summary PID

Vaginal Discharge summary

1. Physiological Discharge

• Description: Normal, non-pathological vaginal secretion that is typically colorless or white, odorless, and non-itchy. Its consistency and volume naturally vary with the menstrual cycle.

• Management: No treatment is required. Reassurance is key unless symptoms like itching, odor, or color change suggest an underlying infection.

2. Non-Infectious Causes of Vaginal Discharge

• Atrophic Vaginitis: Common in postmenopausal individuals due to low estrogen. Leads to thin, watery, sometimes yellow discharge, accompanied by vaginal dryness, itching, and dyspareunia.

• Allergic/Contact Dermatitis: An inflammatory reaction to irritants like soaps, douches, perfumes, laundry detergents, or spermicides. Can cause itching, redness, and a watery discharge.

• Retained Foreign Body: A forgotten tampon or condom can cause a foul-smelling, purulent, and often profuse discharge.

• Cervical Ectropion and Polyps: Benign conditions of the cervix that can lead to increased physiological discharge or intermenstrual spotting.

3. Vulvovaginal Candidiasis (Yeast Infection)

• Organism: Primarily Candida albicans, a yeast.

• Risk Factors: Antibiotic use, pregnancy, diabetes mellitus, and any form of immunosuppression.

• Signs and Symptoms:

  • Discharge: Thick, white, “cottage-cheese” consistency.

  • Odor: Typically odorless.

  • Key Symptom: Intense pruritus (itching) and vulvar erythema (redness).

• Diagnostics:

  • Vaginal pH is usually normal (≤ 4.5).

  • Microscopy with 10% KOH prep may reveal hyphae and budding yeast.

• Treatment:

  • Topical: Azole antifungals (e.g., clotrimazole, miconazole).

  • Oral: Fluconazole (single oral dose).

• Clinical Note: Metronidazole is ineffective against yeast infections.

4. Bacterial Vaginosis (BV)

• Organism: A complex vaginal dysbiosis caused by a polymicrobial overgrowth of diverse anaerobic bacteria, including Gardnerella species, Atopobium vaginae, and others, leading to the formation of a biofilm.

• Clinical Context: While not a classic STI, BV is strongly associated with sexual activity and can be transmitted between partners.

• Signs and Symptoms:

  • Discharge: Thin, homogeneous, grayish-white.

  • Odor: Distinct “fishy” odor.

  • Itching: Mild or absent.

• Diagnostics (Amsel’s Criteria): At least three of the following four criteria must be met for diagnosis.

  1. Discharge: Homogeneous, thin, grayish-white discharge coating the vaginal walls.

  2. Vaginal pH: Elevated pH > 4.5.

  3. Whiff Test: A positive “whiff test,” where a fishy odor is released upon adding a drop of 10% potassium hydroxide (KOH) to a sample of the discharge.

  4. Microscopy: Presence of “clue cells” (vaginal epithelial cells studded with bacteria, obscuring the cell borders) on a wet mount.

• Note on Diagnostics: Nucleic Acid Amplification Tests (NAATs) are increasingly used and are more sensitive than Amsel’s criteria.

• Treatment:

  • First-line: Metronidazole (oral or intravaginal gel) or Clindamycin (intravaginal cream).

5. Sexually Transmitted Infections (STIs)

A Note on Partner Management: For all bacterial STIs (Chlamydia, Gonorrhea, Trichomoniasis, M. genitalium), treatment of sexual partners is essential to prevent reinfection and curb transmission. Where legally permitted, Expedited Partner Therapy (EPT) is an effective strategy.

5.1 Trichomonas vaginalis (Trichomoniasis)

• Organism: Trichomonas vaginalis, a flagellated protozoan parasite.

• Signs and Symptoms:

  • Discharge: Frothy, thin, yellow-green, and malodorous.

  • Other Symptoms: Vulvovaginal itching, soreness, and dysuria.

  • Classic Sign: “Strawberry cervix” (colpitis macularis) – small punctate hemorrhages on the cervix, visible on colposcopy.

• Diagnostics:

  • NAATs are the most sensitive tests and are now the gold standard.

  • Microscopy (wet mount) can show motile trichomonads but has lower sensitivity.

• Treatment:

  • First-line: Metronidazole or Tinidazole (oral). Concurrent treatment of sexual partners is essential.

5.2 Chlamydia trachomatis (Chlamydia)

• Organism: Chlamydia trachomatis, an intracellular bacterium.

• Signs and Symptoms:

  • Crucial Note: Chlamydia is frequently asymptomatic, especially in its early stages. The absence of discharge does not rule out infection.

  • Discharge: When present, it is often a mucopurulent discharge from the cervix.

• Complications: Untreated, it can cause Pelvic Inflammatory Disease (PID), infertility, and Fitz-Hugh-Curtis Syndrome.

• Diagnostics: NAATs are the gold standard (using vaginal swabs or urine).

• Treatment:

  • First-line: Doxycycline (7-day course).

  • Alternative: Azithromycin (single oral dose).

5.3 Neisseria gonorrhoeae (Gonorrhea)

• Organism: Neisseria gonorrhoeae, a gram-negative bacterium.

• Signs and Symptoms:

  • Crucial Note: Like chlamydia, gonorrhea is often asymptomatic in women. Screening is crucial in at-risk populations.

  • Discharge: When present, it is typically a purulent, opaque cervical discharge.

• Complications: Can lead to PID and its sequelae.

• Diagnostics: NAATs are the preferred method.

• Treatment:

  • First-line: A single intramuscular dose of Ceftriaxone. Always treat for chlamydia concurrently unless ruled out.

5.4 Mycoplasma genitalium

• Organism: Mycoplasma genitalium, a small bacterium lacking a cell wall.

• Signs and Symptoms: Often asymptomatic, but can cause watery to mucoid discharge, cervicitis, and dysuria.

• Complications: An increasingly recognized cause of PID.

• Diagnostics: NAATs are the only reliable method for detection.

• Treatment: Challenging due to widespread antibiotic resistance. Treatment should be guided by resistance testing when available.

5.5 Herpes Simplex Virus (HSV)

• Organism: HSV-1 or HSV-2.

• Signs and Symptoms: While known for painful genital ulcers/blisters, initial or atypical outbreaks can present with watery or mucoid vaginal discharge, itching, and pain.

• Diagnostics: Viral culture or PCR of lesion swabs.

6. Pelvic Inflammatory Disease (PID)

PID is a serious complication of ascending infections (commonly gonorrhea, chlamydia, and M. genitalium).

• Clinical Presentation:

  • Core Symptoms: Lower abdominal pain, cervical motion tenderness, and adnexal tenderness.

  • Supporting Signs: Fever, abnormal vaginal or cervical discharge (often purulent).

• Immediate Management for Severe PID:

  1. Hospitalization: Admit for IV fluids and parenteral antibiotics.

  2. Empiric Antibiotics: Start broad-spectrum IV antibiotics promptly. Regimens often include a cephalosporin, doxycycline, and metronidazole. However, antibiotic protocols are regularly updated. Always consult current CDC or local infectious disease guidelines for the most up-to-date recommendations based on regional resistance patterns.

  3. IUD Removal: If an IUD is present, it should be removed after antibiotics have been initiated.

• Treatment Course: Continue IV therapy until clinical improvement, then transition to oral antibiotics to complete a full 14-day course.

7. Management of Recurrent Infections

• Recurrent BV (RBV): A common challenge often linked to a resistant bacterial biofilm. Management may include extended courses of oral antibiotics, followed by maintenance therapy with intravaginal boric acid suppositories or metronidazole gel to prevent recurrence.

• Recurrent Vulvovaginal Candidiasis (RVVC): Defined as four or more episodes per year. Requires a longer initial “induction” course of oral or topical antifungals, followed by a prolonged weekly maintenance regimen (e.g., oral fluconazole) for at least six months.