treated for
  any sexually transmitted disease shall not be
  disclosed ..

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Confidentiality

• except-
• For the purpose of communicating that information
  to a medical practitioner, or to a person
  employed under the direction of a medical
  practitioner in connection with the treatment of
  persons suffering from such disease or the
  prevention of the spread thereof, and
• For the purpose of such treatment or prevention

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Genital Herpes