Vaginal Discharge

Differential Diagnosis:      

•  physiological – (neonate – sticky greyish d/c from mat. est.; thin whitish d/c 6-12 months before menarche; mid-cycle d/c with preg & OCP)
• infectious (cervicitis – gonorrhea, chlamydia; vulvovaginitis – bacterial vaginosis, yeast, trich)
• enterovaginal fistula
• foreign body
• neoplasm – vaginal SC Ca, cervical Ca, fallopian Ca

Bacterial vaginosis          

• not sexually transmitted, but more common in very sexually active women
• qual/quantitative shift in normal vaginal flora (increased anaerobes, decreased lactobacilli)
• Symptoms:                         
  • many asymptomatic; dyspareunia
  • discharge: moderate amount, white/grey, homogenous/ coats vagina, fishy
  • bubbles in d/c due to anaerobes
  • no vulvar or vaginal inflammation
  • pH > 4.7, + amine test
  • saline microscopy – clue cells, coccobacilli
• Criteria for diagnosis (need 3/4): 
  • 1) white homogeneous d/c
  • 2) vaginal pH> 4.7
  • 3) fishy amine odor (with addition of 10% KOH)
  • 4) clue cells
  • gram stain criteria
  • Not culture
• Treatment: 
  • metronidazole 500 mg po bid x 7 days
  • metrogel 5 g pv x 6 days
  • dalacin 100 mg pv x 7 days (clindamycin)

Candidiasis       

• associated with pregnancy, OCP, ABx, DM, immunosuppression
• Symptoms     
  • vulvar pruritus, external dysuria, dyspareunia
  • discharge: scant – mod, white, cottage-cheese consistency, no bubbles
  • vulva/ vagina may have erythema, edema, whitish areas
• Diagnosis:      
  • pH < 4.5, amine test -‘ve
  • saline microscopy – blastospores, pseudohyphae
  • wet prep (KOH) – buds/ hyphae
  • culture
• Treatment:      
  • topical azole derivatives (eg monostat x 10-14 days, canesten x 1-7 days) or polyenes
  • single oral dose fluconazole  150 mg (or x 3 days) – GI SEs common

Trichomoniasis                

• sexually transmitted protozoan
• Symptoms:                      
  • men usually asymptomatic
  • vulvar pruritus, external dysuria (due to rawness around vulva), dyspareunia
  • discharge: profuse, yellow/green, homogenous, frothy, malodorous
  • vagina/ vulva – erythema, edema, “strawberry cervix”
  • Diagnosis:
    • pH 5-6, amine test occ +
    • saline microscopy  – ++ PMNs, motile trichomonads, no clue cells
    • wet prep (saline microscopy), culture, pap
  • Treatment:
    • metronidazole 2 g stat (95% cure, esp if Rx partner)
    • metronidazole 500 mg bid x 7 days (teratogenic so don’t use in pregnancy)

 Chlamydia & Gonorrhea  — See STI Notes