VAGINAL

DISCHARGE/PELVIC
INFLAMMATORY
DISEASE
DR O. M.
AYODELE
INTRODUCTION

 Common gynaecological complaint

 Oestrogen thickens vaginal epithelium & results in large quantities
of glycogen within epithelial cells
 Glycogen produces lactic acid
 Acid environment (pH 3.5-4.0) promotes growth of normal vaginal
flora (lactobacilli & acidogenic corynebacteria)
 Candida may be present in small amounts
 INTRODUCTION

 In pre-pubertal girls, absence of oestrogen results in thin vaginal

epithelium, predisposing them to bacterial infection
 In post-menopausal women, atrophic vagina/vulva predisposes to
trauma & infection,& lactobacilli are replaced with pathogenic
cocci
 Faecal & urinary soiling may be underlying factor in this age-group
CAUSES OF EXCESSIVE VAGINAL
DISCHARGE
 Physiological
 Infective

 Malignant

 Miscellaneous
PHYSIOLOGICAL CAUSES OF VAGINAL
DICHARGE
 Shortly after menstruation
 During pregnancy and puerperium

 During intercourse

 Oral contraceptive usage

 Large cervical ectropion

Physiological discharge

 Normal vaginal secretion is white, yellowish on contact with air

(due to oxidation) & acidic
 It is a transudate containing
 Desquamated vaginal epithelial cells
 Cervical gland mucus
 Endometrial gland secretion
 Bacteria-mostly lactobacilli
 Increases in mid-cycle, during pregnancy & COC use
Vaginal flora

 Mostly lactobacilli
 Mixed flora, especially in hypoestrogenic states
 Gardnerella vaginalis (commonest cause of
bacteria vaginosis)
 Mobiluncus spp.
 Peptostreptococcus
 Bacteroides
 Prevotella
 Mycoplasma hominis
 Ureaplasma urealyticum
 Normal flora is altered when there’s bacterial vaginosis,
there’s overgrowth of these organisms
Pathological discharge: evaluation

 Discharge is considered abnormal if

 There’s an increase in volume
 It is foul-smelling
 Change in colour or consistency
 Associated irritation (pruritus, dysuria, dyspareunia)
 Speculum examination
 Determine pH of secretion
 Place on 2 slides
 Normal saline: trichomonads, clue cells in vaginosis, Candida
 10% KOH: transient fishy smell (Sniff/Whiff test) in vaginosis. Also, candida more
visible
Features Candida Bact. Trichomo Cervicitis
vaginosis niasis
Itching/ ++ - +++ -
soreness
Smell None/ Offensive/ offensive -
Yeasty fishy
Colour White White/ Yellow/ Clear/ coloured
yellow green
Consiste Cheesy/ Thin / homogeneous Mucoid
ncy curdy
pH <4.5 4.5-7.0 4.5-7.0 <4.5
Further Microsc/ Microscop M& Chlamydi
tests culture y C a, Gono.
INFECTIVE CAUSES OF VAGINAL
DISCHARGE
 Bacterial vaginosis
 Monilial (Candida) vaginosis
 Trichomonas vaginosis

 Management is based on systematic clinical enquiry

and examination supplemented by appropriate
investigation
CANDIDA VULVOVAGINOSIS

 Vulvovaginal candidiasis is a mycotic disease

 Usually cause by the dimorphic yeast; Candida albican
 Candida albican is a normal commensal of genital and GI tracts
 Non-candida species; Candida gabrata and Candida tropica are
rare causes of the disease condition
 The clinical features of the above two are indistinguishable
 The prevalence of Candida albican in healthy young women is 20-25%
 Uncomplicated vulvovaginal candidiasis affects about 75% of women
at least once in their lifetime
 Recurrence occurs in < 5% of cases
RISK FACTORS FOR CANDIDIASIS

 Most occur without any obvious cause

 In small proportion, broad spectrum antibiotics treatment from
prior colonization
 There is a strong association with sexual activities
 Diabetes mellitus
 Immunosuppression
 Pregnancy
 Oral contraceptive pill
 Cunnilingus
DIAGNOSIS OF CANDIDIASIS
 Vulval itching
 Burning & soreness of the vulva
 Typically, vulva is red, dry and fissured
 A whitish, curdish discharge adheres to the vaginal and cervix
 Acute infection is confirmed by the presence of candida pseudohyphae
or budding yeast forms
 This is relatively an insensitive test
 Culture of a vaginal swab is the most sensitive test
 The presence of more than 10 colonies support the diagnosis
 Recurrence vulvovaginal candidiasis is defined as 4 or more episodes of
symptomatic candidiasis annually
MANAGEMENT OF VULVOVAGINAL
CANDIDIASIS
 Uncomplicated cases are self-limiting
 Patient should avoid irritants and tightly fitting synthetic garments
 Topically applied azoles (clotrimazole, econazole, miconazole)
are effective
 They should be used with pessaries
 Clotrimazole vaginal tablets (with topical cream for irritation)

 Nystatin 100,000 units for 2wks, vaginally

 Oral fluconazole 150mg stat

 Four days course cures over 50% of infection and 7-days course
cures more than 90%
 Pregnant women should be offered longer courses of treatment than non-
pregnant women
 There is no differences in cure rate between oral and vaginal
routes
 Pregnant women should not be given via oral route
 The oral route is preferred route for non-pregnant women
 With recurrent symptoms, exclude diabetes mellitus
 The treatment of partners is ineffective
BACTERIAL VAGINOSIS

 Commonest cause of vaginal discharge in women of child bearing age

 It is characterized by overgrowth of predominantly anaerobic organisms
(Gardnerelle vaginalis, Provetella sp, Mycoplasma hominis,
Mobiluncus sp.)
 Replacement of Lactobacilli and increased PH from normal of 4.5 to 7
 It can occur in both sexually active and non-sexually active women
 It is more common in blacks, IUCD in-situ and smokers
 Prevalence varies; 5% amongst asymptomatic college students, 50%
in Uganda women, 12% in pregnant women and 30% in women
undergoing VTOP
DIAGNOSIS OF BACTERIAL VAGINOSIS
 Offensive, fish smelling vaginal discharge
 Not associated with vulvo-vaginitis

 Thin, white, homogenous discharge coating the walls of the vagina

and vestibule
 Amsel’s criteria for diagnosing bacterial vaginosis

 Thin, white, homogenous discharge

 Clue cells on microscopy

 PH of vaginal fluid > 4.5

 Release of a fishy odour on adding alkali (10% potassium hydroxide)

Three out of the 4 above should be present for the diagnosis to be

confirmed
COMPLICATIONS OF BACTERIAL VAGINOSIS
 Post VTOP endometritis and PID
 Late miscarriage
 Preterm birth
 Premature rupture of fetal membranes
 Postpartum endometritis
 Increased incidence of vaginal cuff cellulitis and abscess
formation following transvaginal hysterectomy
 Not found to be associated with PID in IUCD insertion
 Routine use of HVS is not advocated as culture of G. vaginalis
is positive in > 50% of normal women
 The Amsel’s criteria is the most consistent method of diagnosis
MANAGEMENT OF BACTERIAL VAGINOSIS

 Advice against vaginal douching, use of shower gels and antiseptic

bath agents
 Antibiotic is recommended for symptomatic women undergoing
surgery and pregnant women
 Recommended regimen includes: metronidazole 500 mg twice daily
for 5-7 days or metronidazole 2 g as a single dose
 Alternative treatment is intravaginal metronidazole gel (0.75%)
once daily for 7 days
 All treatments achieve cure rates of 70-80% after 4 weeks
 No indication for the treatment of male partners
 Routine screening during pregnancy is controversial
TRICHOMONAS VAGINALIS

 The causative agent is Trichomonas vaginalis, a flagellated protozoon

 It is found in the vagina, urethral and paraurethral glands
 Transmission is exclusively sexual in adults
 It can be acquired perinatally and found in 5% of babies of
infected mothers
 If infection is found after 1st year, sexual contact implies
 Between 10-50% of women are asymptomatic
DIAGNOSIS OF TRICHOMONAS VAGINALIS
 Vaginal discharge, offensive in odour
 Vulval itching
 Dysuria
 Occasionally, lower abdominal pain
 The classical frothy yellow discharge occurs in 10-30%
 Vulvitis, vaginitis and cervicitis are associated with
trichomonas infection
 A strawberry cervix appearance is visible to naked eye in approx. 2%
of cases and more on colposcopy
 No abnormalities are found in 10-15% of women
 Direct observation of a wet smear from the posterior fornix will diagnose
40-80% of cases
 Culture will diagnose 95% of infected women
COMPLICATIONS AND TREATMENT
OF TRICHOMONAS
 In pregnancy, preterm delivery and low birth weight infants
 Systemic antibiotics is recommended
 Spontaneous cure occurs in 20-25% of patients
 Highly sensitive to metronidazole with a cure rate of approx. 95%
 Recommended regimens are: Oral metronidazole 2g as a single dose
or metronidazole 400-500 mg twice daily for 5-7 days
 The single dose is cheaper with better compliance, but there is evidence of
high failure rate esp. if the partner is not treated concurrently
 Patient should not drink alcohol for 48hrs after completion of treatment due
to disulfiram-like effect (severe sickness)
 Metronidazole is relatively contraindicated in the 1st trimester, though
no teratogenicity has been found
 Local treatment with clotrimazole pessaries; 100mg daily for 7 days can be used
in symptomatic patients in the 1st trimester. Avoid high dose in pregnancy and
MALIGNANT CAUSES OF VAGINAL
DISCHARGE
 ENDOMETRIAL CANCER

 CERVICAL CANCER

 VAGINAL CANCER
MISCELLANEOUS CAUSES OF VAGINAL
DISCHARGE
 Foreign body e.g. retained or lost tampon, vaginal ring etc.
 Other causes of vaginal discharge such as gonococcal and
chlamydia infection will be discussed during the lecture of pelvic
inflammatory disease.
PELVIC INFLAMMATORY DISEASE

DR O. M. AYODELE
INTRODUCTION
 Pelvic inflammatory disease (PID) is a common cause of morbidity
and accounts for 1 in 60 GP consultations by women under the age of
45
 Delays of only a few days in receiving appropriate treatment markedly
increase the risk of sequelae, which include infertility, ectopic
pregnancy and chronic pelvic pain
 It is an ascending spread of micro-organisms from the vagina and cervix
causing
 Endometreitis

 Salpingitis

 Oophoritis

 Parametreitis
 Tubo-ovarian abscess
 Pelvic peritonitis
 It is sexually-transmitted
 It is a polymicrobial infection.
 Sexually transmitted organisms; Neisseria gonorrhoeae and
Chlamydia trachomatis are the most important.
 Other organisms are; Gardnerella vaginalis, anaerobes and
mycoplasmas, which commonly found in the vagina
RISK FACTORS FOR DEVELOPING PID

 Young age (<25 years)

 Multiple sexual partners
 Past history of STI (in the patient or her partners)
 Termination of pregnancy
 Insertion of IUCD in the past 6 weeks
 Hysterosalpingography
 In-vitro fertilization procedure
 Postpartum endometritis
 Bacterial vaginosis
 A recent new sexual partner (within the previous 3 months)
 DIAGNOSIS OF PID
 Lower abdominal pain and tenderness
 Adnexal tenderness
 Cervical excitation tenderness
 The above + any of these:
 ESR >15 mm/hr
 Temp >380C
 WBC >10,000 X109/L
 Gram stain of endocervix swab yielding Gram negative intracellular diplococci.
 Culdocentesis or laparoscopy –purulent material.
 Pelvic ultrasound: fluid in POD
MICORBIOLOGICAL

 All women with suspected PID should be screened for gonorrhoea and
Chlamydia

 Specimens are taken from; endocervix, urethra or first catch urine

 Gonorrhoea is either direct inoculation in a culture plate or nucleic

acid amplification test (NAAT)

 Chlamydia is NAAT (e.g. PCR, strand displacement amplification)

OTHER USEFUL TESTS FOR PID
 Laparoscopy as a gold standard for diagnosis

 TVS may be useful when there is diagnostic difficulty

 TVS supported by power Doppler can identify inflammed and dilated tubes and tubo-ovarian masses

 MRI may assist diagnosis

 FBC, leucocytosis

 Elevated ESR

 Elevated C-reactive protein, the last two are not specific tests

 M/C/S of HVS and ECS

 Culdocentesis –peritoneal fluid for m/c/s.

Laparascopic classification of PID

Mild PID
 Erythema of the fallopian tubes without pus formation

 Oedema & swelling of fallopian tubes that otherwise freely mobile

Moderate PID
 Sero-purulent exudates from fimbriated end or serosal surface of fallopian

tubes Severe PID.

 Inflammatory mass

 Pyosalpinx

 Abscess
 DIFFERENTIALS

 Acute appendicitis
 Ectopic pregnancy
 Ovarian tumour
 Ruptured Corpus luteum
 Diverticulitis
 Septic abortion
 Torsion of adnexal mass
OUTPATIENT TREATMENT OF PID

 In mild or moderate PID (in the absence of a tubo-ovarian abscess), there is no

difference in outcome when patients are treated as outpatients or admitted to
hospital
 Delay in treatment will result in long term sequelea; ectopic pregnancy,
subfertility and pelvic pain
 oral ofloxacin 400 mg twice a day plus oral metronidazole 400 mg twice a day
for 14 days
 intramuscular ceftriaxone 250 mg immediately or intramuscular
cefoxitin 2 g immediately with oral probenecid 1 g, followed by oral doxycycline
100 mg twice a day plus metronidazole 400 mg twice a day for 14 days.
CRITERIA FOR IN-PATIENT TREATMENT

 Admission to hospital would be appropriate in the

following circumstances:
• Surgical emergency
• Clinically severe disease
• Tubo-ovarian abscess
• PID in pregnancy
• Lack of response to oral therapy
• Intolerance to oral therapy.
RECOMMENDED REGIMENS ARE:
 Intravenous cefoxitin 2 g three times a day plus intravenous doxycycline
100 mg twice a day (oral doxycycline may be used if tolerated),
followed by oral doxycycline 100 mg twice a day plus oral
metronidazole 400 mg twice a day for a total of 14 days
OR
 Intravenous clindamycin 900 mg three times a day plus intravenous
gentamicin: 2 mg/kg loading dose followed by 1.5 mg/kg three times
a day (a single daily dose of 7 mg/kg may be substituted), followed by
EITHER:
 Oral clindamycin 450 mg four times a day to complete 14 days
OR
 Oral doxycycline 100 mg twice a day plus oral metronidazole 400
mg twice a day to complete 14 days7,25,29,30
OR
Intravenous ofloxacin 400 mg twice a day plus intravenous
metronidazole 500 mg three times a day for 14 days.
TREATMENT IN PREGNANCY

 A pregnancy test should be performed in all women suspected of

having PID to help exclude an ectopic pregnancy.
 The risk of giving any of the recommended antibiotic regimens in
very early pregnancy (prior to a positive pregnancy test) is low, with
any significant drug toxicity resulting
 In an intrauterine pregnancy, PID is extremely rare, except in the case
of septic abortion.
 Cervicitis may occur, however, and is associated with increased
maternal and fetal morbidity.
 Treatment regimens will be dependent upon the organisms isolated.
 Drugs known to be toxic in pregnancy should be avoided
e.g. tetracyclines.
 Erythromycin and amoxycillin are not known to be harmful in pregnancy
TREATMENT IN YOUNG PATIENT

 Ofloxacin should be avoided in young women when bone

development is still occurring, based on data from animal studies
 No problems have been reported in human subjects and the British
National Formulary currently recommends that ofloxacin can be used
in children where other options are limited
 Doxycycline can be safely used in children over the age of 12 years
TREATMENT IN WOMEN WITH IUCD

 An intrauterine contraceptive device (IUCD) may be left in situ

in women with clinically mild PID but should be removed in cases
of severe disease.
 An IUCD only increases the risk of developing PID in the first
few weeks after insertion.
 A single small randomised controlled trial suggests that removing
an IUCD does not affect the response to treatment but the study has
suboptimal outcome measures
 An observational study also showed no benefit in removing an IUCD in
this situation.
OTHER MODES OF MANAGEMENT

 Laparotomy/laparoscopy may help early resolution of the disease

by division of adhesions and drainage of pelvic abscesses
 Ultrasound-guided aspiration of pelvic fluid collections is less
invasive and may be equally effective
 It is also possible to perform adhesiolysis in cases of perihepatitis
although there is no evidence as to whether this is superior to
antibiotic therapy alone.
 Contact tracing of sexual partners and treatment are compulsory
for every patient with PID
REVIEW OF PATIENTS WITH PID

 In outpatient setting, review in 72 hours is recommended

 For in-patient setting, further review four weeks after therapy may
be useful to ensure:

• adequate clinical response to treatment

• compliance with oral antibiotics

• screening and treatment of sexual contacts

• awareness of the significance of PID and its sequelae.

ORAL CONTRACEPTIVE PILL AND PID

 The use of the combined oral contraceptive pill has usually

been regarded as protective against symptomatic PID
 Retrospective case–control and prospective studies have,
however, shown an association with an increased incidence of
asymptomatic cervical infection with C. trachomatis
 This has led to the suggestion that the oral contraception may
mask endometritis
 Women using the oral contraceptive pill should be warned that
its effectiveness may be reduced when taking antibiotic therapy.