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MRCOG PART 2 SBAs and EMQs

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Essay 315 - Vaginal discharge

Posted by L S.
LS:
(a) Describe the information you would require from the history [10 marks].
I would enquire about her main concerns and reasons for coming now. I would ask on characteristics of the discharge with respect to colour, consistency, odour, and how it started and what has changed. Associated symptoms along with the discharge like pruritus, dyspareunia (superficial or deep), urinary symptoms like dysuria. Symptoms of pelvic infection enquired like lower abdominal pain, deep dyspareunia, fever, abnormal bleeding or any recent or past sexually transmitted infection. Her contraception history, recent miscarriage or if there is a possibility of pregnancy enquired. Her medical history if she has diabetes or immunocompromised enquired. Drug history if she is on antibiotics or on corticosteroids asked. Detailed sexual history for risk of sexually transmitted infection (STI) which is higher in her age group, details on new partner or more than one partner in the last year. Enquire also on previous treatments and its response and whether the treatments were via over the counter or prescription.
(b) Discuss and justify your investigations [4 marks ].
Physical examination should be carried out to direct investigations should first be carried out. Differential for vaginal discharge can be physiological, infective either sexually transmitted (Trichomonas, Chlamydia, Nesseria) or non-sexually transmitted (Baterial vaginosis or Candida) or non-infective cause (foreign body, malignancy, fistulae or allergic reaction). Abdominal examination to identify mass or tenderness. If present an ultrasonography should be carried out to delineate source and type of mass. Speculum examination, if any erythema noted, nature and odour of discharge noted and presence of vaginal or cervical lesions indentified. Swabs for microbiology taken for infective causes including high vaginal swab and endocervical swab for Nesseria gonorrhoea. Test for Chlamydia if suspicion of STI. Vaginal examination to identify presence of foreign body, uterine tenderness or adnexal tenderness.
Discuss the treatment options for infective causes of vaginal discharge [6 marks].
If she has low risk of STI with no risk of pelvic inflammatory disease on history, empirical treatment can be initiated based on examination. If she has a white discharge associated with an itch and associated with vulval erythema and fissuring seen a diagnosis of Candida can be made and trial of anti fungal treatment instituted. If the discharge was thin and offensive and without a itch could be a possibility of Bacterial vaginosis and treatment with metronidazole or clindamycin orally given. Recurrent infection of Baterial vaginosis would require suppressive therapy either orally for 3 days at beginning and end of menstruation or via intravaginally twice weekly for four to six months after an initial ten day course with metronidazole. Recurrent candidiasis can occurs when more than 4 episodes in a year and this would require maintenance treatment weekly for 6 months after initial treatment. Avoidance of irritants advised like shampoo, antiseptics, tight fitting clothes and perfumed products. Treatment for STI if found should have contact tracing and referral to genitourinary clinic for further and optimum management of infection and counselling as appropriate.
Posted by H H.
hhh
I would ask the patient regarding its colour, whitish curdy discharge which is itchy in candida, grey frothy in Bacterial vaginosis BV.Would ask of smell of discharge, fishy odour which is more apparent with sex in BV, offensive in gonorrhea. Would ask if took treatment during the previous 6 months and results. Would ask if there is associated lower abdominal pain and fever, Pelvic inflamatory disease. Would ask if associated dysuria, gonorrhea. Would ask of effect on quality of life and if affecting her sex life.
Would ask of her parity, previous vaginal delivery,would suspect missed swab. Would ask of her menstrual period, LMP(pregnancy), intermenstrual bleeding or post coital bleeding (chlamydia) . Would ask of her sex life ,if has multiple sexual partners(sexually transmitted inections STI) , unprotected sex and frequency of sex.
Would ask of method of contraception used, combined pills with high estrogen contents associated with candida infection. Would ask of history of STI ,treatment given and if contact tracing done.
Would ask if has medicak disease eg diabetes(candida) and wether controled or not. Would ask if taking medications like immunosuppressive drugs or corticosteroids which increase susceptibility to candida and other infections.
Would ask of previous vaginal surgery(missed swab or stitch sinus). Would ask of any allergy and ask about local hygiene. Excess washing and douching of vagina predispose to irritation and discharge.



Would do FBC for WBC and CRP to detecte presence of infection and inflammatory process. Dipstix for urine for nitrites (infection, so will do MSU for culture sensitivity),glucose(check for diabetes) ,
Test urine by PCR for chlamydia. Will do Tripple swab ( high vaginal swab for BV and candida, endocervical swab for gonorrhea and endocervical swab for chlamydia). Uretheral and rectal swabs for gonorrhea.
Will do wet smear for trichomonas vaginalis, and also could detect candidal mycelia.



Chlamydia is treated with azithromycin as a single oral dose of 1 gm( effective in those who do not comply with long treatments) , tetracyclines taken for 7 days or quinolones.
Gonorrhea can also be treated with azithromycin or cephalosporins or quinolones eg ofloxacin
Ttichomonas vaginalis is treated with metronidazole, either as suppositories or tablets.
Posted by Naheed M.
N.M
I will ask the patient about whether it has been a new onset or recurring problem, how much it affects her quality of life and her psychosocial/sexual health. Her hygiene should be assessed and use any scented soap cream or douches should be asked. I will as if she is allergic to anything such as latex condom or any other barrier contraceptive method she uses. What contraception she uses and if there is any history of recent intrauterine contraceptive device insertion (within few weeks there is higher risk of pelvic infection). I will ask last menstrual period and menstrual regularity to exclude pregnancy as it causes increased physiological vaginal secretions. I will ask (review) her recent cervical smear report.
Her sexual history should be asked for safe sexual practices, number of sexual partners and any history of
Sexual partner’s infection such as gonococcus.
I will ask her about any medical disorder (such as diabetes mellitus, allergies or immunosuppressant condition such as HIV-status). Use of any drugs such as immunosupressants (causing recurrent infections), or antibiotics (which can trigger candidiasis) should be asked.
She should be asked about associated complains such as itching (occur in allergic conditions, candidiasis and trichomonial infection). History of frequency of urine and dysuria may point to associated urinary tract infection. Colour and the smell of vaginal discharge is very helpful to reach the diagnosis. Milky curdy white
Discharge suggest candidial, fishy smelling discharge may point to bacterial vaginosis and yellowish foul smelling discharge occur with trichomonas. Discharge associated with lower abdominal pain and tenderness points to pelvic inflammatory disease or endometritis. She should be asked about history of any recent procedure such as curretage or cervical ablation/excision. Enquiry about rare but possible causes should not be missed such as any ulcer (herpes, syphilis) or any cyst or growth and if the discharge is blood-mixed(malignant growths of genital tract such as fallopian tubes).
Patients attitudes and behaviours in history taking process may also indicate any psychosocial cause and enquiring about any past or current sexual abuse.
B
If there is any history of diabetes mellitus her glycemic control and HbA1C should be checked to see whether poorly controlled diabetes causing the problem or if not diagnosed can be investigated (if suspected from history). Screening for sexually transmitted diseases (including HIV) should be performed in liaison with genitourinary medical clinic.
Swabs (high vaginal, endocervical and uretheral) should be collected for pH, wetmount test, Gram staining and culture-sensitivity.
Wetmount positive for hyphae organism and confirming culture on Nickerson’s medium for candidiasis.
Motile organism on wetmount confirmed on Staurt medium for trichomoniasis.
PH more than 5 and clue cells in wetmount should be cultured for bacterial vaginosis.Gonococcus (Gm negative diplococci) is cultured on Thayer martin medium. Cases suspected for neoplastic or malignant growths should be reffered for clposcopic diagnostic (biopsy) and therapeutic procedures.
C.
Treatment depends upon the causative organism, their sensitivity cost and patient’s choice. Candidial infection should be treated with local nystatin cream or oral fluconazole. Metronidazole is effective against bacterial vaginosis and trichomonas. The women who can’t tolerate metronidazole, clindamycin is the suitable alternative. Chlamydial infection is best treated with azithromycin, doxycyclin (100mg twice a day for 10-14 days) or erythromycin. Gonococcal infection is treated by ceftriaxone; oflaxacin should be avoided because of higher rate of developing resistance. Sexually transmitted infections are treated in collaboration with GUM (according to C/S) where contacts are also traced and treated.
The conditions which cause recurrent infections such as poorly controlled diabetes should be treated.
Posted by SYAMALRANJAN S.
SRS
a)Describe the information you would require from the history [10 marks].

Long duration of vaginal discharge may cause anxiety. Proper diagnosis is important for differentiating whether this is due to physiological or pathological( such as infective/ non-infective / others like foreign body).
I would enquire about associated symptoms with discharge such as pruritus, dyspareunia . Nature of discharge like fishy or offensive smell( suggestive of bacterial vaginosis) , yellow / green ,frothy( may be trichomoniasis),white curdy (candidiasis), intermittent bloody discharge(cervicitis) might be suggestive of the cause of discharge.
Details of menstrual history(LMP, cycle length, regularity) may point the cause(intermestrual bleeding may related to infective cause).
Obstetrical history including last delivery , any miscarriage, induced abortion would be noted.
The use of contraceptive pill or an IUD may provide a clue to the cause.
Bladder symptoms(dysuria, frequency), peri-anal pruritus (thread worms), any symptoms suggestive of abdomino-pelvic swelling should be enquired.
Life-style ( local hygiene, local use of deodorant, soap causing allergy) and drug abuse, alcohol intake , smoking history are to be noted carefully.
Sexual history including multiple partners , use of condoms are to be enquired which might be related to sexually transmitted infections.
Drug history which will include chronic intake of steroids , antibiotics, immunosuppressive drugs may be related to candidiasis.
Medical history of any systemic diseases like diabetes mellitus, chronic bronchial asthma(steroid intake) are enquired.

(b) Discuss and justify your investigations [4 marks ]

Relevant history taking and clinical examination are very important for diagnosis.
Swabs from varius sites which includes high vaginal (HVS), endocervical (ECS), urethal , rectal.
HVS should be utilized for wet-film and microscopy, culture and sensitivity, potassium hydroxide(10% KOH) mixing for diagnosing bacterial vaginosis ( assessing Amsel criteria), trichomoniasis, candiasis (mycelia).
ECS is to be used for gram stain for diagnosing gonorrhoea, Chlamydia trachomatis specific tests ( polymerase chain reaction)
Urethral swabs and urine(first void ) are used for diagnosis Gonococcus and Chlamydia.
Thread worms should be excluded from stool examination.
Cervical cytology if cervical condition suggests.

Discuss the treatment options for infective causes of vaginal discharge [6 marks].

Chlamydial infection is treated by azithromycin(1gm single dose ) or doxycyclin(100mg twice daily one week). Alternative option is ofloxacin. If pregnancy is associated then erythromycin or amoxicillin is prescribed.
Ciprofloxacin , ofloxacin, ampicillin plus probenacid are the drugs used in gonorrheal infection. Local pattern of resistance should be kept in mind.
Trichononiasis is treated by oral metronidazole((400mg twice daily for 7days or 2gm single dose). Alcohol is to be avoided during and 48 hr after treatment. Higher failure rate if partners are not treated.First trimester pregnancy prescription should be avoided.
Bacterial vaginosis is treated by either oral metronidazole (400mg twice daily for 7days or 2gm single dose) or intravaginal metronidazole gel / clindamycin cream.
Candidiasis is treated by topical imidazoles (clotrimazole, miconazole) or oral triazoles (fluconazole, itraconazole). Recurrent vulvovaginal candidisis (4 or more episodes annually)can be palliated by prolonged antifungal therapy.
Where the identified cause is an STI, then genitor-urinary medicine clinic(GUM clinic) referral must be done for contact tracing, offering HIV screening, appropriate treatment


Posted by SRABANI M.
SM
a. I would like to know the woman’s main concerns & why is she presenting now . It is very important to know the characteristics of discharge like odour, onset, consistency,colour, duration & what has changed. I would also like to know any associated symptoms like dysuria, superficial dyspareunia or itch & also symptoms indicative of upper genital tract infection like abdominal pain, deep dyspareunia, fever, abnormal bleeding or STI. As she is 23 yr old, she has got high risk of getting STI & hence sexual history is very important for this woman which include new partner , more than one partner in last one year, past history of STI. Contraception history is also important including use of intrauterine contraceptive device ( copper coil) or Mirena coil. Information about pregnancy, termination of pregnancy, miscarriage or postpartum period should be gathered. I would like to ask about her medication like antibiotic, corticosteroids etc if she is on anything.Any treatment in the past should also be asked about. Any medical condition like diabetes, immunocompromised state are also relevant .Also I will like to consider non-infective causes of discharge like foreign body, cervical ectopy or polyp, genital tract malignancy.

b. A woman of reproductive age complaining of vaginal discharge should be investigated if she requests any investigation, high risk of STI, recurrent infection, upper reproductive tract symptoms, failed treatment, postpartum or post-termination, medical conditions or 3 wks within intrauterine contraceptive coil insertion . Assessment of vaginal pH may help to manage woman with vaginal discharge as itmay be >=4.5 in bacterial vaginosis or trichomonas vaginalis infection & it may be < 4.5 in candida infection but it is a nonspecific test. A vaginal swab should be taken from lateral vaginal wall & posterior fornix.It should be stored at 4 degree C for no longer than 48 hrs , if it is not transported immediately.Endocervical swab should be sent if gonorrhoea is suspected as N.gonorhoeae infects columnar cells of endocervix.Other swabs like urethral, rectal or oropharyngeal can be sent if clinical history suggests.C. Trachomatis can be detected from endocervical swab or Nucleic acid amplification technique can be used for urine or vaginal swab. Gram stained slide from high vaginal swab may detect candida ( pseudohyphae) or clue cells in bacterial vaginosis ( dry slide). Wet microscopy may detect protozoa in trichomonas vaginalis or pseudohyphae in candida infection .Culture can be used to detect candida, trichomonas vaginalis & it is the method of choice to detect N. Gonorrhoeae in UK. NAATS tests have 90% sensitivity & >99% specificity & it is used for Chlamydia infection

Treatment for bacterial vaginosis is oral metronidazole 400mg twice daily for 7 days & it is non-sexually transmitted.Sexual partner does not need to be treated.Valvovaginal candidiasis can be treated with vaginal or oral antifungal (fluconazole/ itraconazole) & no need to treat male partner.Valval antifungal cream may be used if she has got valval symptoms.women should be advised not to use latex condom, cap or diaphragm while using vaginal antifungal cream.Nystatin preparation can also be used but not routinely used in valvovaginal candidiasis. Use of lactobacillus in Candida or bacterial vaginosis infection has got poor evidence of effectiveness. Trichomoniasis can be treated with metronidazole 400mg twice daily for 7 days orally or 2 g single oral dose.Chlamydia can be treated with Azithromycin 1 gm orally in a single dose ( <25 yrs) or Doxycycline 100mg BD for 7 days.In pregnancy Erythromycin 500mg four times daily for 7 days can be used. Other alternatives are ofloxacin 200mg twice daily or 400mg once daily for 7 days. For N. Gonorrheoea ceftriaxone 250 mg IM as a single dose or Cefixime 400mg oral as single dose or spectrinomycin 2 g IM as single dose can be used.Alternative regimens are Ciprofloxacin 500mg orally as a single dose or Ofloxacin 400 mg orally as single dose or Ampicillin 2g plus probenecid 1 g orally. Cefpodoxime can be used as well as a single dose of 200mg.Azithromycin 2g as single dose can be used. Pregnant women should avoid quinolone or tetracycline.Ceftriaxazone 250mg IM single dose or cefixime 400mg oral single dose or spectrinomycin 2g IM single dose can be used in pregnancy.Partner notification should be pursued & partners should be treated in infected women .A test of cure is recommended in pregnant women or noncompliant patient.Advise to not to have sex until both patient & and her partner(s) are treated or partner ( s) have negative test.
c.
Posted by Sarika N.
A 23 year old woman has been referred to the gynaecology clinic with a 6 months history of vaginal discharge. (a) Describe the information you would require from the history [10 marks]. a)Vaginal discharge has significant implications on woman psycological health, in infective cases future fertility and increase women morbidity.
Non - offensive vaginal discharge could be physiological. Most which are smelly or itchy due to infection, foul discharge could be due to foreign body ( forgotten tampons). Presence of copious watery discharge could be due to tubal malignancy.
Thrush is the commonest cause of vaginal discharge and associated with itching, reddness and white curds in the discharge. Risk factors are immunodeficiency, diabetes, pill, antibiotics and pregnancy.
Presence of thin, bubbly,fishy smelly discharge could be caused by Trichomonas or bacterial vaginosis. Gonorrhea often asymptomatic, but can present with discharge, dysuria, Bartholinitis, arthritis, also often partner is symptomatic with urethritis.50% of the patients with urethritis or cervicitis ( post coital bleeding) also have Chlamydia infection. Co existing low abdominal pain, deep dyspareuria, past episode of fever or persistent low grade fever can indicate chronic pelvic inflammatory disease.
Multiple sexual partners or new partner,unprotected intercourse, alcohol, drug abuse are risk factors for sexually transmitted infections.
History of allergy and changing the soap could be excluded.
(b) Discuss and justify your investigations [4 marks ].

Abdominal palpation to exclude tenderness, pelvic mass. Speculum and bimaniul vaginal examination to exclude foreign body, cervicitis, cervical malignancy. Presence of tuboovarian mass, bilateral tenderness and positive cervical exicitation test could be suggestive of pelvic inflammatory disease.
During the speculum examination high vaginal swap should be taken for micsroscopy, culture and sensitivity, as presence of \"clue cells\" on wet microscopy could be suggestive of BV, strings of myceliem - Candida infection, excess leucocytes - for PID. Endocervical swaps for Gonorrhea and chlamydia , preferably using NAAT( high sensitivity) should be performed. Additional sample from urethra can increade the diagnosis for chlamidia and gonorrhea if NAAT is not available.
USS TVS could be helpful with colour Doppler to identify tubo ovarian mass, inflamed tubes but evidence limited.
If PID suspected laparoscopy could be of value, but in third cases may have no evidence of acute infection.

Discuss the treatment options for infective causes of vaginal discharge [6 marks]
If thrush infection confirmed the single clotrimazole pessary with cream is effective, reassure that not sexually transmitted.
For bacterial vaginosis and trichomonas infection use of metronidazole 400mg bd for 5 days should be used. With thrichomonas vaginalis partner should be treated as well.
Chlamidia and gonorrgea are sexually transmitted diseases with significant implications for fertility and complications. Patient and partner should be reffered to GUM clinic with the 6 months tracing. Both partners should be treated and adviced to avoid intercourse while on the treatment.
Chlamydia should be treated with doxycicline 100mg bd for 7-14 daysor stat dose of azithromycin 1g po (better compliance).Gonorrhea should be treated with cefixime 400mg. If PID is diagnosed broad spectrum antibiotics are usually required to cover gram+, gram- and anaerobes.
Patient and her partner should be followed up to ensure adequate clinical responce, screening and treatment sexual contacts, awareness of sequelae of STD.
Posted by Bindi J.
BJ:

The woman should be approached sensitively to explore her main concerns and its impact on quality of life. Course of this condition along with colour and consistency of discharge should be obtained. Information regarding offensive odour of discharge should be obtained. Enquire about associated symptoms of itching, dysuria and superficial dyspareunia for candidiasis. History of upper abdominal pain, dyspareunia, abnormal bleeding and pyrexia are indicative of upper reproductive tract infection. Sexual history should be obtained to exclude her at being risk of sexually transmitted infections and ask for her stability in sexual relationship. Detailed menstrual history with last menstrual period to exclude pregnancy should be taken. History of recent miscarriage, termination of pregnancy and if she is in postpartum period should be obtained. History of intake of immunosuppressant medications (long term use of corticosteroids) and antibiotics should be taken. History of Diabetes, ulcerative colitis and Chron’s disease should be obtained. History regarding the possibility of retained tampon or retained condom should be sought. History of cancer cervix should be obtained.


Full blood count for leucocytosis and raised C-reactive proteins are non specific markers of inflammation. High vaginal swab should be obtained to test for bacterial vaginosis, BV, (clue cells) and candida. Amslers criteria( should be used to confirm the diagnosis of BV. Testing for gonorrhoea should be done by taking endocervical specimen and sending for culture or by using NAAT (Nucleic acid amplification test). Urethral swab can also be taken for N. Gonnorrhoea. Testing for Chlamydia should be from endocervical specimen using NAAT. First catch urine sample may also provide specimen for Chlamydia testing. Vaginal ph determination as bacterial vaginosis is present in alkaline ph (>4.5) and Candida in ph below 4.5.


The presence of any sexually transmitted infection like Chlamydia, gonorrhoea and Trichomonas warrants a referral to Genito urinary clinic for contact tracing and partner notification and screening for other sexually transmitted infections. Bacterial vaginosis can be treated by vaginal Clindamycin cream or Metronidazole gel. Oral regimen with Tablet Metronodazole 400mg TDS for 5-7 days or a single dose of 2 gm is also effective. Oral and vaginal regimen have equal efficacy of 70-80%. Candida infection can be cured by removing the cause like stopping the antibiotic if medically not indicated. It can be treated by Clotrimazole pessary of 500mg single dose or Miconazole intravaginal cream, Nystatin pessary or cream with a cure rate of 80-90%. This regimen is safe for treatment of vaginal candidiasis in pregnancy. Oral regimen includes Fluconazole capsule 150 mg single dose. Trichomonas vaginalis can be treated by oral regimens of Metronidazole 400–500 mg twice daily for 5–7 days or single 2 g dose with a cure rate of 95%. Chlamydia and gonorrhoea can be treated by Tab Doxycycline 100 mg twice daily and Tab Metronidazole 4oomg twice daily for 14 days. In pregnancy Chlamydia should be treated by Erythromycin or combination of Metronidazole 400mg twice daily for 14 days and single dose of Tablet Azithromycin. A follow up appointment should be arranged in 4-6 weeks to repeat the tests and to see the clinical response to treatment.
Posted by drvimaladkm@yah K.
I would like to know the nature of the vaginal discharge, amount, colour, consistency with or without pruritus, fowl smelling, associated with burning sensation or not, pain lower abdomen,backache.(Pelvic inflammatory disease) Its association with/without dysuria, with /without dyspareunia to be foundout. Its association with menstrual cycle ( pre with candidasis / post menstrual with Trichomoniasis) along with LMP. Her parity details and use of any contraception to be elicited.(candidiasis may be found more commonly in pregnancy. Presence of Bacterial vaginosis may lead to premature labour).Previous H/O similar episodes & taken any treatment to be obtained. H/O presence of medical illness such as Diabetes mellitus to be made out. Drug or cosmetic allergy to be noted. H/O any associated rashes, lesions in the vulval region to be found out.(viral infection like Herpes genitalis Type2& Human papilloma virus(HPV) 6&11). Sensitively history of multiple sexual partners, any genital lesions in the partner to be elicited.
Fungal infections like candidiasis produces thick curdy white discharge with intense pruritus, which is more commonly found with low pH, & immunocompromised patients.Wet smear with potassium hydroxide shows branching filaments with spores.Culture is done using Sabaraud’s medium. Protozoal infection like Trichomoniasis is associated with yellowish or greenish frothy irritant vaginal discharge with less pruritus & fowl smelling and dysuria.It is diagnosed by hanging drop technique of vaginal discharge & by wetsaline smear showing pearshaped slightly larger than leucocyte, multiflagellated motile organisms. Culture is with Wittington medium. Bacterial vaginosis (B.V.)is mainly due to bacteroids, mycoplasma hominis, ureaplasmaurealyticum, gardenerella vaginalis, The discharge is homogeneous thin white vaginal discharge with pH above4.5 with fishy odour when mixed with 10%potassium hydroxide(Amsel’s criteria-3/4 to be positive)Clue cells with faded cell margins with bacteriae attached are characteristic of B.V. Viral infections like Herpes genitalis is associated with painful vesicular rashes(primary infections) in the vulval region with excessive watery discharge. Condyloma acuminatum(CA) is due to HPV virus with proliferative cauliflower like growths in mucocutaneous junctions of fouchette or in vagina.Viral lesions has to be diagnosed with serum specific IgG & IgM (fresh infections)antibodies.Gram staining & culture in cases of Gonorrhoea & PCR with first pass urine & vulvovaginal swabs diagnose Chlamydia trchomatis infection.HIV is diagnosed by Elisa tests.
Candidiasis is treated with local clotrimazole cream or pessaries / Nystatin pessaries or oral Fluconazole(single dose) or Ketoconazole tabs.Chronic cases need prolonged treatment like everymonth for 3 to 4 months. Trichomoniasis is treated with metronidazole, or stat dose of Tinidazole with nausea, vomiting .Metallic taste is common with Metronidazole.(CI- with alcohol.)Bacterial vaginosis is also treated with Metronidazole for 5 to 7 days along with antibiotics in symptomatic women. Herpes genitalis vulval lesions treated with local antiviral acyclovir ointment and Ayclovir tabs 200mgs 5 times/day.Oral tabs in the last 4 weeks of pregnancy decreases viral shedding & recurrence. Not terratogenic, avoided under 20 wks of pregnancy.CA is treated with Podophylline (25%)treatment in nonpregnant & elctrocautery or cryocautery excision of lesions done along with analgesia. Gonorrhoea with quinolones/4th generation cephalosporins/Spectinomycin during pregnancy & Chlamydia with Doxycycline/Clindamycin & Spirochetal infection with Penicillins or Erythromycin in pregnancy.HIVis treated with antiretroviral therapy(HAARTS).
VDKM
Posted by Seham S.
SESA

(a) I would ask the woman about her concern and reasons for presenting now. I would ask her about characteristics of discharge ( odour, colour, consistency ) and if there is associated symptoms as itching,redness ,burning or superficial dysparonia . Urinery Symptoms like frequency,dysuria should be asked about .Upper abdominal pain,deep dysparonia,abnormal bleeding which indicate upper genital tract infection . Medical history as diabetes mellitus and immunocompromised state help in increase risk of candida infection. Contraceptive history and current contraception used as high dose COC may be associated with candida infection.Drug intake as steroids and immunosupressive therapy .Sexual history and if there a is new partener or multiple parteners in last year.I would ask her about her habites and use of vaginal douches,bubble bath,shower gel. History of any treatment taken before and its efficacy or side effects.

(b) investigation include vaginal PH , it increase in trichomonal and bacterial vaginosis and decrease in candida infection. high vaginal swab(HVS) for culture.It can diagnose candida , bacterial vaginosis and trichomonas infection. .Addition of 10% KOH can help in diagnosis of bacterial vaginosis by giving fishy odour. Endocervical swab for neisseria gonorrhea and clamydial infection. Urin sample for PCR for diagnosis of clamydia.Uretheral swab for gram stain for gonorrhea diagnosis.

(c)Infective causes will be either sexually transmitted (clamydia ,gonorrhea and trichomonal infection ) or non sexually transmitted (candida and bacterial vaginosis).Treatment of candida will be clotrimazol pessaries as single dose 500 mg or 200 mg every night for 3 days or 100 mg nightly for 6 days.Oral regimen is flucanazol 150 mg cap. single dose or Itraconazol 200 mg twice daily for one day.Bacterial vaginosis is treated by oral regimen metronidazol 400-500 mg twice daily for 5-7 days or single dose of 2mg .Clindamycin 300mg twice daily for 7 days is another option.vaginal regimen as metronidazol gel for 5 days or clindamycin (2%) daily for 7 days.Trichomonal infection can be treated by metronidazol 400-500mg twice daily for 5-7 days or single dose of 2g .Clamydial infection is treated with Azithromycin 1g single dose or oflaxacin 400mg daily for 7 days.Doxycyclin ,erythromycin and clindamycin are also effective. Gonorrhea can be treated with Azithromycin 1g single dose,Amoxicillin 3g + probencid 2g as single dose or Ceftriaxon 250 mg IM single dose .Referral to GUM clinic in sexually transmitted infection (STI) . Screening and treatment of partener in case of STI.
Posted by shmaila S.
DR.SAS
a)Her main concerns and reason for her presenting now should be enquired about.The effect on her quality of life(interfering with her social and daily activities) should be asked about.The colour(clear,white,green,bloody) of the discharge should be asked.She should be asked about the consistency(watery,mucoid,frothy,curd-like) of the discharge.The amount of the discharge,wether it is panty liner or pad is required should be asked.History of associated symptoms like itching,burning,dysparuenia or dysuria should be taken.Relationship of discharge to menstrual cycle should be enquired.History of precipitating factors including pregnancy,postpartum,COCP,TOP/miscarriage,sexual intercourse should be taken.History of abdominal pain,STI,abnormal vaginal bleeding,pyrexia,dysuria and deep dysparuenia should be taken as they are suggestive of upper reproductive tract infection.Sexual history to asses for risk factors for sexaually transmitted infection like multiple partners or more than one partner in one year,previous STI,previous TOP should be taken.Use of douches,antiseptics,bath products and talcum products should be asked to asses her hygeine practice.History of allergy to these products should also be asked.Foreign bodies like tampons,condoms,IUD,postpartum swab which can cause vaginal discharge should be enquired.History of any prevoius episodes of vaginal discharge and treatment(prescribed and non-prescribed) taken should be asked.History of concurrent medical condition(diabetes,immunocompromised states,genital tract malignancy) and drugs(antibiotics,corticosteroids) should be taken.Cervical smear history should be taken.Travel history including sexual contact abroad should be asked.

b) Vaginal PH measurement should be done as PH>4.5 is sugesstive of bacterial vaginosis(BV).Saline wet mount and gram staining should be done.Clue cells sugesstive of BV may be seen.HVS swab(amies transport medium)for culture should be taken to identify candida or tichomonas.Endocervical swab should be taken for chlamydia and gonorrhoea(amies transport medium).Urine sample for PCR for chlamydia by NAAT should be taken since it is more sensitive.Uretheral swabs increaes the diagnostic yeild for chlamydia and gonorrhoea,and should be considered.Pelvic scan should be considered if symptoms are suggestive of PID.

c)Non-sexually transmitted infected causes of vaginal discharge includes BV and candidiasis.For BV oral regime offer 70-80% cure.Metronidazole 500mg BD for 5-7 days or single 2gm dose should be given.If oral treament is not tolerable than metronidazole gel or clindamycin 2% cream can be given(70-80% cure) .Vaginal regime offers 80-95% cure for candida.Antifungal treament lincluding Clotrimazole,Econazole or Miconazole can be offered as vaginal pessaries or creams.Fluconazole capsules can be offerd orally(150mg single dose).Oral regimes are contraindicated in pregnancy.Routine screening and treament of male partner is not recommended for non-infective causes.Sexually transmitted infective causes includes tichomonas,chlamydia and gonorrhoea.Trichomonas should be treated by metronidazole(95% cure).This should be avoided in first trimester of pregnancy.For chlamydia azithromycin 1gm as single dose(>90% effective) or doxycycline 100mg BD for 5-7 days should be given.Erythromycin should be offered during pregnancy.Gonorrhoea is treated with ofloxacin orally or ceftiaxone 250mg I/M(single dose).In pregnancy cephalosporin or spectinomycin should be given.Contact tracing and treament of male partner is recomended for infective causes.Screening for other STI\'s should be done.Woman should be advised to avoid intercourse untill she and her partner have completed the antiboitic course.
Posted by fluffy F.
from fluffy
a) History regarding the type of discharge, whitish curd like , associated with itching and non fowl smelling suggestive of candida infection. Copious greyish discharge , fowl smelling fishy odour and associated without itch is usually bacterial vaginosis. A greenish discharge with itching is suggestive of trichomonas vaginalis. History of vaginal discharge , with deep dyspareunia, lower abdominal pain and fever on and off sugestive of pelvic inflamatory disease.History of sexual activity, multiple sexual partners, or a new sexual partner, age less than 25 years is at higher risk of sexually transmitted infections.History of diabetes or immunocompromise patient has a higher risk of vaginal infections.History of taking antibiotics or steroids.History of contraception, pregnant , post partum or recent delivery .History of using tampoons or inserting foreign body into the vagina can cause infection and vaginal discharge.history of bleeding per vaginum sugestive of cervical ectropion or polyp.

b) A full blood count , as a raised total white count would suggests on going infection. Ph of the vaginal secretion , as a Ph more than 4.5 suggestive of bacterial vaginosis. An endocervical swab for gonorhoea and a test kit done for chlamydiae. A high vaginal swab sent for culture and sensitivity ,from the vaginal discharge. In cases of suspected bacterial vaginosis, clue cells can be seen on microscopy and the potasium hydroxide added on to the vaginal secretions emit at fishy odour.

c) treatment will depend on the diagnosis . For candida ,vaginal pessary cotrimoxazole a single dose is effective or nystatin pessary which has to be given for 14 days . Oral treatment for candidiasis with fluconazole or itraconazole is also effective . Liver function test should be monitored in patients treated with oral antifungal and contraindicated in pregnancy as it is teratogenic.
For trichomonas vaginalis , metronidazole orally for 5-7 days is effective. For bacterial vaginsosis, oral clindamycin or metronidazole is effective. Clindamycin cream can also be used . If pelvic inflammatory disease , chlamydiae and gonorhoea is suspected , treatment can be on an outpatient basis if she is stable and has minimal symptoms . Oral treatment with ofloxacin and metronidazole for 14 days. Other options is intramuscular ceftriaxone single dose followed by oral doxycycline and metronidazole for 14 days . Oral azithromycin is also effective and given once a week for 2 weeks . In cases of sexually transmitted infections , chlamydiae , gonorhoea contact tracing should be done and the partner treated as well .
Posted by ASB -.
ASB
(a) I would ask the patient why she think this discharge is different from her physiologic discharge to bring her to the clinic and whether she has concerns about its aetiology. I would ask about charecteristics of discharge ( colour , odour , consistency ) as this guide the diagnosis. Ask about associated manifestations like itching , dysuria , superfacial dyspareunia as this guide the diagnosis . Ask about manifestations indicative of upper genital tract infection like abdominal and pelvic pain . deep dyspareunia ,abnormal vaginal bleeding and fever . Sexual history including the presence of new partneror more han one partner in the last year to assess risk of STI . History of medical disorders particularly diabetes and immunocompromised disease as they may predispose to infection . Drug history including previous treatment of this condition and their effect and other drugs particularly antibiotics and corticostroids . Contraceptive use should be inquired about . Pregnancy , recent delivery or abortion should be asked about as this would alter her managment .History of genital malignancy or use of foreign bodies like barrier contraceptives should be asked about as this may be the aetiology of her problem.

(b)Vaginal PH can be checked on secretions obtained from lateral vaginal wall using narrow range papers . It is helpful in suppoting certain diagnoses as PH <4.5 is associated with vaginal candidiasis while PH> 4.4 is associated with bacterial vaginosis (BV) or trichomonas vaginalis (TV) . High vaginal swab ( HVS) obtained from lateral vaginal walls and posterior fornix can be used for gram staining microscopy , wet smear microscopy or culture . With gram stainig , clue cells can be seen with BV and pseudohyphae can be seen with candidiasis . Wet smear enable visualization of flagellated protozon with TV . Culture enable diagnosis of neisseria gonorrhea ( on chocolate agar ) and cadidiasis ( on sabourauds medium ) . Endocervical swab with culture on chocolate agar is required if gonorrhea is suspected as nesseiria gonococci infect the columnar epithelium of the endocervix . Urine sample or endocervical swabs can be used for nucleic acid amplification technique ( e.g PCR ) to detect chlamydia trachomatis

(c)For BV : medical treatment is effective (cure rate 70-80%). recommended regien is metronidazole 400-500mg twice daily for 5-7 days or 2 gram single dose . Alternative regimen include vaginal metronidazole or clindamycin ; oral clindamycin or single dose 2 gram tinidazole . relapse rate may be up to 60 % at 3 month . routine partner notification and treatment is not recommended . Trichomonas vaginalis has cure rate of 95% with metronidazole 400-500 mg twice daily for 5-7 days . partner notification and treatment is reommended as well as screening for other STI. For vaginal candidiasis , oral and vagial azoles are equally effective with 80-95% cure rate which is slightly higher than that of vaginal nystatin ( 70-90 %). routine partner notification and treatment is not recommended .For gonorrhea and chlamydia trachomatis , oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days is effective . alternative regimen include IM ceteriaxone 250 mg injection immediately or 2 gram cefoxitin IM immediately with oral probecid 1 gram oral followed by doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily for 14 days .
Posted by Shamita S.
ANS
A detailed description of the discharge to be enquired for like the colour ,consistency ,odour and associated itching .As a greyish white ,thin discharge with a fishy odour would suggest bacterial vaginosis ,a curdish white thick discharge with itching vaginal soreness, dyspaerunia would suggest candidial infection and a profuse npurulent malodourous discharge accompanied with vulvar pruritus would suggest trichomonal infection .Associated factors like pain in the lower abdomen ,deep dyspaerunia or fever should be assked for to rule out pelvic inflammatory disease.A history of intermenstrual bleed ,postcoital bleed would suggest a cevical pathology,drug history to be taken for intake of steroids or antibiotics would predispose fungal infectios ,would history to be taken as diabetes would cause a predisposition for candidial infection ,contraceptive history to be taken as use of COCPs could cause an increase chance of STI.Change of partner or multiple sexual partners to be asked for , as it could suggest a chlamydial or gonnococcal infection as the cause of discharge .History of a possibility of a foreign body to be ruled out as use of a sheath ,or any swab which could have been left behind after any operative intervention .obestetric history as to recent deliveries or miscarrages to be asked for .A history of treatments taken so far for this symptom to be taken to see if she needs further refferals . A change in the toileteries to be asked for as it could be an allergic cause also.


A smear to be taken from the vagina for the pH as a pH >5 would be suggestive of BV where a normal pH indicate candidial infection.A wet mont preparation to be examined under teh microscope to lok for the motile trichomonas ,or the mycelia of a fungal growth ,an increasd num of clue cells would be seen in BV ,whiff test with KOH would be positive in BV ,it would give a fishy odour ,it would be negative in candidial infection .
A swab from the vagina, cervix and urethra to be taken for chlamydia and gonnoccocal detection with nucleic acid amplification test. and also for culture and sensitivity .
Blood FBC to be done for evidence of leucocytosis if PID is suspected ,CRP,ESR may be raised althogh not diagnostic
If PID is suspected and mass palpable during examination a TVS to be done to rule out any TO mass.


Bacterial Vaginosis to be treated by metronidazole which can be given orally as 500mgs twice a day for 7 days .even intravaginal apllication of gel can be considered. with equal results .Clindamycin is another drug to be considered can be used orally as 300mgs twice a day for 7 days or intravaginal gel application .
For trichomonal infections metronidazole is the drug of choice to be given orally as 500mgs twice a day for 7 days or 2gms single dose therre is no role of gel application in trichomonal infection .sexual partner to be treated .
for candidial infection topically applied azole drugs are more effective than nystatins .oral antifungals can be prescribed .If STIs are suspected it should be treated accordingly with refernce to the GUM physician.
.
Posted by tahira jabeen J.
TJ
a)
recurrent vaginal discharge is distressing problem so pt will be dealt in sensitive manner.she will be asked about duration of problem,how frequently she is having episodes,what treatment she has used.i willask about colour of discharge (as greenish yellow can be due to bacterial infection),cosistency(curdish ca n be due to cadida),odour(can be fish smelly due to bacterial vaginosis.if clear watery ca be normal.associated symptoms with dis charge like lower abd pain,pruritis,vulval sorerness,dysparunia,intermenstural bleeding(as it ca happen with chlamydial infection).
her menstural history will be enquired to know about LMP ( as some drugs are terato genic).patien will be asked about method of contraceptio she is using as use of COCP,IUCD can expose to infection.her sexual history will be asked to find out risk factors for STIs like multiple sexual parteners,recent change in partener.
her last cervical smear history will be asked.
Past medical history as diabetes mellitus ca nbe cause of candidal infections.h/o drugs like steroids which can make her prone for infections.
B)
high vaginal swab for wet smear for direct microscopy to see trichomonas,or mycelial braching if cadidial infection ,also KOH test if fishy odour will cofirms bacterial vaginosis.also PH will be taken if more than 5 will indicate bacterial infection.
tripple swab from vagina,cercix,urethra for culture & sensitivity.
for chlamydia nucleic acid amplification test can be done as it is very sesitive for chlamydia.if NAAT not available early morning urin specimen can be taken for chlamydia.
patient blood sugar levels to r/o diabtese.
if lower abd tenderness suggestive of PID ,CBC,crp,uss should be done.cervical smear will be taken if any abormality on examination.
c)
i will advise patient about general measures like proper hygiene
front to back stroke washing,frequent pad changing in mesturation,not to use tampons,not to use frequently antiseptics and vaginal douches as it ca n cause irritation or aggrevate candidal infection.she will be advised to wear cotto n penties,loose clothings.
as patient belongs to age group more prevelant to have STIs ,if history and examination suggestive of this pt will be reffered to GUM physician ,contact tracing will be done,pt will be advised for other STI screening,barrier contraception and parteners will be treated.if bacterial vaginosis will be treated with metronidazole 500mg three times for 7 days.if candidal infections will be treated with antifungal agents like itraconazole,flucanazole local pessaries or oral as this case is recurrent can be given for 6 months. chlamedia will be treated with azithromax 1 gm single dose.gonococcal infection will be treated with cephlosporins.
Posted by G. K.
GSK
A)
The patient should be asked about the severity of symptom and it\'s effect on her quality of life.She should be asked about the color, smell and consistency of discharge. Copious and greenish color could point towards trichomoniasis (TV). If greyish and frothy witha fishy foul smell, could be due to bacterial vaginosis (BV). If thick , white and curdy, could be due to candidiasis. If clear and non irriritating, could be normal physiological discharge.She should also be asked about use of soaps or wash since the discharge could be secondary to the toiletries she\'s using.
A thorough contraceptive and sexual history is mandatory in this case since the prevalence of chlamydia and gonorrhoea infections is high in the undr 25 age group. She should be asked about the type of contraception if she\'s using any and and number of sexual partners or any change in sexual partner within the last 6 months. She shoulsd be asked about previous history of any sexually transmitted disease (STDs) and whether she was contact traced or had received any treatment.
Menstrual history should be taken regarding regularity of cycles, any intermenstrual bleeding(IMB) or breakthrough bleeding if she\'s on the combined oral contraceptive pill since both IMB and breakthrough bleeding can happen in pelvic inflammatory disease(PID) secondary to chlamydia and gonorrhoea.Similarly dyspareunia can be menifestation of chronic PID due to STDs.
B)
investigations includes and endocervical swabs for cultue and sensitivity for investigations of and chlamydia and gonorrhoea.Rectal swabs can also be taken concurrently for the diagnosis of chlamydia and gonorrhoea. Nucleic acid amplification tests (NAATs) if implied can give a quicker result. quicker result.
High vaginal swab for the detection of TV and candiada are taken for culture and sensitivity.For bacterial vaginosis a high vaginal swab is taken as well . Amsel\'s criteria is used to detect BV which includes vaginal ph>4.5, emmision of fishy smell when KOH is added to the vaginal discharge and presence of clue cells on microscopy.
C)
Treatment depends upon the cause. For chlamydia and gonorhoea antibiotics are prescribed such as a combination of doxycycline and metronidazole for 14 days or depending on the sensitivity of the pathogen. The advice of microbiologist should be sought.For candidal infections, antifungal creams, tabletsor pessaries can be prescribed. For BV and TV metronidazole can be prescribed for 7 days. The patient should be advised to use condoms for contraception and contact tracing of her and her sexual contacts should be done in case of chlamydia and gonorrhoea.She should receive information leaflets about the causes of vaginal discharge and their prevention and treatment.
Posted by Dr Dyslexia V.
X

a) The information include to the onset of the vaginal discharge, association with menstrual cycle such as clear and watery discharge during early of the menstrual cycle and thick and sticky at end of the cycle nearly points to an exaggerated form of physiological vaginal discharge. If the vaginal discharge is think yellowish and malodorous this could indicate infective in origin such as bacterial vaginosis or sexually transmitted disease (STI). If the discharge is thick yellowish and associated with a itch or soreness it could point to candidiasis. Other symptoms such as dysparunia and the post coital bleeding could point to ascending infection which could indicate STI. History of multiple sexual partners, unprotected coitus previous history of STI , previous history of an ectopic pregnancy could also indicate presence of sexually transmitted disease. History of recent abortion, delivery or pregnancy could also indicate endometritis or other associated infective cause. History of other underlying chronic disease such as diabetes or usage of immunosuppressive therapy such as steroids could point to a opportunistic infection such as candidiasis. History of recent insertion of IUCD could also point to STI. Malignancy is another important but rare factor and history of DES exposure to mother could be of some merit.

b) High vaginal swab or lateral vaginal swab could be taken to look for clue cells and could be seen under microscope for flagellated protozoa such as trichomonas vaginalis. PH of more than 4.5 could also suggest bacterial vaginosis with presence of clue cells in microscopy. Endocervical swab could be done for nucleic acid amplification test for chlamydia and gonorrhea. A full blood count with presence of leukocytosis could suggest an ongoing infection. Cervical smear could be done to rule out cervical malignancy inspite of her age if she is sexually active for more than 5 years. A pelvic scan could be done to look for evidence of retained product of conceptus or tuboovarian mass for infection suggesting pelvic inflammatory disease.

c) Infective cause could be due to bacterial vaginosis which could be treated with metronidazole 400mg twice daily for 5 days. For candidiasis, the use of nystatin pessary 100,000 unit for 14 days or clotrimazole pessary 500 mg for 1 day. Usage of oral flucanozole could also be used but contraindicated in pregnancy. Trichomonas could be treated with also metronidazole 400 mg twice daily for 5 to 7 days or with clindamycin. The use of Rocephine for gonorrhea and azitrhomycin for chlamydia could be used to treat the infection. The treatment of the sexual partner is of paramount important to avoid recurrence. Other normal advice such as to avoid feminine wash, antiseptic lotions or douching should be avoided. They should also avoid tight fitting clothes and the use of cottons for undergarments. Other advice should also include safe sexual practice such as the use of condom could be of benefit to avoid recurrence.
Posted by Ulduz A.
a)Character of discharge,color,quantity,associated itching,dyspareunia,pelvic pain,any dysuria asked. Sinificance of discharge and effect on quality of life asked.Obstetrical history,ferrtility wises noted.Gynecological history,any uterine instrumentation as D&C,HCG,previous History of abnormal vaginal discharge,STDs,PID and treatments asked.Drug history,use of immunosupressants,broud spectrum antibiotics asked.Medical history ,presece of DM is important.Contraceptive history,use of hormonal,barrier contraception is important.Sexual history,number of sexual partners are asked.b)Initial investigations include FBC(WBC) and inflamatory markers as CRP/ESR done.HVS,cervical,urethral and rectal swabs for Chlamydia and Gonorrhea taken.Wet mount for Candida and Trichomonas performed.PCR of urine for Chlamydia performed if appropriate.Urine dipstix for nitrates and glucose done.If pelvic masses suspected pelvic USS/CT will be appropriate.c)Treatment options depend of the cause,effect on the QoL,patients wishes to be treated.Chlamydia will be treated by Azitramycin 1gr po single dose which is effective 90% or with Doxacyclin 100 po BID for 7 days.
if gonorrhea diagnosed,ceftriaxone 250 mg im single dose,or cefixime 400mg po single dose,or streptomycin 2g im single dose given.Trichomonas and bacterial vaginosis will be treated with metronidazole 2g po single dose or metronidazole 400-500mg BID for 5-7 days.In cases if STDs diagnosed contact tracing and partner treatment via GUC performed.Candida will be treated byClotrimazole 500 mg pessary and/or topical Clotrimazole cream,or Flucanozole 150 mg po single dose given.UTI will be treated with an appropriate antibiotic according to culture results.patient education about safe sex practices,about importancy of early recognition and treatment of STDs should be given in a sensitive manner.

Posted by Ulduz A.
a)Character of discharge,color,quantity,associated itching,dyspareunia,pelvic pain,any dysuria asked. Sinificance of discharge and effect on quality of life asked.Obstetrical history,ferrtility wises noted.Gynecological history,any uterine instrumentation as D&C,HCG,previous History of abnormal vaginal discharge,STDs,PID and treatments asked.Drug history,use of immunosupressants,broud spectrum antibiotics asked.Medical history ,presece of DM is important.Contraceptive history,use of hormonal,barrier contraception is important.Sexual history,number of sexual partners are asked
.b)Initial investigations include FBC(WBC) and inflamatory markers as CRP/ESR done.HVS,cervical,urethral and rectal swabs for Chlamydia and Gonorrhea taken.Wet mount for Candida and Trichomonas performed.PCR of urine for Chlamydia performed if appropriate.Urine dipstix for nitrates and glucose done.If pelvic masses suspected pelvic USS/CT will be appropriate.c)Treatment options depend of the cause,effect on the QoL,patients wishes to be treated.
c)Chlamydia will be treated by Azitramycin 1gr po single dose which is effective 90% or with Doxacyclin 100 po BID for 7 days.
If gonorrhea diagnosed,ceftriaxone 250 mg im single dose,or cefixime 400mg po single dose,or streptomycin 2g im single dose given.Trichomonas and bacterial vaginosis will be treated with metronidazole 2g po single dose or metronidazole 400-500mg BID for 5-7 days.In cases if STDs diagnosed contact tracing and partner treatment via GUC performed.Candida will be treated byClotrimazole 500 mg pessary and/or topical Clotrimazole cream,or Flucanozole 150 mg po single dose given.UTI will be treated with an appropriate antibiotic according to culture results.patient education about safe sex practices,about importancy of early recognition and treatment of STDs should be given in a sensitive manner.

Posted by Ulduz A.
Sorry,i had problems with sending the massage.confused
Posted by Lilantha W.
(a) Colour, consistency and amount of vaginal discharge is necessary to recognise possible aetiology. Yellow, frothy, profuse, offensive discharge indicates Trichomonas vaginalis (TV). Creamy, whitish discharge may be due to candidosis. Blood stained, profuse mucous discharge indicates Gonococcus (GC) or Chlamydia trachomatis (CT). Grey, offensive (fishy-smell) discharge can be due to bacterial vaginosis (BV) secondary to Gardinerella vaginalis. Whereas, clear, non-offensive discharge may be due to cervical ectropion or sexual excitement where the discharge can be scanty. The relationship of the vaginal discharge to menstrual period or hormonal contraceptive should be found. Details of her menstrual history are important to recognise a precipitating factor such as pregnancy and a lost tampon in the vagina. Intermenstrual bleeding and post coital indicate CT or GC infection. Associated symptoms such as dysuria, frequency, urgency, pelvic pain(urethritis); arthritis; deep dysparunia (PID); pruritus; ulceration and warts should be asked for. Onset, progression and current state of vaginal discharge and its associate symptoms should be found. Douching, change of bath products or pants (allergies) may correlate with the onset aggravation and precipitation. Use of broad-spectrum antibiotics may precipitate candidosis.

Number of pregnancies she has had and their outcomes are important, it may be secondary to termination of pregnancy or incomplete miscarriage. It may be after the insertion of an intra uterine device. A sensitive enquiry into her sexual practices should be made. A detailed sexual history which includes, last intercourse, method, contraception used, any symptoms in the partner and whether it was with a regular or casual partner. If she has had multiple partners, above questions should be repeated. History of previous sexually transmitted infections (STI) including treatment and risk of blood born infections (HIV, Hep B/C) should be assessed. Past medical history of diabetes, renal transplant requiring immunosuppressant therapy or treatment for malignancy may be relevant.

The extent to which this vaginal discharge has affected quality of her personal and sexual life should be assessed. The treatment that she has had had so far, and allergies, if any are also important.

(b) STI screening is justifiable as STIs are commonly at this age group and they can be effectively treated upon the diagnosis which will also prevent complications. CT and GC can be diagnosed by many ways. An endocervical swab would recognise gram negative diplococci in GC. ELISA of an endocervical swab can confirm CT. Nucleic acid amplification test (NAAT) of a low-vaginal swab or first-catch urine sample can be highly sensitive to recognise CT. A urethral swab can be an adjunct particularly if urethritis coexists. A low-vaginal swab may pick up candidosis and bacterial vaginosis. Recognition of ‘clue cells’ in a wet mount of the vaginal discharge is diagnostic of bacterial vaginosis. Gram-staining and KOH wet mount can be done in a Genito Urinary Medicine (GUM) setting. A high vaginal swab can pick up rare cause of TV.

Possibility of pregnancy should be excluded with urinary pregnancy test. A FBC would indicate leukocytosis which along with high CRP and/or ESR indicates PID as the likely cause. Serum screening for blood born infections (HIV, Hep B/C) and other STIs (syphilis, herpes) can be offered when necessary. A pelvic ultrasound scan is essential to rule out possibility of tubo-ovarian or ovarian mass. A diagnostic laparoscopy is a second line investigation for this cause. A cervical smear may be offered, if deemed high risk of developing cervical cancer.

(c) STIs can be treated on specific diagnosis as well as empirically. Empirical treatment is justified as a vaginal discharge is a common presentation of STI/PID in this age group. Moreover, the benefits of its treatment far outweigh the risks. Outpatient treatment for PID can be done with different regimens. Oral Ofloxacin 400mg bd + oral Metronidazole 400mg bd is one regimen. This covers GC, CT and anaerobes. IM Cefotaxime 250mg + oral Probenecid 1g once followed by oral Doxycycline 100mg bd + oral metronidazole 400mg bd for 14 days is another. Outpatients should be reviewed 72h of commencing treatment to review the response to treatment. Inadequate response requires hospital admission, IV antibiotics and perhaps surgical treatment. If severe PID, inpatient treatment with IV Ofloxacin 400mg bd + IV Metronidazole 500mg bd for 14 days. IV Gentamycin + Clindamycin until 24h after clinical improvement followed by oral Clindamycin for 14 days can also be adopted. Abstinence during the treatment results in better recovery.

CT alone can be treated with oral Azitromycin 1h given as a single dose or Erythromycin 250mg qds for 2 weeks, if sensitive to Azitromycin. BV and TV are treated with 1 week course of Metronidazole 400mg tds. Vaginal candidosis can be treated with Cotrimazole 500mg vaginal pessary as a single dose.

Treatment of underlying problem is essential. If a tubo-ovarian mass is found, laparoscopic salpingectomy or draining should be considered. Laporotomy may be required to drain a severe pelvic collection. If intra uterine device is found, it should be removed. Infective nidus can be a lost tampon. Similarly, contact tracing and partner treatment is necessary to prevent recurrence which can ideally be done at a GUM clinic, therefore a referral to a local GUM clinic should be made. Offer condoms and advice on safe sexual behaviour.
Posted by Bgk H.

A. Information need to be obtained in sensitive manner as patient may be anxious with regards to her condition. The severity of the discharge need to be determined as it may affect her quality of life leading her to be socially withdrawal. The amount of the discharge need to be asked whether she need to use sanitary pad or very minimal not requiring any extra precaution. The colour and odour of the discharge need to be discussed in detail. Curdy white and yellowish discharge may suggest moniliasis. Its relation to the menstrual cycle need to be asked as it may worsen during menstruation. Any pregnancy symptoms need to be asked as pregnancy may cause production of discharge. Association with chronic lower abdominal pain may suggest pelvic inflammatory disease. Frequency of the discharge need to be asked. Any previous episode and treatment received. Her sexual history need to be obtained including number of partners, usage of barrier method to assess the risk of sexually transmitted disease. Sexual practice and exercise including usage sexual device or foreign body need to be asked as it may cause vaginal discharge. Her contraception history and the future fertility wishes need to be determine. Any recent use of intrauterine device or oral contraceptive pills needs to be asked. History of loss of weight, loss of appetite may suggest malignancy. Family history of gynaecological malignancy should be asked. Her risk diabetes need to be assessed such as symptoms of polydipsia and strong family history is important.

B. I will perform high vaginal swab and send it for culture and sensitivity to enable detection of any specific cause organism such as candidiasis, Chlamydia. I will perform Potassium hydroxide test to look for evidence of bacterial vaginoses. I will also perform cervical screening if patient is sexually active and suspicious lesion at the cervix. I will arrange pelvic scan to rule out any pelvic mass.

C. Treatment option includes conservative management if it is minimal and not affecting her lifestyle. However advice on hygiene and safe sex practice need to be given. The specific treatment to the infection should be given. It can be either using per vaginal route or taken orally. The possible cause of infection should be remove such as cervical polyps.
Posted by Green K.
Green:

a) Severity of vaginal discharge and its effect on the quality of life. Nature of the discharge with regards to colour, appearance and odor. White discharge may suggest Candidiasis. Frothy discharge may suggest Trichomoniasis. Fishy smelling discharge may suggest bacterial vaginosis. Presence of blood staining or post coital bleeding may be suggestive of genital tract tumors such as cervical polyps or cervical erosion. Relation of discharge to menstrual periods as it may suggest physiological discharge at the time of ovulation. Presence of associated features such as itching or burning sensation at the vulval and perineal area to suggest infective or irritative cause. Usage of bubble bath and douching as it may alter the normal bacterial flora in the vulva and vagina. Last menstrual period and regularity to deduce the possibility of pregnancy as a cause of the physiological vaginal discharge. Usage of tampon to deduce the possibility of retained or forgotten tampon. History of recent Chlamydia screening if sexually active. Previous history of pelvic inflammatory disease and treatments as this may be a recurrence. Presence of similar episode in her sexual partner which may suggest sexually transmitted ideas such as Chlamydial infection, Trichomoniasis and gonorrhea. Current treatment and duration of treatment and its effect as it may alter the management plan. History of intake of steroids or immunosuppressives which may alter immune status. Her HIV status and any medical condition that may cause a reduction in immune status such as leukemia.

b) Triple test would be done. This involves a high vaginal swab for culture and sensitivity to detect Garderella vaginalis, Candida albicans and Trichomonas vaginalis. Endocervical swab to detect Chlamydia trachomatis and Neisseria gonorrhea. First catch early morning urine sample for culture and sensitivity to detect Neisseria gonorrhea may be considered if patient also has concurrent dysuria. Vaginal pH testing using narrow range pH paper may be used for screening to differentiate bacterial vaginosis (pH > 4.5) or vulvovaginal candidiasis (pH<4.5).

c) Treatment would be guided by culture and sensitivity report of the vaginal swab.
Bacterial vaginosis would be treated with oral metronidazole 400mg bid for 7 days or a stat dose of 2 gm. Oral Climdamycin 300mg for 7 days or topical clindamycin cream 2% 5gm nocte for 7 days. Advice avoidance from alcohol during treatment with metronidazole till 48 hours after treatment. Single high dose regime avoided if breastfeeding. Advice additional contraceptive methods during the duration of treatment and 7 days after treatment.

Candidiasis would be treated with vaginal imidazole preparations (clotrimazole, econazole, miconazole) or oral fluonazole 150mg. Treatment option depends on patient\'s preference. Oral treatment avoided if pregnant due to potential teratogenicity.

Chlamydia infection would be treated with oral doxycycline 100mg bid for 7 days or oral Azithromycin 1gm single dose. Doxycycline is avoided if pregnant.

Gonorrhoea would be treated with single dose intramuscular Ceftriaxone 250mg or single oral dose of cefixime 400mg.

Trichomoniasis would be treated with single oral dose of metronidazole 2gm or metronidazole 400mg bid for 5 days.

Patient would be given information leaflets regarding the relevant infection and referred to genito-urinary medicine specialist if presence of sexually transmitted infection for contact tracing and treatment.
Posted by Nadira N.
A) I,ll take history sensitively as talking about vaginal discharge may be very embarrasing for her.Vaginal dischrges can cause severe discomfort and at times its a very distressing condition therefore impact on quality of life should be assessed.The onset of discharge its relationship with cycle should be asked.The amount, colour, odour and consistancy of discharge should be asked.Any precipitating factors such as sexual intercourse or use of antibiotics is important.Associated symptoms such as itching irritation or sourness of vulva vagina need to be asked.Post coital bleeding intermenstrual bleeding lower abdominal pain and dysurea may indicate PID.Sexual history is very important therefore past history of any sexually transmitted disease, recent change of sexual partner ,symptoms in partner and use of condoms should be asked. Personal hygiene practices e.g douching ,bubble bath need to be assessed.Details of the treatment she has already taken should be asked.As the history is from past 6 months so number of episodes of the currant complaint is also important.Use of IUCD should be asked .Any recent instumentation in uterus need to be asked.
B) I,ll do her speculum examination and look for any lesion in vagina or cervix.presence of ectopion on cevix and colour of cervix are noted .Red cevix or irregular cevix or extension of columner epithellium in vagina is an indication for colposcopy.If inflmmed cevix with mucopurulant discharge is seen the swabs should be taken from urethra and endocervix and send to lab in amies medium for gonorrhoea, and for clamydia enzyme linked immunoabsorbant essay or direct florescent antibody testing should be asked.Most women with clamydia and 50% with gonorrhoea are asymptomatic therefore if history is suggestive of STD the sceening is indicated in asymptomatic women also.For other infections once I,ll remove the speculum I,ll make two slides from its tip.One slide is made with saline for direct microscopy to detect trichomonas and clue cells of bacterial vaginosis(BV).To other slide I,ll add two drops of KOH if it gives fishy odour it indicate BV .KOH will dissolve WBCs and epithelial cells and psedohyphae and spores are easily seen.PH of discharge is checked with narrow range paper PH more than 4.5 is seen with BV and less than 4.5 is seen with candida.Cytology is indicated if there has not been a recent smear.
C) Treatment for BV is metronidazole 400 mg twice daily for 5 to 7 days or a single dose of 2 grams.Alternative regime is metronidazole 0.75 gm% 5 gm daily or clindamycin 2% 5gm daily for 7 days.In case or recurrant BV condoms should be advised as the seman raise PH and can precipitate this condition.Treatment of partner is not indicated.For candida clotrimazole pessary 500 mg as single dose or miconazole pessary 100mg for 14 days is prescribed.Oral treatment is with fluconazole 150 mg capsule as single dose or itraconazole 200 mg twice daily for one day is given,both are contarindicated in pregnancy and lactation.Recommended treatment for clamydia is Doxycycline 100mg orally twice daily for 7 days or azithromycin 1gm in a single dose.During prgnancy and lactation erythromycin 500mg four times a day for 7 days is given.For gonorrhoea treatment is Ceftrioxone 250mg as a single dose or Cefixime 400mg as a single dose.Treatment of trichomonas vaginalis is metronidazole 2 gm as a single dose or metronidazole 400 mg twice daily for 5 days.In the absence of any positive findings following examination and testing the likelihood for discharge is physiological and only ressurance is required.
Posted by Bee N.
Bee

A 23 year old woman has been referred to the gynaecology clinic with a 6 months history of vaginal discharge. (a) Describe the information you would require from the history [10 marks]. (b) Discuss and justify your investigations [4 marks ]. Discuss the treatment options for infective causes of vaginal discharge [6 marks].

A) I will start by asking for onset of symptom to differentiate between a chronic problem which is less likely due to an infective process from a resent onset discharge which is more like infective such as sexually transmitted diseases. I will ask for timing and frequency of discharge as some discharges are physiological (mid cycle). I will enquire about the colour and odour. Fish smell is usual in trichomonas vaginalis. Greenish or yellow \"pus like\" colour is more likely to be infective as opposed to clear vaginal discharge without odour. White curd like discharge is usual in fungal infection (candidiasis). I will ask for other associated symptom such as pruritus which can be found in fungal infections, deep dyspareunia in pelvic inflammatory disease and dysuria as in gonococcal infection (urethritis).I will ask about systemic symptoms such as fever, loss of appetite,vomiting and malaise. The extent of this will contribute towards determining need for hospitalisation. I will take a sexual history asking about number of sexual partners in a very sensitive way. I will ask about sexual orientation (anal, oral etc) as this will determine areas where swabs need to be taken if an sexually related infective cause is suspected. Number of sexaul partners may also help in contact tracing. I will ask about contraception. Barrier contraception will significantly help reduce risk of sexual transmitted infection. I will ask about her smear history to know if smear test should be considered. I will ask about the use of tampons as this can cause serious endometritis with staphylococcus and anearobis organisms. I will enquire how the vaginal discharge has impacted on her life as she may require counselling. I will ask about her menstrual history to rule out pregnancy and elicit presence of menorrhagia and dysmenorrheor which may indicate endometritis. Drug history to know if she is on antibiotics which may cause fungal infection or bacterial vaginosis and immunosuppresant such as steriods which may predispose to infection. I will also take a history of her any present medical condition which may predispose her to infections. A social history if an infective process in necessary to find out if she is a drug abuser and her risk for hepatitis B and HIV.

B) Investigations will include a taking blood for full blood count and C- reactive protien. This will point to infective process if her white cell count is raised and/or if CRP is high. Depending on if a systemic illness is suspected such as in very high temperature, blood culture will be performed. I will take two endocervical swabs for gonorrhoea and chlamydia as well as a high vaginal swab for bacterial vaginosis etc. I may also take swabs from her urethra orifice, oral cavity and rectal swabs for gonorrhoea depending on if the history is suggestive of possible infection in this area. Vaginal PH which can be taken is not commonly done but may help differentiate organism that thrive in low PH of less than 4.5 such as candida and those in higher PH such as trichomonas vaginalis or bacterial vaginosis. The swabs sent are for microscopy which may reveal parasites such as trichomonas or psuedo hyphea in candida. Culture and sensitivity will also be carried out on the swabs to know appropriate antibiotics required for treatment. A pelvic ultrasoound scan will be ordered if complications such as pyometria or pyosalpinx is suspected.

C) Infective causes will include fungal e.g candida which can be treated with nystatin pessary(One pessary nocte) and cream. Gonorrhoea is usually sensitive sensitive to Azithromycin 1g stat dose or ofloxacin 750mg tid for 7 days. Chlamydia can be treated with tetracyclines such as doxycycline. Trichomonas vaginalis is usually treated with metronidazole 400mg bd for 7 days. Bacterial vaginosis is sensitive to the same treatment. Patients allergic to metronidazole can be treated with clindamycin. If a sexual transimtted infection is found, patient will need to be referred to the genitourinarymedicine clinic for appropriate treatment, contact tracing and follow up to ensure complete recovery.
Posted by M E.
SAM
a) I would enquire about why she has presented now and how the discharge has affect her quality of life. I would ask about the characteristics of the discharge. A thin malodourous , fishy discharge may be suggestive of bacterial vaginosis. While a thick white non offensive discharge may be suggestive of candidiasis.
Associated symptoms of puritus, dysuria or superficial dyspareunia may aid in determining the type of discharge. Other symptoms such as pyrexia, abdominal pain, deep dyspareunia and per vaginal bleed indicate a upper genital tract infection.

I would enquire whether this is the first time she has presented in this manner. Whether she had a previous history of STI and what treatment was given. I would elicit a sexual history, number of partners, recent new partner since this will increase the liklihood of a STI. Whether she is currently on contraception such as the OCP or the IUCD. Her cervial smear history, whether abnormal and if she is undergoing treatment. Her obstetric history, whether she had any recent TOP.

A drug history of any antibiotics that may have been precribed to treat the discharge and whether it had any effect. Current usage of steroids may increase the risk of infection. Medical conditions such as diabetes and immunocompromised states increase the risk of genital infections.

Additional information about gneral hygiene and the usage of douches and antiseptic washes should be obtained, since these destroy normal vaginal flora and increase the rick of infection
b) Vaginal pH greater than 4.5 is present with bacterial vaginosis. A high vaginal swab should be taken for microscopy, culture and senstivity. Presence of clue cells confirms the diagnosis of bacterial vaginosis. Endocervical and urethral swabs should be taken to test for Chlamydia and gonorrhea. Urine sample should be sent for NATT since it is more sensitive for the identification of chlamydia. Pelvic ultrasound can be helpful to identify any adnexal masses.

c) Bacterial vaginosis can be treated with oral metronidazole 400mg twice daily for one week and is assocaited with a 80% cure rate. Similarly oral clindamycin 300mg twice daily for a week can be used. Patient should be advised to avoid douching and usage of antiseptic washes.

Candidiasis should be treated with clotrimizole pessary 200mg for three nights. Other preparations include miconazole intravaginal cream or oral fluconazole.

Trichomonas vaginalis should be treated with Methronidazole 400 twice daily for a week. Partner should be notified and also treated. Patient and partner should be screened for other STI.

Chlamydia infection should be treated with azithromycin 1g orally as a single dose or doxycline 100mg orally twice a day for a week.

For gonorrhea, ceftriaxone 1g IM can be administered. Alternatively oral regimens with ciprofloxacin can be used.

Patients with sexually transmitted diseases should be referred to the GUM clinic for follow up and tracing.
Posted by Mark C.
a) Timing of her discharge in relation to her menses would be useful to identify physiological discharge. The smell and colour of discharge is also important (e.g. greyish discharge with a fishy smell in BV). Whether it is related to pain and pruritus and whether there are any aggravating of relieving factors. I would need to know her smear history to exclude cervical pathology, whether there were previous STIs and STI screening. Her current method of contraception, cycle pattern (regularity, length, symptoms).
An obstetric history would be also needed and when the last one occured, and when her symptoms started in relation to the last pregnancy; and whether there were any previous procedures. Sexual history including number of partners, use of condoms. Hygiene is also required including use of scented soaps, nylon underwear and tight trousers. Other medical conditions including history of diabetes, use of corticosteroids and other immunosuppressives.

b) I would need to take HVS sent for C&S to exclude any vaginal infections and if there are to have sensitivity. Also endocervical swab sent for culture and NAAT to exclude chlamydia and gonorrhoea, and an early morning urine sample NAAT for chlamydia.

c) Treatment is directed to the isdentified cause. If a candida infection is identified, oral or topical fluconazole can be used. With chlamydia oral azithromycin, gonorrhoea oral metronidazole. Oral or topical metronidazole can also be used for other bacterial infections.
Posted by R S.
R S

a. Nature of vaginal discharge is explored like color and odour, also presence of other symptoms like pruritus and soreness.
Clear discharge that’s odourless with no other symptoms goes with leukorrheo which is normal vaginal discharge. Fungal infection like candidiasis is associated with white creamy discharge, cheese –like with intense itching while the presence of yellowish greenish discharge may reflect trichomonus vaginalis.
Furthermore, bacterial vaginosis can be presented with frothy grey discharge with fishy odour after unprotected intercourse. Presence of mucopurlent discharge with intermenstrual bleeding, deep dyspareunia or post coital bleeding can reflect Chlamydia trachomatis infection or gonorrheo.
History of medical diseases is explored such as DM, HIV, blood dyscrasia or other immunosuppressive conditions, also drug history like prolong corticosteroids or antibiotics as all these condition are risk factors for persistent vaginal discharge particularly candidiasis.
Risk of acquiring STD is assessed by asking about number of partners in the previous 6 months, also if her partner has other partners. Being les than 25 years old also put her at risk of having STD.
History of difficult labour, obstructed labour, vaginal or pelvic surgery is taken as she might have urinary fistula with urinary leaking. The leaked urine gives amonical odour with perineal soreness and erythema.
In addition, we enquire about previous treatments; compliance and response.

b. High vaginal swab is taken for microbiological examination with culture and sensitivity. Self taking swabs (vulval, vaginal or urethral) can be examined alternatively. It can reveal fungal mycelia threads of candida , also trichomonous vaginalis micro-organism. Wet vaginal smear can show clue cells which reflect bacterial vaginosis. Presence of WBC is not diagnostic of PID but have high negative predictive value ie if no WBC presence; PID is unlikely.
Endocervical smear for microscopical examination, culture and sensitivity can reveal Chlamydia trachomatus or gonorrhea. Antichlamydial antibodies test is also helpful. First catch urine can be used also to diagnose Chlamydia of GC using PCR method. Vaginal PH is not routinely measured. A vaginal washing with KOH solution can reveal the fishy odour of bacterial vaginosis by creating an alkaline media.

c. Fungal infection (candidiasis) is treated by systemic and local antifungal like clotrimasole cream and suppositories. Oral fluconazole 15o mg can be used for treatment and future prophylaxis against candidia. Trichomonous vaginalis is treated by Metronidazole 200 mg twice daily for 7 days. Clindamycin vaginal cream can be used to treat bacterial vaginosis. Alternatively metronidazole vaginal cream or suppositories. In majority of cases a mixed infection is present which will need multi agent therapy. If there is suspicion of PID, prompt treatment ir required without waiting the culture result because of its serious consequences like chronic pelvic pain, infertility and ectopic pregnancy. Treatment includes oral ofluxacin 200 mg twice daily for 7-10 days. Alternatively, ceftriaxone injection 250 mg single dose with doxidar capsule 100 mg X2 and metronidazole 400 mg bid for 10-14 days.
Posted by Preethi A.
(a) Clinical history including the colour, nature ,presence of any odour along with symptoms of any vaginal itching ,abdominal pain , abnormal bleeding pattern,dysuria,dysparunia need to be elicited to identify and differentiate the cause of vaginal discharge like Bacterial Vaginosis(BV),Candidisis or Sexually Transmitted Infections(STI)like Chlamydia ,trichomoniasis or gonorrhoea.
Sexual history including any new partner in the last year or more than one partner in the last year helps to assess the risk of sexually transmitted infections.
Other medical conditions like diabetes or immunocompromised state or any recent medications like antibiotics and steroids can increase the risk of infection .
Any treatment either prescribed or over the counter will influence the need for investigation and the treatment given.
Contraceptive use ,history of unprotected intercourse ,postpartum or post abortion state increase the risk of infection and need to be enquired.
Any history suggestive of presence foreign body should also be sought.
(b) Abdominal examination to elicit any tenderness or presence of mass as well as speculum examination and bimanual examination to identify the presence of foreign body , cervical ectopy or presence of a mass will help to identify and correctly treat the cause of the vaginal discharge.
Vaginal pH is >4.5 in most infections like tricomonas and Bacterial vaginosis and <4.5 in candidisis and can hence provide as a valuble tool in the treatment of discharge.
A High Vaginal Swab taken from the posterior fornics and lateral vaginal wall as well as an endocervical swab will identify the causative organism like candidiasis ,bacterial vaginosis trichomoniasis ,Chlamydia or neisseria and help to give the correct treatment.
A saline wet microscopy identifies trichomonas and need to be considered .
(c) Empirical treatment without investigations in a women with low suspicion of STI and no evidence of upper reproductive tract infection can be started and include clotrimazole or metronidazole based on the symptoms.
Oral regimes include metronidazole 2g stat or 400-500mg twice daily for 5-7 days(for BV and Trichomonas)and
Vaginal gels like metronidazole or pessaries like clotrimazole 500mg stat or 200mg for 3 days or 100mg for 6 days(for candidiasis) can also be used.
Clindamycin 300mg twice daily for 7 days can be used in special situations like pregnancy for the treatment of BV
Chlamydia is treated with stat dose of Azithromycin 1gm orally.
Recurrent infections can be treated with maintanence regimes, for example metrinidazole 400mg weekly for 6 months for trichomonas or suppressive regimes like metronidazole 400mg twice daily for 3 days at the beginning and end of menstruation for recurrent BV infections.
Partner screening is indicated in sexually transmitted infections like trichomonas .
Alcohol should be avoided with metronidazole as it can cause reactions.
Posted by Im F.
A 23 year old woman has been referred to the gynaecology clinic with a 6 months history of vaginal discharge. (a) Describe the information you would require from the history [10 marks]. (b) Discuss and justify your investigations [4 marks ]. Discuss the treatment options for infective causes of vaginal discharge [6 marks].


A
information on the characteristic of dischage purulent ,fowl smelling ,blood stained .symptoms like ichinees and soreness ,pain associated with it.urinary symptoms like dysuria urgency frequency which maybe because of lower urinary tract infection.loose motion constipation and pain on defeacation should be inquired to exclude inflamatory bowel disease.menstrual history should be asked regarding last menstrul period ,regularity of periods ,intermenstrula bleeding postcoital bleeding. information on use of contraception , type and the duration of its use should be gathered.sexual history regarding new partner or no of partner should be inquired.maintaining confidenciality explore about the relationship with her partner to exclude abuse.previous history of drugs such as imunosuppresives should be asked. use of recreational drugs,alchol and substanse abuse need to be asked.information on previous treatment for vaginal discharge .


B
FBC to look for raised white cell count could point towards chonic infection.CRP if raised will inform about any inflammatory condition .urine analysis to check for WBC ,RBC will point towrds urinary tract infection. vaginal swabs for gonoorrhea NAAT , chlamydia and candida for culture and sensivity.uretral swabs rectal should be taken for culture.random blood sugar to exclude diabetes mellitus.ultrasound scan of pelvis tolook for masses.if history sugestive of drug abuse HIV and heb B screening should be offered.

C
treatment for gonoorrhea,chlamydia can be started with ofloxacin and doxycycline for 10 days.metronidazole to cover trichomonas clotiamazole passary for fungal infecton with topical antifungal cream.refer to G.U.M clinic to trace and treat partner as well.advice on perineal hygiene should be give. advice to wear cotton underwear and loose clothing .follow up appoint to review investigation and ensure compliance.leaflets on sexually transmitted disease and contraception to be given with website address.