Sexually Transmitted Infections (STIs)
Subtopic:
Abnormal Vaginal Discharge Syndrome
This syndrome is recognized when a woman experiences a change in her usual vaginal discharge, specifically in its color, odor, or consistency (e.g., if it becomes discolored, pus-like, or has an unpleasant smell).
While vaginal discharge is a normal bodily function for all women, it becomes a medical concern when it deviates from the typical presentation. This condition is primarily linked to infections originating within the vagina itself, such as bacterial vaginosis and vaginal candidiasis. Importantly, these are generally not considered exclusively sexually transmitted infections, although sexual activity can be a contributing factor.
It is crucial to understand that while Candida vaginitis and bacterial vaginosis are linked to sexual activity as a risk factor, they are not classified as sexually transmitted diseases (STDs) in the traditional sense.
Case Definition:
Defined by vaginal discharge that is considered abnormal in quantity, color, and/or smell, and may or may not be accompanied by lower abdominal discomfort or specific risk factors.
Etiology:
The causes are broadly categorized into:
Vaginitis and Vaginosis: Frequently caused by bacterial vaginosis (associated with bacteria like Gardnerella vaginalis, Mycoplasma hominis), vulvovaginal candidiasis (yeast infection), and trichomoniasis (parasitic infection).
Cervicitis: Infections of the cervix, like gonococcal and chlamydial infections, can lead to cervicitis. Cervicitis is often without symptoms and is less commonly a direct cause of noticeable vaginal discharge.
Clinical Presentation:
The management approach for all women presenting with vaginal discharge involves considering treatment for trichomoniasis, bacterial vaginosis, and candidiasis.
General Symptoms: Patients may report an increase in the amount of discharge, changes in color, and the presence of an unusual odor. Other possible complaints include lower abdominal pain, itching in the vaginal area, and discomfort experienced during sexual intercourse.
Specific Infection Presentations:
Candida Albicans Vaginitis (Yeast Infection): Typically presents with intense vaginal itching and a thick, white discharge that may be described as lumpy or cottage cheese-like. The vulva often appears red and inflamed.
Trichomonas Vaginalis (Trichomoniasis): Characterized by an itchy, frothy discharge that is often greenish-yellow in color and has a noticeable, unpleasant odor.
Bacterial Vaginosis (BV): Commonly manifests as a thin discharge accompanied by a distinctive fishy smell.
Cervicitis-Related Discharge:
Gonorrhea-Related Cervicitis: Rarely the primary cause of vaginitis symptoms. Discharge, if present, is usually pus-like, thin, mucoid, and slightly yellowish, lacking a strong odor and typically non-itchy.
Chlamydia-Related Cervicitis: May result in a thin, colorless discharge that is not typically itchy.
Important Note: Microscopic examination of the discharge and speculum examination of the cervix are advisable to rule out other cervical issues, including early signs of cervical cancer.
Management:
The recommended management strategy for women with vaginal discharge is guided by a clinical flowchart. This flowchart helps differentiate between cases of candidiasis and other types of vaginal discharge to direct appropriate treatment.
Treatment Approach:
Because identifying cervicitis is currently challenging, and to ensure comprehensive care, the protocol is as follows:
Broad Treatment: All women with abnormal vaginal discharge are treated for bacterial vaginosis, trichomoniasis, and candidiasis. Furthermore, given the difficulty in identifying cervicitis in all settings, any woman with a discharge that is not curd-like should also receive treatment that covers cervicitis.
Management Protocol for Abnormal Vaginal Discharge Syndrome:
Initial Evaluation:
Take a detailed medical history and check for genital sores and abdominal tenderness.
Perform a speculum exam to look for cervical abnormalities.
Assess the risk for sexually transmitted infections.
Lower Abdominal Pain and Sexual Activity:
If lower abdominal tenderness is present and the person is sexually active, manage according to guidelines for Pelvic Inflammatory Disease (PID).
Thick, Lumpy Discharge with Itching and Redness/Scratching (Likely Yeast Infection):
Administer Clotrimazole vaginal suppositories 100 mg: Insert deeply into the vagina once daily at bedtime for 6 days, or twice daily for 3 days.
Alternatively, prescribe Fluconazole 200 mg tablets as a single oral dose.
Consider a single 2-gram dose of Metronidazole if needed.
Large Amount/Smelly Discharge (Possible Trichomonas or Vaginosis):
Prescribe a single 2-gram dose of Metronidazole.
Pus-like Discharge, High STD Risk, or Previous Treatment Failure:
Treat for Gonorrhea, Chlamydia, and Trichomonas:
Single dose of Cefixime 400 mg orally or Ceftriaxone 1g injection (IV or IM).
Doxycycline 100 mg orally twice a day for 7 days.
Single 2-gram dose of Metronidazole.
If pregnant, replace Doxycycline with Erythromycin 500 mg every 6 hours for 7 days or a single 1-gram dose of Azithromycin.
Ensure treatment for sexual partner(s).
Ongoing Discharge or Painful Urination Despite Partner Treatment:
Refer the individual for further evaluation.
Key Management Points:
Treatment for Vaginal Infections: All women are treated for bacterial vaginosis, trichomoniasis, and candidiasis. Due to the difficulty in confirming cervicitis, all women with non-curd-like discharge are also treated for cervicitis.
Promote Comprehensive STD Management: Encourage adherence to full STI management, including partner treatment, prevention strategies, and health education.
Communication is Key: Explain to patients that vaginitis can be caused by factors within the body and can recur, to help prevent relationship problems. Partners of women with abnormal vaginal discharge who have urethral discharge should be treated for cervicitis.
Evaluation and Referral: Persistent abnormal vaginal discharge needs evaluation to rule out cervical cancer. Speculum examination and referral to a specialist may be necessary.
Counseling and Education: Provide thorough advice to all patients on:
Following treatment instructions completely.
Using condoms and provide condoms.
The importance of partner treatment.
Offer or refer for HIV testing and counseling if needed.
Schedule a follow-up visit.
Avoiding sexual activity until symptoms are fully gone.
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