Leukorrhea

(Vaginal Discharge)

leukorrhea (leuko white, rheo flow)
vaginal discharge


2
1. (Physiologic vaginal discharge)
2. (Pathologic vaginal discharge) , ,
fistula

1. sebaceous Bartholin
skene glands
2.
3. (exfoliated)
4. (cervical mucous)
5. (Endometrial fluid)
6. (Oviductal fluid)
7. metabolite product

 aerobes anaerobes 10 -10 Colony 1

Lactobacillus acidophilus aerobic hydrogen peroxide 62-82 %

monosaccharides (lactic
acid) lactobacilli pH 4.5 (3.84.2)
8

(floccular) dependent portion

posterior fornix

,
1.

, , , ,

o
o , , , dyspareunia
o Toilet habit, ,
2.
3.
o

1. Wet-mount preparation
(normal saline) 0.4
cover slip secretion
secretion
(well suspened preparation)
Vaginal secretion superficial cell (WBC : epithelial cell <
1:1) clue cell wet smear : trichomonas vaginalis, clue cell, filamentous
form

 : Clue cell superficial vaginal epithelial cell ( G.vaginalis)

granular stippled appearance

2. Potassium hydroxide preparation (KOH smear)

10 % KOH secretion 1-2 cover slip
epithelial cell hyphae pseudohyphae


3. Whiff test (Amine test)
10 % KOH secretion 1-2 (fishy amine like odor)
bacterial vaginosis vaginal trichomoniasis
4. pH

pH paper
pH > 5.0 : bacterial vaginosis trichomoniasis atrophic vaginitis
pH < 4.5 : fungal infection

5. Gram stain

vaginal discharge
endocervical discharge intracellular gram negative diplococci
presumptive diagnosis gonococcal endocervicitis gonococci PMN (> 30
HPF) presumptive diagnosis chlamydial endocervicitis

6. Pap smear
vaginal discharge

7. Culture

Pathologic Vaginal Discharge

3
1. Bacterial vaginosis (BV) 50 %
2. Trichomonas vaginitis 25 %
3. Candidiasis 25 %

1. Bacterial Vaginosis (BV)

: anaerobe
lactobacillus hydrogen peroxide
alkalinization
Gardnerella vaginalis facultatively anaerobic
gram variable ( culture) cocco-bacilus
30-40 % BV
40 % G.vaginalis (transient)
BV anaerobe
( Prevotella sp., Mobiluncus sp.) Mycoplasma hominis Gardnerella vaginalis
(symbiosis synergism) anaerobe Gardnerella
10 100 lactobacilli
vaginosis vaginitis

(musty) (fishy)
semen aromatic amines vulva irritation

(frothy) 10 %
(Holmes and Eschenbach)

 3 4
1.
2.
3.
4.

thin, homogenous discharge

pH > 4.5 ( 4.7-5.7)
Whiff test : KOH fishy, amine like odor (putrescine, cadaverine)
wet smear clue cell > 20 % epithelium

Wet smear BV lactobaulli leukocyte leukocyte
cervical infection trichomoniasis
curved rods cork screw motility clue cell
Mobiluncus species BV

1. : Metronidazole drug of choice anaeroke

lactobacilli 2

500 . 2 7 95 %
2 84 %

24
metronidazole ethanol metabolism disulfiram like reaction
, metallic taste, ,
metronidazole

Clindamycin 300 mg 2 7 94 %
Amoxicillin 500 mg + clavulanic acid (AugmentinR) 3 7
lactobacilli
ciprofloxaim, cephalexin, tetracycline, ampicillin, erythromycin

2. Topical therapy BV superficial mucosal infection

1. metronidazole 500 mg 7

2. metronidazole gel, 0.75 % 5 2 5

3. clindamycin cream, 2 % 5 7
ampicillin, tetracycline sulfa cream

BV ( ) 5-10

Gardnerella 90 %

1.
2.
3.
4.
5.

PID
postabortal PID
postoperative cuff infection
abnormal cytology
PROM, preterm labor, chorioamnionitis, postcesarean endometritis

2. Trichomoniasis

Trichomonas vaginalis(TV) anaerobe flagellated protozoon fusiform

10-20 flagella 4

Skene's duct paraurethral gland
70 % male partner
48 85
% 4-28
2 33 % BV 60 % Trichomonas
vaginitis


immune factor inoculum
24
6 50 %
(profuse discharge)
(frothy)
10-25 % TV BV
patchy erythema capillary dilation puntate
hemorrhage strawberry appearance ( < 10 %)
25 % 20 %
vestibule labia minora candida vulvovaginitis

1.
2. pH > 5.0 (5.0-7.0)
3. Wet smear : high power condenser contrast
smear TV smear TV
smear TV inflammatory cell epithelium ( TV
cytotoxic intracellular bridges epithelium smear)
wet smear 80-90 %
4. Whiff test (~ 50 % )
5. Culture : Diamond, Fernberg Kupferbery media

6. Pap smear false positive false negative wet

smear
7. fluorescent monoclonal antibody, PCR

1. 1
3 3 TV

 metronidazole drug of choice 2

95 %
o 2 g 1 g
82-88 % ( > 95 %)
o 500 mg 2 ( 250 mg 3 ) 7
metronidazole gel trichomonas vaginitis
2 2 gm 3-5
topical therapy intravenous metronidazole
metronidazole topical clotrimazole imidazole derivative
6 48-66 %
1. sexual partner reinfection 1.5
urethritis
2. STD Neisseria gonorrhoeae chlamydia trachomatis, VDRL,
Anti HIV

Vulvovaginal Candidiasis (VVC)

candida airborne gram positive fungus 3 C.albicans 8095 % C.grabata C.tropicalis 5-20 %
C.albicans dimorphic fungi 2 blastospores (
colonization ) filamentous form ( colonization
facilitate ) 75% VVC 1
40-45% VVC candidia 25%
mucosal surface commensal saprophyte rectum
3-4 2
(oppotunistic pathogen) lactobacilli
lactobacilli overgrowth broad spectum antibiotics 10-14
colonization 3 moniliasis
plant pathogen VVC ,
, ( high dose estrogen)

 VVC
2
1. (uncomplicated VVC)

(sporadic) (infrequent)

C. albicans

2. (complicated VVC) 10-20%

(recurrence) 4

non-albicans

VVC pruritus vulvar burning,external dysuria, dyspareunia

(Watery)
(flocculation) 1
vulva (excoriation)
pustulopapular lesion
(curd) (clump) (plaque) male partner
balanoprosthitis , penis

1.
2. pH (< 4.5)

3. furgal element budding yeast filamentous form ( active disease) wet smear
10 % KOH preparation ( C. grabata filamentoes form) 65-80 %
4. Whiff test
5. Culture Nickerson Sabouraud medium presumptive diagnosis (
pH secretion )
recurrent
6. Pap smear 25 %

()
1. : azole nystatin
2-3
. Clotrimazole 85-90 %
- 100 mg 7 2 3
- 500 mg
. Nystatin 100,000 U 14 75-80 %
2.
1. Ketoconazole 200 gm 2 5
2. Itraconazole 200 mg 3 400 mg
3. Fluconazole 150 mg
3. :

Clotrimazole 1 % cream 5 gm 7-14

Miconazole 2 % cream 5 gm 7

4.

1 % gentian violet 4 7
3-4 imidazole
C.grabata C.tropicalis
5. VCC glucose toterance test
, immunocompromised
7-14 Fluconazole 150 mg 72
(maintenance) 6

Clotrimazole 500 mg
Ketoconazole 100 mg
Fluconazole 100-150 mg
Itraconazole 400 mg 100 mg

ketoconazole 1 10,000-15,000
30-40%
6.

7. VCC non-albicans fluconazole azole
7-14 boric acid 600 mg in gelatin capsule 2
70% nystatin 100,000

8. azole 7
6. balanitis penile dermatitis

1. Mishell DR Jr, Stenchever MA, Droegemueller W, Herbst AL, editors. Comprehensive gynecology. 3 ed. St.
Louis: Mosby Year Book, 1997:625-35.
2. Soper DE. Genitourinary infections and sexually transmitted diseases. In: Berek JS, Adashi EY, Hillard PA,
editors. Novak's gynecology. 12 ed. Baltimore: Williams & Wilkins, 1996:429-45.
3. Heine P, McGregor JA. Trichomonas vaginalis: a re-emerging pathogen. Clin Obstet Gynecol 1993; 36:137-44.
rd

th

4. Sobel JD. Candida vulvovaginitis. Clin Obstet Gynecol 1993; 36:153-65.

5. Center for Disease Control. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002;(RR-6):4851.