6.1 TRICHOMONIASIS
This has become less common in recent years and usually presents as quite a heavy yellow discharge associated with vulval and vaginal soreness. The motile trichomonads are easily seen on wet-mount microscopy (i.e. examination of a sample of vaginal discharge in a drop of normal saline under a cover slip; Figure 6.1); however, as this is rarely available in non-GU medicine settings, the diagnosis should be made by vaginal swab culture. This should be transported to the laboratory as soon as possible as the organism is quite friable.
Treatment is with oral metronidazole, preferably a 2 g stat dosage, although 400 mg b.d. for 5-7 days may be used. Metronidazole is better tolerated if taken with or after food, and alcohol should be avoided during treatment and for 24 hours afterward.
Most cases of trichomoniasis are sexually transmitted; sexual partners should therefore be assessed and treated. Men usually carry the infection without symptoms.
6.2 STREPTOCOCCAL INFECTION
Lancefield Group A and Group B streptococci are uncommon causes of vaginitis. Only approximately 50% of women with Group B infection report symptoms, usually vaginal soreness and irritation. Group A infection is less common but more likely to produce symptoms. There is frequently a marked vaginitis with a serosanguineous discharge.
6.3 DESQUAMATIVE VAGINITIS
This is an uncommon cause of discharge of unknown aetiology. The appearance is that of trichomoniasis, there being a marked vaginitis and profuse yellow discharge (Figure 6.2). Colposcopic examination of the vagina and cervix may show a macular pattern (as is often seen in trichomoniasis- so-called "strawberry cervix"). Gram stain and microscopy of the discharge shows an absence of lactobacilli with cocci-form bacteria and vaginal basal epithelial cells present (as seen in a post menopausal woman with an atrophic vaginitis). There is often a good response to intravaginal Clindamycin cream.
Figure 6.1. Wet-mount preparation showing a trichomonad (Trichomonas vaginalis infection)
Figure 6.2. Macular vaginitis - seen in some cases of Trichomoniasis and desquamative vaginitis
6.4 FOREIGN OBJECTS
Liberal views on sexual experimentation have led to various devices becoming lodged or even lost in the vagina. Although the patient is usually only too aware that something has "gone missing," occasionally bits of "sex toys" can break off unknowingly and give rise to a vaginal discharge some days later.
More commonly a tampon can inadvertently be pushed deep into the vagina and be forgotten. After a few days this produces an unpleasant smelling discharge. Bits of tampons occasionally latch onto threads of an IUCD and later cause problems. These small pieces of cotton wool can often be very difficult to detect. Similarly, small fragments of toilet paper can be left at the entrance of the vagina following a hurried wipe after urination. Sexual activity can push these deep into the vagina only to produce a discharge after a few days.
Very occasionally condoms split during intercourse with the result that fragments of rubber may be retained in the vagina and eventually give rise to a malodorous discharge.
6.5 CERVICITIS
Cervical inflammation may cause a mucopurulent discharge which, although originating from the cervix, presents as a yellow vaginal discharge, sometimes blood stained.
6.5.1 Important Points
(1) Cervicitis is often difficult to distinguish from cervical ectopy as in both cases the cervix appears red to the naked eye. Indicators of cervicitis include mucopurulent secretions (Figure 6.3) and contact bleeding on touching the cervix with a cotton wool swab, for example when taking an endocervical swab for Chlamydia (not when scraping the cervix with a wooden spatula for cervical cytology). in Gu medicine, cervical secretions are often examined under the microscope and the number of polymorphs present quantified. A count of greater than 30 polymorphs per high power field (HPF-X1000 magnification) is suggestive of a cervicitis.
A cervical ectopy may produce excessive mucus in the absence of infection. This can be treated by cryotherapy or diathermy but should only be considered when infection has been adequately checked for and discounted.
Figure 6.3. Mucopurulent cervicitis
(2) Chlamydia trachomatis is the commonest cause of cervicitis in the UK. Remember to gently wipe the cervix clear of discharge before taking a swab for Chlamydia. Cellular material rather than mucus is required for diagnosis, although this is less of an issue with nucleic acid amplification tests than with enzyme immunoassays.
(3) Although gonorrhea is less common than Chlamydia, a swab should be taken from the cervix for Neisseria gonorrhoeae culture. The gonococcus is a fragile organism and therefore the sample must be transported to the laboratory as soon as possible; if there is likely to be an overnight delay then keep the swab at room temperature rather than in the refrigerator. Women with suspected gonorrhea should ideally be referred to Gu medicine. The appropriate swabs from the cervix (not vagina), urethra, rectum, and pharynx (if appropriate) can then be taken and plated directly on to specific media and incubated prior to transport to the laboratory. Owing to the anatomical close proximity of anus and vagina, rectal infection may be present in the absence of a history of anal intercourse.
(4) In many cases no causative organism can be found and the diagnosis is one of "non-specific cervicitis" (the female equivalent of "non-specific urethritis"). Mycoplasma genitalium may prove to be an important cause of cervicitis although currently this is a difficult organism to identify by routine microbiological testing.
6.5.2 Management of Cervicitis
Non-specific cervicitis and chlamydial infection should be treated with a tetracycline (e.g. doxycycline 100 mg bd for 7-10 days), erythromycin 500 mg b.d. (a 14-day course is usually required to adequately treat a chlamydial infection), azithromycin 1 g stat or azithromycin 500 mg stat followed by 250 mg daily for 4 days (more effective than 1g dosage for M. genitalium infection). Sexual partners should be assessed for urethritis; this is often asymptomatic. Failure to treat partners may lead to reinfection.
As mentioned above, patients with suspected gonorrhea should be referred to Gu medicine for treatment, follow-up, and contact tracing (partner notification). If the diagnosis of gonorrhea has been confirmed by culture and there is a delay before the patient can be seen by Gu medicine, consider treating with oral cefixime 400 mg stat and then refer to Gu medicine for follow-up and contact tracing.
Penicillin- and ciprofloxacin-resistant gonorrhea is now seen in the uK, hence the recent move to using cephalosporins (oral cefixime and i.m. ceftriaxone are the favored choices). Intramuscular spectinomycin may be required for multiple resistant gonococcal infections but we are now moving into specialist territory. Most laboratories will provide details of antibiotic sensitivities for their gonococcal isolates.
Prescribing a 10-day course of tetracycline in addition to antigonococcal treatment to cover possible co-infection with Chlamydia is to be recommended.
6.6 PHYSIOLOGICAL DISCHARGE
Many women present with excessive vaginal discharge for which no infective cause can be found. In some cases this will be an increased awareness or a true increase in volume of normal vaginal secretions. Desquamated vaginal epithelial cells, cervical mucus, and transudated fluid from the vaginal mucosa are the main constituents of normal vaginal secretions and the amount produced may vary with the phase of the menstrual cycle. It is worth emphasizing that physiological discharge should be diagnosed only when both microscopy and culture of vaginal and cervical secretions prove negative; a clinical judgment is insufficient. Explaining the nature of the discharge and providing reassurance that no infection is present is often all that is required in the way of management. If the discharge is particularly troublesome, gentle douching with a povidone-iodine solution may be considered; because of the increased risk of pelvic infection associated with douching, it is important to ensure that infection is absent, in particular bacterial vaginosis and Chlamydia.
Some women with cervical ectopy produce an excessive amount of mucus and will often describe their discharge as "thick and stringy." Non-infected cervical mucus is clear or white; yellow mucus is highly suggestive of infection. Irrespective of the clinical findings the appropriate swabs must be taken to check for infection (see above) in addition to cervical cytology, if this has not been performed recently. Treatment with cryotherapy or diathermy should be considered once infection and cervical pathology have been excluded.