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Vaginal Discharge
Vaginal Discharge
Who to swab?
Introduction Some patients can be given treatment without the need for full
Vaginal discharge is a common condition. Discharge is mainly investigations. A patient who complains with a first episode of
physiological. It is affected by hormonal variation throughout the vaginal discharge with a clear clinical evidence of either vulvo-
lifetime of females. Diagnosis of abnormal discharge is quiet vaginal candidiasis (VVC) or bacterial vaginosis (BV), and no
challenging. Conditions such as pregnancy and co-morbidities other risk factors, can be given empirical treatment without
like diabetes mellitus make the management really challenging. further investigations. However, the following risk factors
Pathologies such as vaginitis, cervicitis or cervical atopy may require further investigations:
also contribute to vaginal discharge. The most common causes of High STI risk (past history of STI, multiple sexual partners,
vaginal discharge are bacterial vaginosis, candidiasis and Tri- sharing needles and intravenous drug use)
chomonas vaginalis. Symptoms suggestive of an alternative cause (e.g. vaginal
bleeding and urinary or bowel symptoms)
Recent gynaecological procedure
BV associated with pregnancy
Indications to obtain a swab:
STI risk/requesting STI screening
Alexandra Rice MRCOG is a Specialty Trainee in Obstetrics and Symptoms suggestive of upper genital tract infection
Gynaecology, South East of Scotland, Victoria Hospital, Kirkcaldy,
Postpartum, post-miscarriage, TOP or recent instrumenta-
Fife, UK. Conflict of interest: none.
tion of the uterus
Mohamed ElWerdany MBBCh MSc is a Specialty Trainee in Obstetrics Recurrent symptoms despite treatment
and Gynaecology, South East of Scotland, Victoria Hospital, Abnormal symptoms of unknown cause
Kirkcaldy, Fife, UK. Conflict of interest: none.
Cervicitis found on examination.
Essam Hadoura FRCOG is a Consultant Obstetrician and
Gynaecologist at Victoria Hospital, Kirkcaldy, Fife, and Honorary
Taking appropriate swabs
Senior Lecturer, University of St. Andrews, St Andrews, UK. Conflict
of interest: none. There should be appropriate documentation sent with the swab
Tahir Mahmood MD FRCPI FACOG FRCPE FRCOG is a Consultant to aid proper testing in the lab. The site that was sampled should
Obstetrician and Gynaecologist at Victoria Hospital, Kirkcaldy, Fife, be well documented. Symptoms, any recent treatments (e.g.
UK. Conflict of interest: none. systemic antibiotics), pregnancy status and any recent
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 26:11 317 Ó 2016 Published by Elsevier Ltd.
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gynaecological procedures should be mentioned. Different labs amplification testing) took its place. Culture should be
will have different capabilities with regards to the specific testing undertaken in patients with negative microscopy despite
they offer, therefore you should check your local laboratory prior symptoms and those with apparent recurrent disease.
to sending samples.
G. NAAT (nucleic acid amplification tests)
A. High vaginal swab (HVS) Is effective in detecting Chlamydia and gonorrhoea. Reported
A swab taken from the lateral wall or posterior fornix of the detection rates of 100% with BV although its use in the diagnosis
vagina under direct vision. The swab should then be placed in of BV is not widespread.
Amies transport medium with charcoal. The high number of
commensal bacteria that reside in the vagina can often make H. Intrauterine contraceptive devices (IUCDs)
interpretation of results difficult and these should be interpreted The entire device should be sent to microbiology. The presence
in the context of the clinical picture. It should only be obtained if of an IUCD may be associated with PID. Infections may be pol-
there is a clinical need for testing and not as a routine with ymicrobial with the isolation of both Gram positive and Gram
speculum examination. It should be obtained when symptoms do negative aerobic and anaerobic organisms. Actinomyces species,
not lead to a diagnosis. Abnormal discharge in pregnancy, post- particularly Actinomyces israelii, may be significant isolates. We
partum, post-termination and post instrumentation should al- recommend that IUCDs are only cultured where there are clinical
ways be swabbed. Similarly, if there is recurrence of symptoms indications of PID or other inflammatory conditions.
or possible treatment failure then a swab should be obtained.
Physiological discharge
B. Endocervical swab (ECS)
Physiological vaginal discharge is a normal finding in all women
The cervical os should be cleaned with a disposable swab and
and most commonly described as an inoffensive discharge. The
discarded. The ECS should then be inserted into the cervical os
fluctuating levels of oestrogen and progesterone during the
and rotated firmly. The swab should then be placed in Amies
menstrual cycle greatly affects the consistency and composition
transport medium with charcoal. It is mainly used in the inves-
of the physiological discharge. Oestrogen makes the discharge
tigation of Chlamydia and gonorrhoea. The swab is sent for
thin and clear for easy passage of sperm through the cervix at the
NAAT (nucleic acid amplification testing). Some labs are now
time of ovulation. Progesterone makes the discharge thick and
analysing these samples for BV and TV.
sticky after ovulation.
C. pH testing The vaginal environment maintains its stability by the action
A swab from the lateral vaginal wall is placed on a narrow of commensal organisms. Lactobacilli colonize the vagina since
spectrum litmus paper. BV and TV (T. vaginalis) will have pH puberty under the influence of oestrogen. These are responsible
>4.5. There is good evidence that clinical features and mea- for converting glycogen to lactic acid, maintaining a vaginal pH
surement of vaginal pH is a sensitive (but not specific) predictor. of around 4.5. Other commensal organisms are streptococci,
If HVS and ECS are also obtained, there is an increased accuracy enterococci and coagulase negative staphylococci. A few other
of diagnosis. Therefore, a swab should be obtained if features are organisms which are part of the normal flora, but are associated
not suggestive of BV/VVC. with vaginal infections, include, anaerobic Bacteroides, anaer-
obic cocci, Gardenella vaginalis, Candida, Ureaplasma ure-
D. Microscopy alyticum and Mycoplasma species.
Wet microscopy requires a certain level of expertize and tech-
nical skills for proper implementation. A small sample of the Bacterial vaginosis
discharge should be placed on two ends of a slide. Normal saline Aetiology and transmission
is put on one end and potassium hydroxide on the other. A cover Bacterial vaginosis is the commonest cause of vaginal discharge
slip is placed on the slide and these are visualized under a mi- in women; during their childbearing period. It has been found in
croscope. This test is of varying sensitivities depending on the postmenopausal women and rarely prepubertal. It is more
offending organism: common in black African and American women (45e55%).
70% sensitivity for TV (TV swabs need to be processed Caucasian women have a prevalence of approximately 5e15%.
with wet microscopy within 6 hours). Previously, it was considered as a harmless finding, but we now
Saline microscopy will show spores/pseudohyphae in 40 know it to be associated with many pathological conditions such
e60% of Candida as puerperal endometritis, preterm labour, premature rupture of
30e50% sensitivity for Gonorrhoea membranes, PID and UTI.
The condition is associated with a prevalence of the anaerobic
E. Gram stain
species in preference to the normal Lactobacillus species. Or-
Commonly used for the diagnosis and grading of BV
ganisms associated with bacterial vaginosis include the Prevotella
65e68% detection in symptomatic Candida
species, G. vaginalis, Mobiluncus species, Peptostreptococcus
F. Culture species and Mycoplasma hominis. Some women experience the
Candida grows best on Sabouraud agar (95% growth on change in the microorganism environment really abruptly, while
culture). Its growth can be classified as light, medium or others take longer time interval to feel the change.
heavy. Culture was considered the gold standard for Bacterial vaginosis is experienced more in patients with
detecting T. Vaginalis before NAAT (nucleic acid multiple sexual partners, no use of condoms or douching. Most
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carriers are asymptomatic. Women who were never sexually Preoperative for vaginal surgery
active are rarely affected. Pregnant women, if further investigated with direct mi-
Women with bacterial vaginosis are more likely to acquire croscopy (due to persistent negative gram stain findings
other sexually transmitted infections, pregnancy complications, and still symptomatic or failure of treatment) and found
post-surgery complications and disease recurrence. However, positive.
due to insufficient data, routine screening for these groups is not Treatment individualized in patients with positive direct
recommended. microscopy without symptom.
Recommended regimens:
Diagnosis 500 mg Metronidazole: oral tablets, twice daily for 7 days,
Diagnosis of bacterial vaginosis is either clinical or by using the or
gram stain. Gram stain is considered by many laboratories as the 2 gm Metronidazole: Single oral dose, or
golden standard for diagnosis. It is used to estimate the con- 0.75% Metronidazole gel: one full applicator (5 g) intra-
centration of lactobacilli (Long gram positive rods) and the gram vaginally, once daily for 5 days, or
negative anaerobes. 2% Clindamycin cream: one full applicator (5 g) intra-
Nugent scoring system and Amsel’s clinical criteria are the vaginally at bedtime for 7 days
most common diagnostic systems used to diagnose bacterial Alcohol, sexual intercourse or vaginal douching may hinder
vaginosis. Nugents scoring system is considered the gold stan- the effectiveness of treatment. Alcohol should not be consumed
dard for diagnosis. However, it is costly, time consuming and during treatment up to 24 hours after completion of metronida-
requires laboratory expertize, to implement. Physicians prefer zole course, as it may precipitate a disulfiram-like reaction.
Amsel’s criteria as it is simpler and comparably as effective as Clindamycin cream may affect latex condoms and diaphragms
Nugent scoring system. Hay Ison criteria is recommended by the and reduce their effectiveness for up to 5 days after its use.
Bacterial Special Interest group of BASHH to be implemented in Vaginal douching increases the risk of recurrence and insufficient
GUM clinics. data supports their use for treatment or symptom relief.
A. Clinical criteria (using Amsel) require three of the following Some studies have further evaluated the effectiveness of
symptoms or signs: intravaginal lactobacillus formulations in the treatment of bac-
1. Homogeneous, grey-white discharge; terial vaginosis. No improvement in the disease has been noticed
2. Clue cells on wet microscopy; and their use requires further research.
3. pH of vaginal fluid >4.5;
4. Fishy odour with or without the addition of 10% KOH Pregnancy
(whiff test). In the UK, a BV prevalence of 12% was found in women
B. Nugent score: attending antenatal care, and 30% in women opting for termi-
This method estimates the relative proportions of bacterial nation of pregnancy.
types on a Gram stained vaginal smear. A score between Treatment of bacterial vaginosis is recommended for all
0 and 10 is then assigned. symptomatic women. Metronidazole regimen (500 mg) is similar
1. Score of <4 is normal, to non-pregnant population. Using Amstel criteria to define cure,
2. Score of 4e6 is intermediate Yudin MH et al., found that oral metronidazole was as effective
3. Score of >6 is BV. as metronidazole gel for treatment during pregnancy, with a cure
C. Hay Ison criteria: based on findings on a Gram stained smear rate of 70%. Metronidazole use during pregnancy is not associ-
and gives an idea about flora types. ated with an increase in congenital malformations. A study by
1. Grade 0: Not related to BV, epithelial cells only, no Ugwumadu A. et al. using gram stain criteria showed an 85%
lactobacilli. cure in patients receiving clindamycin. Newer studies have
2. Grade 1: (Normal): Lactobacilli predominate shown that vaginal clindamycin is safe to administer in preg-
3. Grade 2: (Intermediate): Mixed flora with some Lac- nancy. Both oral and topical regimens are both as effective and
tobacilli, and Gardnerella or Mobiluncus also present safe to be prescribed in pregnancy.
4. Grade 3 (BV): Few or absent Lactobacilli. Gardnerella Mixed results have been noticed in preterm delivery rate in
and/or Mobiluncus morphotypes, clue cells, patients treated. Harm, no harm and benefit have been found in
predominate. several studies. Another study showed a decrease in late
5. Grade 4: Not related to BV, no lactobacilli, Gram þ ve miscarriage and adverse neonatal outcome in the treated group.
cocci only. However, treatment is recommended for all symptomatic women
Some other tests such as OSOM BV Blue test, Affirm VP III test with BV as benefits outweigh the risks.
and DNA hybridization probe test are comparable to the gram Insufficient data is available for treating asymptomatic preg-
stain in results. Card tests to detect elevated pH and the cervical nant women for which bacterial vaginosis was incidentally
smear tests have low specificity and sensitivity and are not rec- discovered. Therefore, routine screening for bacterial vaginosis
ommended. PCR as a diagnostic tool in BV is still under research. in pregnancy is not recommended.
G. Vaginalis culture is not specific and not recommended. Metronidazole is secreted in breast milk. Studies have
revealed metronidazole and its metabolites in the plasma of ba-
Treatment bies, but this level was insignificant a lot lower than the levels
Treatment is recommended for the following group of patients: used by the mother to treat the infection. However, some ob-
Patients with symptoms. stetricians recommend deferring breastfeeding for at least 24e48
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hours after completion of treatment. Treatment in breastfeeding B. Complicated vaginal candidiasis is either:
should be with metronidazole twice daily for 5e7 days rather 1. Recurrent
than a one off dose. Although metronidazole treatment produces 2. Severe
parasitologic cure, certain trials have shown no significant dif- 3. Albicans/non-albicans candidiasis
ference in perinatal morbidity following metronidazole 4. During pregnancy
treatment. 5. Immunocompromised conditions
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Immune/autoimmune induced inflammation: erosive is not recommended, except in special circumstances. DIV is an
lichen planus, cutaneous vesiculobullous disorder uncommon severe form of vaginitis and should be considered
Hormonal conditions: oestrogen deficiency (atrophic among women where symptoms have persisted for a long time
vaginitis) despite multiple pharmaceutical treatments. Examination, his-
Contact dermatitis: chemical vaginitis, allergy (latex, tory and investigations are all complementary in the diagnosis
sperm) and the management process to prevent over treatment or under
Miscellaneous: trauma, foreign body, urinary incontinence diagnosis of susceptible women. A
including vesico-vaginal fistula, or cervical tumour,
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