Leukorrhea

Leukorrhea
Increased vaginal discharge Physiologic/Pathologic

Normal Vaginal Discharge

Creamy white discharge
Vulvar secretion
Bartholin glands Sweat glands Sebaceous glands Skene glands

Vagina Cervix Endometrial glands Fallopian tubes

Normal Vaginal Discharge

Increased when
Ovulationendocervical glands Premenstrual phase Pregnancy Sexual excitementBartholins glands

pH < 4.5

Physiological Vaginal Discharge

Newborns Puberty Congestion of pelvic organs Cervical ectopian Contraceptives Vaginal douche

Pathological Vaginal Discharge

Vaginitis in infancy and childhood Senile vaginitis (Atrophic vaginitis) Candidiasis Bacterial vaginosis Trichomonas vaginitis Mucopurulent cervicitis Foreign bodies Neoplasm Urinary and fecal discharge

Vaginitis in infancy and childhood

Low immunity Age 1-5 years Infection/Foreign body/Tumor Wet smear, Gram stain, culture, speculum Treatment
Rest antibiotics estrogen

Atrophic vaginitis
Postmenopause Decreased estrogen
Vaginal wall thining Decreased acidic environment

Yellow/Green/Bloody Pruritic/Painful Dysuria Dyspareunia/Postcoital bleeding Vaginal wall thining, colpitis macularis, patchy ulceration, adhesive vaginitis

Atrophic vaginitis
PAP smear, Gram stain, culture +- Cervical biopsy, Fractional curettage Treatment:
Antibiotics estrogen (local/systemic)

Candidiasis
Yeast cells/Pseudohyphae Inflammation and curd-like discharge Predisposing factors
Diabetes Obesity Pregnancy Antibiotics Contraceptives Low immunity Premenstrual period

Candidiasis
KOH preparation, Gram stain (positive) Subourauds/Nicersons media culture Treatment:
Uncomplicated
Clotrimazole V.P. (100) Vg suppo OD 6days Clotrimazole V.P. (200) Vg suppo OD 3days Itraconazole (400) PO stat Fluconazole (150) PO stat

Complicated
Clotrimazole V.P. (100) Vg suppo OD 14 days then Clotrimazole V.P. (500) Vg suppo weekly for 6 months Repeat Fluconazole 3 days after then weekly for 6 months

Partner?

Bacterial vaginosis
Decreased amount of Lactobacilli Increased amount of anaerobes Low immunity, fatigue, frequent sexual intercourse, vaginal douche Mostly asymptomatic Increased (foul-smelling) discharge

Bacterial vaginosis
Amsel criteria (3/4)
Gray-white discharge pH > 4.5 Clue cells Whiff test

Treatment:
Metronidazole (500) 1 tab PO bid pc 7 days Clindamycin (300) 1 tab PO bid pc 7 days

Trichomonas vaginitis
Anaerobic flagellated protozoa Mainly sexually transmitted Yellowish green/white discharge Itchy Dysuria, dyspareunia Vaginal mucosa inflammation colpitis macularis, strawberry cervix

Trichomonas vaginitis
Wet smear, Gram stain to rule out gonococcal infection Treatment
Metronidazole (500) 1 tab PO bid pc 7 days Clotrimazole V.P. (100) Vg suppo OD 6days

Must also treat partners, no intercourse until resolved

Mucopurulent cervicitis
Mucopurulent discharge Dysuria Vulval inflammation N. gonorrhoeae, C. trachomatis, HSV Gram stain intracellular gram negative diplococci

Mucopurulent cervicitis
Dual therapy Gonococcal infection
Ceftriaxone 125 mg IM stat

Chlamydial infection
Doxycycline (100) 1 tab PO bid pc 7 days Azithromycin (1g) 1 tab PO stat

Must also treat partners, no intercourse until resolved

Foreign Bodies
Children Adultscontraceptive devices, pessary, swabs, tampons Purulent vaginal discharge; foul-smelling, bloody Speculum; may use nasal or aural speculum Removal then antiseptics

Neoplasm
Benign/Malignant Leukorrhea purulent, foul-smelling, bloody if infected/malignant

Urinary and fecal discharge

Urinary discharge
Urethro-vaginal fistula Vesico-vaginal fistula Uretero-vaginal fistula

Fecal discharge
Recto-vaginal fistula

Summary
Physiologic Pathologic
Vaginitis in infancy and childhood Senile vaginitis (Atropic vaginitis) Candidiasis Bacterial vaginosis Trichomonas vaginitis Mucopurulent cervicitis Foreign bodies Neoplasm Urinary and fecal discharge

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