Operational Obstetrics & Gynecology - 2nd Edition: The Health Care of Women in Military Settings
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In operational settings, most women complaining of vaginal discharge will have no other associated symptoms (pain, bleeding, fever, vulvar lesions, etc.) You can solve 95% of these vaginal discharge complaints by asking two questions:
- Does it itch?
- Does it have a bad odor?
If it itches, give the patient Monistat (or other antifungal medication). If there is a bad odor, give Flagyl. If it itches and has a bad odor, give both Monistat and Flagyl. You will solve most of the vaginal discharge problems and will miss nothing important for very long.
Those women whose symptoms persist despite this expedient treatment will need a more thorough evaluation. For those, the diagnosis of vaginal discharge is based on a History, Physical Exam, and a few simple diagnostic tests.
Ask the patient about itching, odor, color of discharge, painful intercourse, or spotting after intercourse.
- Yeast causes intense itching with a cheesy, dry discharge.
- Gardnerella causes a foul-smelling, thin white discharge.
- Trichomonas gives irritation and frothy white discharge.
- Foreign body (lost tampon) causes a foul-smelling black discharge.
- Cervicitis causes a nondescript discharge with deep dyspareunia
- Chlamydia may cause a purulent vaginal discharge, post-coital spotting, and deep dyspareunia.
- Gonorrhea may cause a purulent vaginal discharge and deep dyspareunia.
- Cervical ectropion causes a mucous, asymptomatic discharge.
Inspect carefully for the presence of lesions, foreign bodies and odor. Palpate to determine cervical tenderness.
- Yeast has a thick white cottage-cheese discharge and red vulva.
- Gardnerella has a foul-smelling, thin discharge.
- Trichomonas has a profuse, bubbly, frothy white discharge.
- Foreign body is obvious and has a terrible odor.
- Cervicitis has a mucopurulent cervical discharge and the cervix is tender to touch.
- Chlamydia causes a friable cervix but often has no other findings.
- Gonorrhea causes a mucopurulent cervical discharge and the cervix may be tender to touch.
- Cervical ectropion looks like a non-tender, fiery-red, friable button of tissue surrounding the cervical os.
- Infected/Rejected IUD demonstrates a mucopurulent cervical discharge in the presence of an IUD. The uterus is mildly tender.
- Chancroid appears as an ulcer with irregular margins, dirty-gray necrotic base and tenderness.
Obtain cultures for chlamydia, gonorrhea, and Strep. You may test the vaginal discharge in any of 4 different ways:
- Test the pH. If >5.0, this suggests Gardnerella.
- Mix one drop of KOH with some of the discharge on a microscope slide. The release of a bad-smelling odor confirms Gardnerella.
- Examine the KOH preparation under the microscope ("Wet Mount"). Multiple strands of thread-like hyphae confirm the presence of yeast.
- Mix one drop of saline with some discharge ("Wet Mount"). Under the microscope, large (bigger than WBCs), moving micro-organisms with four flagella are trichomonads. Vaginal epithelial cells studded with coccoid bacteria are "clue cells" signifying Gardnerella.
Read more about how to perform a wet mount.
In addition to specific treatment of any organism identified by culture or other test...
- Any patient complaining of an itchy vaginal discharge should probably be treated with an antifungal agent (Monistat, Lotrimin, etc.) because of the high likelihood that yeast is present, and
- Any patient complaining of a bad-smelling vaginal discharge should probably be treated with Flagyl (or other reasonable substitute) because of the high likelihood that Gardnerella is present.
Ectropion, Erosion or Eversion
Ectropion, erosion or eversion (all synonyms) occurs when the normal squamo-columnar junction is extended outward from the its; normal position at the opening of the cervix.
Grossly, the cervix has a red, friable ring of tissue around the os. Careful inspection with magnification (6-10x) will reveal that this red tissue is the normal tissue of the cervical canal, which has grown out onto the surface of the cervix.
Cervical ectropion is very common, particularly in younger women and those taking BCPs. It usually causes no symptoms and need not be treated. If it is symptomatic, producing a more or less constant, annoying, mucous discharge, cervical cauterization will usually eliminate the problem.
When faced with a fiery red button of tissue surrounding the cervical os, chlamydia culture (in high-risk populations) and Pap smear should be performed. If these are negative and the patient has no symptoms, this cervical ectropion should be ignored.
Inflammation or irritation of the cervix is rarely the cause of significant morbidity. It is mainly a nuisance to the patient and a possible symptom of underlying disease (gonorrhea, chlamydia).Some patients with cervicitis note a purulent vaginal discharge, deep dyspareunia, and spotting after intercourse, while others may be symptom-free. The cervix is red, slightly tender, bleeds easily, and a mucopurulent cervical discharge from the os is usually seen.
A Pap smear rules out malignancy. Chlamydia culture and gonorrhea culture (for gram negative diplococci) are routinely performed.
No treatment is necessary if the patient is asymptomatic, the Pap smear is normal, and cultures are negative. Antibiotics specific to the organism are temporarily effective and may be curative. Cervical cautery may be needed to achieve permanent cure.
This sexually-transmitted disease is caused by "chlamydia trachomatis". It very commonly locates in the cervical canal although it can spread to the fallopian tubes where it can cause PID.
The diagnosis is often made on the basis of clinical suspicion but can be confirmed with chlamydia culture. Such cultures are frequently performed routinely in high-risk populations.
Treatment is:
- Azithromycin 1 g orally in a single dose, OR
- Doxycycline 100 mg orally twice a day for 7 days, OR
- Erythromycin base 500 mg orally four times a day for 7 days, OR
- Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days, OR
- Ofloxacin 300 mg twice a day for 7 days, OR
- Erythromycin base 250 mg orally four times a day for 14 days, OR
- Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days.
Lost and forgotten tampons are the most common foreign body found in the vagina, although other objects are occasionally found. Women with this problem complain of a bad-smelling vaginal discharge which is brown or black in color. The foreign body can be felt on digital exam or visualized with a speculum.As soon as you suspect or identify a lost tampon or other object in the vagina, immediately prepare a plastic bag to receive the object. As soon as it is retrieved, place it in the bag and seal the bag since the anaerobic odor from the object will be extremely penetrating and long-lasting.
Have the patient return in a few days for follow-up examination. Normally, no other treatment is necessary, but patients who also complain of fever or demonstrate systemic signs/symptoms of illness should be evaluated for possible toxic shock syndrome, an extremely rare, but serious, complication of a retained tampon.
Gardnerella (Hemophilus, Bacterial Vaginosis)
The patient with this problem complains of a bad-smelling discharge which gets worse after sex. Cultures will show the presence of "Gardnerella Vaginalis," the bacteria associated with this condition. While this problem is commonly called "Gardnerella," it is probably the associated anaerobic bacteria which actually cause the bad odor and discharge.The diagnosis is confirmed by the release of a bad odor when the discharge is mixed with KOH ("whiff test"), a vaginal pH greater than 5.0, or the presence of "clue cells" (vaginal epithelial cells studded with bacteria) in the vaginal secretions.
Treatment is:
- Metronidazole 500 mg orally twice a day for 7 days, OR
- Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days, OR
- Metronidazole gel 0.75%, one full applicator (5 g) intravaginally twice a day for 5 days. OR
- Metronidazole 2 g orally in a single dose, OR
- Clindamycin 300 mg orally twice a day for 7 days.
This sexually-transmitted disease is caused by a gram negative diplococcus. The organism grows easily in the cervical canal, where it can spread to the fallopian tubes, causing PID. It may also infect the urethra, rectum or pharynx.Many (perhaps most) women harboring the gonococcus will have no symptoms, but others complain of purulent vaginal discharge, pelvic pain, and deep dyspareunia. There may be no significant pelvic findings, but mucopurulent cervical discharge, pain on motion of the cervix, and tenderness in the adnexa are all classical.
The diagnosis is often made on the basis of clinical suspicion but can be confirmed with chocolate agar culture or gram stain.
Treatment is:
- Cefixime 400 mg orally in a single dose, OR
- Ceftriaxone 125 mg IM in a single dose, OR
- Ciprofloxacin 500 mg orally in a single dose, OR
- Ofloxacin 400 mg orally in a single dose,
PLUS
- Azithromycin 1 g orally in a single dose, OR
- Doxycycline 100 mg orally twice a day for 7 days.
Sexual partners also need to be treated.
Sooner or later, as many as 5% of all intrauterine devices will become infected. Patients with this problem usually notice mild lower abdominal pain, sometimes have a vaginal discharge and fever, and may notice deep dyspareunia. The uterus is tender to touch and one or both adnexa may also be tender.Treatment consists of removal of the IUD and broad-spectrum antibiotics. If the symptoms are mild and the fever low-grade, oral antibiotics (amoxicillin, cephalosporins, tetracycline, etc.) are very suitable. If the patient's fever is high, the symptoms significant or she appears quite ill, IV antibiotics are a better choice (cefoxitin, or metronidazole plus gentamicin, or clindamycin plus gentamicin).
If an IUD is present and the patient is complaining of any type of pelvic symptom, it is wisest to remove the IUD, give antibiotics, and then worry about other possible causes for the patient's symptoms.
IUDs can also be rejected without infection. Such patients complain of pelvic pain and possibly bleeding. On pelvic exam, the IUD is seen protruding from the cervix. It should be grasped with an instrument and gently removed. It cannot be saved and should not be pushed back inside.
Read more about IUDs Gradual onset of mild bilateral pelvic pain with purulent vaginal discharge is the typical complaint. Fever <100.4 and deep dyspareunia are common.Moderate pain on motion of the cervix and uterus with purulent or mucopurulent cervical discharge is found on examination. Gram-negative diplococci or positive chlamydia culture may or may not be present. WBC may be minimally elevated or normal.
Treatment consists of Doxycycline 100 mg PO BID x 10-14 days, plus one of these:
- Cefoxitin 2.0 gm IM with probenecid 1.0 gm PO, OR
- Ceftriaxone 250 mg IM, OR
- Ceftizoxime 1 gm IM, OR
- Cefotaxime 0.5 gm IM
Alternative treatment includes:
- Ofloxacin 400 mg orally twice a day for 14 days, PLUS
- Metronidazole 500 mg orally twice a day for 14 days
With moderate to severe PID, there is a gradual onset of moderate to severe bilateral pelvic pain with purulent vaginal discharge, fever >100.4 (38.0), lassitude, and headache. Symptoms more often occur shortly after the onset or completion of menses.Excruciating pain on movement of the cervix and uterus is characteristic of this condition. Hypoactive bowel sounds, purulent cervical discharge, and abdominal dissension are often present. Pelvic and abdominal tenderness is always bilateral except in the presence of an IUD.
Gram-negative diplococci in cervical discharge or positive chlamydia culture may or may not be present. WBC and ESR are elevated.
Treatment consists of bedrest, IV fluids, IV antibiotics, and NG suction if ileus is present. Since surgery may be required, transfer to a definitive surgical facility should be considered.
ANTIBIOTIC REGIMEN: (Center for Disease Control, 1998)
Doxycycline 100 mg PO or IV every 12 hours, PLUS either:
- Cefoxitin, 2.0 gm IV every 6 hours, OR
- Cefotetan, 2.0 gm IV every 12 hours
This is continued for at least 48 hours after clinical improvement. The Doxycycline is continued orally for 10-14 days.
ALTERNATIVE ANTIBIOTIC REGIMEN: (Center for Disease Control, 1998)
- Clindamycin 900 mg IV every 8 hours, PLUS
- Gentamicin, 2.0 mg/kg IV or IM, followed by 1.5 mg/kg IV or IM, every 8 hours
This is continued for at least 48 hours after clinical improvement. After IV therapy is completed, Doxycycline 100 mg PO BID is given orally for 10-14 days.Clindamycin 450 mg PO daily may also be used for this purpose.
ANOTHER ALTERNATIVE ANTIBIOTIC REGIMEN: (Center for Disease Control, 1998)
- Ofloxacin 400 mg IV every 12 hours, PLUS
- Metronidazole 500 mg IV every 8 hours,
ANOTHER ALTERNATIVE ANTIBIOTIC REGIMEN: (Center for Disease Control, 1998)
- Ampicillin/Sulbactam 3 g IV every 6 hours, PLUS
- Doxycycline 100 mg IV or orally every 12 hours.
ANOTHER ALTERNATIVE ANTIBIOTIC REGIMEN: (Center for Disease Control, 1998)
- Ciprofloxacin 200 mg IV every 12 hours, PLUS
- Doxycycline 100 mg IV or orally every 12 hours, PLUS
- Metronidazole 500 mg IV every 8 hours.
When the discharge is suspended in normal saline and examined under the microscope, the typical movement of these large organisms (larger than white blood cells) is obvious. Itching may be present, but this is inconsistent. Trichomonas is transmitted sexually and you may wish to treat the sexual partner, particularly if this is a recurrent trichomonad infection.
Alternative treatments consist of:
- Flagyl, 250 mg TID for 7 days, OR
- Flagyl, 2 gm PO stat, OR
- Flagyl, 500 mg BID for 5 days
These infections are particularly troublesome in operational settings where they are both frequent and annoying. Yeast thrives in damp, hot environments and women in such circumstances are predisposed toward these infections.Women who take broad-spectrum antibiotics are also predisposed towards these infections because of loss of the normal vaginal bacterial flora.
Yeast organisms are normally present in most vaginas, but in small numbers. A yeast infection, then, is not merely the presence of yeast, but the concentration of yeast in such large numbers as to cause the typical symptoms of itching, burning and discharge. Likewise, a "cure" doesn't mean eradication of all yeast organisms from the vagina. Even if eradicated, they would soon be back because that is where they normally live. A cure means that the concentration of yeast has been restored to normal and symptoms have resolved.
The diagnosis is often made by history alone, and enhanced by the classical appearance of a dry, cheesy vaginal discharge. It can be confirmed by microscopic visualization of clusters of thread-like, branching Monilia organisms when the discharge is mixed with KOH.
Treatment consists of Monistat 7 cream or any other anti-fungal agent (Mycelex, Lotrimin, Terazol, Femstat, nystatin, gentian violet, etc.) Oral Diflucan 150 mg orally once is also highly effective and well-tolerated. Whenever the skin of the vulva is involved, more frequent treatment for a longer period of time may be necessary.
Reoccurrences are common and can be treated the same as for initial infections. For chronic recurrences, many patients find the use of a single applicator of Monistat 7 at the onset of itching will abort the attack completely. Sexual partners need not be treated unless they are symptomatic.
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