Vaginal Discharge And STD

Vaginal Discharge Discharge and
STD’s STD STD’s s
Tracie Wilcox MD
Assistant Professor of Medicine
Resident’s Women's Health Curriculum

• Etiology: gy
– Infectious causes
Vaginal Discharge
• BV
• Candidiasis
• Trichimonas
• Cervicitis - GC/Chly, trich, mycoplasma genitalium,
ureaplasma urealyticum
– Chemical irritants
– Hormone deficiency – atrophic vaginitis
– Malignancy
– Physiologic - normal discharge
– Nonvaginal – ex: abscess, abscess urethral discharge

Epidemiology
• Lifetime risk for yeast vaginitis 75%
– Antifungal medication among top 10 of all
nonprescription meds
• Estimated $275 million annually
• Self-diagnosis based upon symptoms
Self-diagnosis based upon symptoms
frequently incorrect

Vulvovaginal Candidiasis
• Accounts for 17-30% of cases of vaginitis g
– >90% of cases due to C. albicans
• Signs and symptoms:
– Thick Thick, curdy, curdy white, white nonodorous discharge
– Burning, itching, irritation, dyspareunia
• Risk factors
– antibiotic use
• Rate of symptomatic infection 20-25%
– Diabetes
–HIV
– Sexual activity
– Pregnancy

• Dx:
Vulvovaginal Candidiasis
– Physical exam findings
• Erythema and edema of vulva and vagina
• Clumpy, white adherent discharge
– Wet mount
• pH normal (4-4 (4-4.5) 5)
• Yeast/hyphae seen in 60-70% on KOH stain
• No increase in PMN’s on saline stain
– Culture
• Recurrent Candida vaginitis or for vaginitis unresponsive to
antimycotic y therapy py

KOH For Budding Budding Yeast Yeast & Hyphae
Medscape p today. y
Candidiasis. 1999

Treatment
• Uncomplicated infection
• Sporadic, infrequent episodes
• Not pregnant
– Oral and intravaginal treatments equally effective w/
clinical cure rate > 80%
– OOral l fluconazole fl l 150 mg po x one ddose
– Intravaginal clotrimazole, miconazole,
terconazole for 11,3,7, 3 7 or 14 days

Treatment
• Complicated infections
– Poorly controlled diabetes, pregnancy,
recurrent infection, immunocompromised,
infection with non-albicans Candida, or severe
disease choose prolonged therapy
• 2 doses of oral fluconazole 72 hours apart
• 7-10 days of topical therapy
– Pregnant women
– > 4 episiodes/yr
• Maintenance regimen of fluconazole 150 mg po
once weekly x 6 months

Bacterial Vaginosis
• Replacement of Lactobacillus species by
vareity of anaerobic bacteria
– Gardnerella vaginalis
– Mycoplasma hominis
• MMost t frequent f t cause of f vaginal i l discharge di h
– 22-50% of all cases
• > 50% of affected women are
asymptomatic

• Risk factors
BV
– Multiple sex partners
– Douching
– IUD use
– AA race
– Exposure to STI’s

• Diagnosis g
– Hx and PE:
BV
• Thin, white-gray vaginal discharge
• Malodor noticed after intercourse or menses
• Itching, burning, irritation of vagina
– Wet mount:
• Clue cells on saline prep
• Fishy odor on KOH prep
• Vaginal pH >4.5
– Inclusion of any 3 of either 1,4,5,6 gives sensitivity of
92% and specificity of 77% = Amsel’s criteria

Clue Cells

• Treatment
BV
– Metronidazole 500 mg po BID x 7 days
• Preferred regimen in pregnant women
– Metronidazole gel 0.75% - 1 applicator full
(5g) intravaginally for 5 days
– Clindamycin cream 2% - 1 applicator full (5g)
IV x 7 days y
• Preferred regimen if metronidazole allergy

• Recurrent disease
BV
– 30 % of women will develop recurrence
– Women with more than 3 episodes in one
year
• Suppressive therapy with metro gel 2x/wk x 6
Suppressive therapy with metro gel 2x/wk x 6
months

Trichomonas Trichomonas Vaginalis
• Infection with protozoan trichomonas
vaginalis
• Accounts for anywhere b/w 44-35% 35% of
cases of vaginitis
• SSexually ll ttransmitted itt d

Trichomonas Trichomonas Vaginalis
• Clinical features:
– Purulent, malodorous, thin discharge
– Vaginal burning, burning pruritis pruritis, dysuria dysuria, dyspareunia
• PE fi findings: di
– Vulvar and vaginal erythema
– Green discharge (10-30%)
– Punctate hemorrhages on cervix ( 2%)

• Diagnosis
Trichomonas Trichomonas Vaginalis
– Motile trichomonads on wet mount (50-70%)
– Ph > 44.5 5
– Increased WBC’s on wet mount ( >5 per high
power field)
– culture

Trich on on Saline Wet Mount
Buxton, R. Examination of vaginal secretions.2/6/07: Microbelibrary.org

• Treatment
– Metronidazole
Trichomonas
• 2 grams po x one
• 500 mg po BID x 7 days
• 85-90% cure rate
• Desensitization if allergic
• No alcohol for 24 hrs after treatment
• Do not use intravaginal therapy
• Treat partner p
• No intercourse for one week after treatment
completed

At Home Home Testing
Testing
• Vagisil screening kit available OTC for
women with vaginal d/c, itching,
unpleasant odor
• Tests pH of vaginal discharge
• If 4.5 4 5 - recommend dttreatment t tf for yeastt
• If 5 or greater - recommend following up
with doctor for further evaluation

Atrophic Vaginitis
• Dryness and inflammation of vaginal mucosa
with thinning of epithelium due to estrogen
deficiency
• Prevalence in postmenopausal women 47%
• Can also be seen in premenopausal p p women
– Post partum
– Lactating
– Anti-estrogenic medications

Atrophic Vaginitis
• Clinical manifestations
– Vaginal dryness
– Burning
– Dyspareunia
– Vaginal itching
– Vaginal discharge
– VVaginal i l spotting tti or bleeding bl di
– Urinary tract symptoms

• Clinical
– History
– Pelvic exam
Atrophic Vaginitis
• Loss of pelvic hair
• Diminished elasticity and turgor of vulvar skin
• Urethral prolapse
• Pale, dry,smooth y and shiny y vaginal g epithelium p
• Friability of epithelium

Atrophic Vaginitis
• Treatment
– Local moisturizers and lubricants
• Ex: replens
– estrogen t therapy th
• Intravaginal therapy
– estrogen ring
– estrogen t tablets t bl t
– Estrogen cream
• Dose: 1/8th of applicator q day x one week then 2-3 x per
week
• Progestin not necessary in women on low dose therapy
• No estrogen therapy in women with hx of breast cancer

Chlamydia
• Chlamydia trachomatis most commonly
reported STD in US
– Higher rates in adolescents and AA women

Chlamydia
• Clinical presentations
– Cervicitis
• > 50% may be asymptomatic
• Vaginal discharge, abdominal pain
– Urethritis
–PID
• Seen in 30% of untreated women
– Pregnancy risks
• PROM, , low birth rate, , conjunctivitis, j , pneumonia p

• Diagnosis
Chlamydia
– Nucleic acid amplification
• Gold standard
– Endocervical, urethral, or urine sample
– 94-98% sensitive for endocervical sample and 80-99%
sensitive iti ffor urine i sample l
– Expensive but most sensitive test available
– can also be used to detect Neisseria gonorrhoeae in the
same specimen

• Treatment
Chlamydia
– Azithromycin 1 gram po x one
– Doxycycline 100 mg po BID x 7 days
– Both with 97-98% cure rates
• Treat partners
• Test for other STD’s
• No need to test for cure but should repeat
screening to rule out recurrent infection
within one year

N. Gonorrhea
Gonorrhea
• Clinical presentation
– Asymptomatic
– Cervical infection
• Pruritis and mucopurulent discharge
– Urethritis
–PID
• Seen in 10 10-40% 40% of women with gonorrhea
– Oropharyngeal infection

N. Gonorrhea
Gonorrhea
• Diagnosis g
– Nucleic acid amplification test – best test available
• Endocervical swab
• Liquid based pap smear
• Urine
– Lower sensitivity due to substances in urine that can interfere
with test (85% vs 96%)
– Not approved by FDA
• Self-collected Vaginal swab – kits available via mail on line
– Culture from endocervical sample
• Only 65-80% sensitive in asymptomatic women
– DNA probe from endocervical swab

N. Gonorrhea
Gonorrhea
• Treatment for cervicitis/urethritis
– Increased resistance to penicillin, tetracycline
and ciprofloxacin
– Recommended: ceftriaxone 125 mg IM x1
– oral alternative: cefixime 400 mg po x 1
– Treat for concomitant chlamydia infection
• Azithromycin 1 gram po x 1
– Increasing to 2 grams po x 1 will trx both gon/chl but
limited by side effects
• Doxycycline 100 mg po BID x 7 days

• Follow up
N. Gonorrhea
Gonorrhea
– No need to test for cure
– Check for other STI’s STI s

Pelvic Pelvic Inflammatory Disease
• Acute infection of the upper genital tract
structures in women, involving any or all of
the uterus uterus, oviducts, oviducts and ovaries
• Microbiology
– NN. gonorrhea h – 1/3 of f cases
– Chlamydia – 1/3 of cases
– Mi Mixed d iinfection f i – strep, e.coli, li kl klebsiella, b i ll
anaerobes

• Risk factors
PID
– Number of sexual partners
– Age
• 15-25 years old w/ highest frequency
– Symptomatic male partner
– Previous PID
– African American women

Pelvic Pelvic Inflammatory Disease
• Clinical symptoms y p
– Abdominal pain
– Vaginal bleeding
– Vaginal discharge
– Urethritis
• PE
– Abdominal pain
– Fever
– Bimanual exam with CMT or adnexal tenderness
– Cervical discharge

• Diagnosis
– Pregnancy test
– U/A
PID
– Cervical sample for GC/ Chlamydia
– Pelvic ultrasound

• Treatment
– Outpatient
PID
• Ceftriaxone 250 mg IM x 1 + doxycycline 100 mg po BID x
14 days
• Add metronidazole if concern for pelvic abscess, suspected
infection with Trichomonas, or recent instrumentation
– Inpatient
• Cefoxitin 2 G IV q 6 + doxycycline 100 mg po/IV Q12
• Amp/Sulbactam 3 G IV q 6 + doxycycline po/IV
• Oral administration of doxyxycline preferred due to pain
associated with drug administration when infused
– bioavailability of oral AND IV preparation equivalent

• Complications
PID
– Perihepatitis: Fitz-Hugh Curtis Syndrome
• RUQ pain with pleuritic component
• Abnormal LFT’s
– Tubo-ovarian Tubo ovarian abscess
– Chronic pelvic pain –seen in 1/3 of patients
– Infertility
– Ectopic pregnancy

Anogenital HPV
• Single or multiple smooth or verrucous
papules on the penis, vulva, cervix,
vagina vagina, perineum perineum, or anal region
• Most common viral STD in US

Chemical:
Treatment Options
– Aldara (Imiquimod)
( q )
– Podofilox 0.5%
– TCA
– Podophyllin resin
– Interferon alpha
– 5 FU epinephrine gel
Surgical Options:
Cryotherapy
Laser
Scalpel Excision

• Home treatment
Imiquimod Imiquimod (Aldara)
• 5% cream self administered
• Apply 3x/week for up to 16 weeks
• Immune modulator
• Leave on for 6 hours then remove with soap and
water (generally apply QHS)
• Avoid in mucosal areas areas, do not use with
diaphragm
• Clearance rate: 50-100% 50 100%

• Self-administered
Self administered
• Anti-mitotic agent
Podofilox
• AApplied li d 2 2x/d /d x 3 ddays th then 4 dday rest t
period
– May repeat up to 4 times
• Cure rate - 45-90%

• TCA
Trichloroacetic Trichloroacetic acid
– In office procedure
– 70% success rate
– Apply 1x per week for 4 weeks
– Caustic agent g which pphysically y y destroys y the
wart tissue
– Can get painful chemical burns, scarring and
ddepigmentation i t ti of f surrounding di areas
– Can be used in pregnancy

Genital HSV HSV Infection
Infection
• Most common cause of genital ulcers
• Genital disease may be from HSV 1 or
HSV 2
• Rates increased in females, AA, age 14-
40’ 40’s, and d in i patients ti t without ith t previous i HSV
1 antibodies
• Recurrent disease more common with
HSV 2 infection

Clinical Clinical Manifestations
• Primary infection
– Genital pain and itching
– Dysuria
– Painful LAD
– Systemic y symptoms y p –HA, , fever, , malaise
– Genital lesions
• Secondary y infection
– Less severe with less lesions and usually
unilateral w/o systemic symptoms

Physical Exam
• Vesicles Vesicles, followed 2-3 2 3 days later by
pustules, then ulcers, then crusted lesions
• Lesions isolated or coalesced
• Tender LAD

Herpes

Diagnosis
• Viral culture of lesion = standard dx method
– Unroof alcohol wiped vesicle with needle and remove
fluid with cotton swab and place in viral culture
medium
• Serology
– a ffourfold f ld or greater t rise i in i antibody tib d titers tit is i observed b d
between acute and convalescent sera in patients with
primary p y infection
– HSV subtypes helpful in predicting risk of recurrence

Treatment
• Primary y infection
– Acyclovir 200 mg po 5x/d x 7-10 d
– Valacyclovir 1 g po BID x 7-10 d
• Recurrent episodes
– Acyclovir 800 mg po 3x/d x 2 days
– Valacyclovir 500 mg 2x/d x 3d
• Suppressive therapy - >5 / yr
– Valacyclovir 500 mg po QD
– Acyclovir 400 mg po BID
– Famciclovir 250 mg po BID

Prevention
• Suppressive therapy
• Condom use
• AAvoid id sexual l encounter t dduring i bbreakout k t
The Relationship between Condom Use and Herpes Simplex Virus Acquisition1.Anna Wald , MD, MPH;
Langenberg , MD; Elizabeth Krantz , MS et al al. Annals of Internal Medicine. Medicine November November 15 15, 2005vol 2005vol. 143 no no. 10 707 707-713.
713
Andria G.M.

Syphilis
• Sexually y transmitted disease caused by y the
bacterium Treponema pallidum
• Most cases occur in persons 20 - 39 years of age
• Increasing rates of infection
• Clinical manifestations:
– Primary syphilis
– Secondary syphilis
– Latent and Late (tertiary) syphilis

Primary Primary Syphilis
Syphilis
• single g sore (chancre) ( ) or multiple p sores occurring g
10 -90 days after infection is acquired ( avg 21
days)
• chancre h is i usually ll fi firm, round, d small, ll and d
painless
• The chancre lasts 3 to 6 weeks then heals
without treatment

Chancre

Secondary Syphilis
• Hematogenous dissemination occurring 2-8 2 8
weeks after chancre
• Skin rash
– Rough, red, red-brown, classically on palms and
soles
– Non itchy
• Mucocutaneous lesions
• LAD
• HA, muscle aches, fatigue, sore throat
• Genital condyloma latum

Latent Latent Syphilis
• Asymptomatic stage after symptoms of
secondary syphilis subside
• Early latent defined as < 1 year after
primary infection

Tertiary Tertiary Syphilis
Syphilis
• Cardiovascular - aortitis involving
ascending aorta, aortic aneurysms, aortic
regurgitation
• Neurologic - most common manifestation
in US
• Osteomyelitis
• hepatitis

• Asymptomatic
• Symptomatic
Neurosyphilis
– Meningovascular syphilis - 4-7 4 7 yrs after infection
• Stroke, cranial nerve abnormalities
– Paraenchymatous syphilis
• Decades after infection
• Progressive dementia, personality changes
• Sensory ataxia, loss of proprioception, lighting pains,
y , p p p , g g p ,
autonomic dysfunction, optic atrophy, disturbed sensation

Diagnosis
• Dark field microscopy
• Antibody levels
– RPR or VDRL - nontreponemal tests
• Titers useful to monitor response to therapy
– FTA-ABS or TPHA - treponemal p tests -
confirmatory
• LP - mononuclear pleocytosis, increased
protein value; VDRL 30-70% sensitive in
spinal fluid

Treatment
• Primary, y, secondary, y, early y latent infection
– Benzathine Penicillin G 2.4 million units IM x one
• Alternatives: doxy 100 mg BID x 14 days, tetracycline 500
mg po QID x 14 days
• Late latent, tertiary
– Aqueous Benzathine penicillin G 2.4 million units IM q
week x 3 weeks
• Neurosyphilis - PCN G 3-4 million units IV q day
x10 x 10 - 14 days
– desensitization if allergic
Diagnosis and Management of SyphilisDAVID L. BROWN, MAJ, MC, USA, and JENNIFER E. FRANK,
CPT, MC, USADeWitt Army Community Hospital, Fort Belvoir, VirginiaAm Fam Physician.ﾊ2003ﾊJulﾊ
15;68(2):283-29

Follow Up
• After adequate treatment treatment, non treponemal
tests titers will decline and will become
nonreactive though may have persistent
low level positive titer
– Consider re re-treatment treatment if levels don’t don t decrease
4 fold in 12-24 months
• Treponemal tests will remain reactive for
• Treponemal tests will remain reactive for
life

Screening Guidelines
• Screen for Chlamydia in the following groups
(CDC and USPTF):
– All sexually active women age 25 years or younger
(including pregnant women)
– Sexually active women older than 25 years with risk
factors
• new partner in prior 60 days, more than one sex partner,
inconsistent condom use, unmarried, or history of STD
– Insufficient evidence to recommend routine screening
in sexually active men

Screening Continued
• Screening for N. Gonorrhea
– Sexually active women younger than 25 years
– Inconsistent condom use
– A history of multiple partners or a partner with multiple
contacts
– SSexual l contact t t with ith a partner t with ith culture-proven lt STD
– A history of repeated episodes of STD
– Sex work or drug use
– Pregnancy

Screening Continued
• HIV screening:
– recommended for all patients b/w 13-64 in
health care settings (CDC)
– USPTF gives A recommendation for
screening patients with one risk factor or in
area where prevalence >/1%
– USPTF gives g C recommendation for all other
patients