Genital Discharge


Bacterial vaginosis

Bacterial vaginosis (BV) is a disorder characterized by an offensive vaginal discharge. The etiology and pathogenesis are unclear but a mixed flora of Gardnerella vaginalis, anaerobes including Bacteroides, Mobiluncus spp. and Mycoplasma hominis, replaces the normal lactobacilli of the vagina. Amines and their breakdown products from the abnormal vaginal flora are thought to be responsible for the characteristic odor associated with the condition. It is not regarded as a sexually transmitted disease.

Clinical features

Vaginal discharge and odor are the most common complaints although a proportion of women are asymptomatic. A homogeneous, grayish white, adherent discharge is present in the vagina, the pH of which is raised (greater than 5). Associated complications may include chorioamnionitis and an increased incidence of premature labour in pregnant women.

Diagnosis

Three of the following should be present for the diagnosis to be made:

  • Characteristic vaginal discharge
  • The amine test: raised vaginal pH using narrow-range indicator paper (> 4.7)
  • A fishy odor on mixing a drop of discharge with 10% potassium hydroxide
  • The presence of clue cells on microscopic examination of the vaginal fluid.

Treatment

  • The presence of clue cells on microscopic examination of the vaginal fluid.
  • Topical 2% clindamycin cream 5 g intravaginally once daily for 7 days

Candidiasis

Vulvovaginal infection with Candida albicans is extremely common. The organism is also responsible for balanitis in men. Candida can be isolated from the vagina in a high proportion of women of childbearing age, many of whom will have no symptoms. Predisposing factors include pregnancy, diabetes, and the use of broad-spectrum antibiotics and corticosteroids. Immunosuppression can result in more florid infection.

Clinical features

In women, pruritus vulvae is the dominant symptom. Vaginal discharge is present in varying degree. Examination reveals erythema and swelling of the vulva with broken skin in severe cases. The vagina may contain adherent curdy discharge. Men may have a florid balanoposthitis. More commonly, self-limiting burning penile irritation immediately after sexual intercourse with an infected partner is described. Diabetes must be excluded in men with balanoposthitis.

Diagnosis

  • Microscopic examination of a smear
  • Culture

Treatment

  • Topical - Pessaries or creams containing imidazole antifungals such as clotrimazole used intravaginally
  • Oral - The triazole drugs such as fluconazole or itraconazole
  • Recurrent candidiasis - fluconazole for 6 months, or clotrimazole pessary for 6 months

Chlamydia trachomatis

Genital infection with Chlamydia trachomatis (CT) is common. It is regularly found in association with other pathogens: 20% of men and 40% of women with gonorrhoea have been found to have coexisting chlamydial infections. As CT is often asymptomatic much infection goes unrecognized and untreated, which sustains the infectious pool in the population. The long-term complications associated with Chlamydia infection, especially infertility, impose significant morbidity.

Clinical features

In men CT gives rise to an anterior urethritis with dysuria and discharge; infection is asymptomatic in up to 50% and detected by contact tracing. Ascending infection leads to epididymitis. Rectal infection leading to proctitis occurs in men practicing anoreceptive intercourse.

In women the most common site of infection is the endocervix where it may go unnoticed; up to 80% of infection in women is asymptomatic. Symptoms include vaginal discharge, post-coital or intermenstrual bleeding and lower abdominal pain. Ascending infection causes acute salpingitis.

Neonatal infection, acquired from the birth canal, can result in mucopurulent conjunctivitis and pneumonia.

Diagnosis

  • Direct fluorescent antibody (DFA) test
  • Enzyme immunoassays (EIA)
  • Nucleic acid amplification techniques such as PCR or ligase chain reaction (LCR)
  • Cell culture (gold standard)

In men first-voided urine samples are tested, or urethral swabs obtained. In women endocervical swabs are the best specimens, and up to 20% additional positives will be detected if urethral swabs are also taken. Urine specimens are much less reliable than endocervical swabs in women and are not recommended. Specimen quality is critical and it must contain cellular material.

Treatment

  • Oral doxycycline or azithromycin
  • Sexual contacts must be traced and treated

Gonorrhoea

Neisseria gonorrhoeae is a Gram-negative intracellular diplococcus, which infects epithelium particularly of the urogenital tract, rectum, pharynx and conjunctivae. Humans are the only host and the organism is spread by intimate physical contact. It is very intolerant to drying and although occasional reports of spread by fomites exist, this route of infection is extremely rare.

Clinical features

Up to 50% of women and 10% of men are asymptomatic. In men the most common syndrome is one of anterior urethritis causing dysuria and/or urethral discharge. Complications include ascending infection involving the epididymis or prostate leading to acute or chronic infection. In homosexual men rectal infection may produce proctitis with pain, discharge and itch.

In women the primary site of infection is usually the endocervical canal. Symptoms include an increased or altered vaginal discharge, pelvic pain due to ascending infection, dysuria, and intermenstrual bleeding. Complications include Bartholin's abscesses and in rare cases a perihepatitis (Fitzhugh-Curtis syndrome) can develop. On a global basis GC is one of the most common causes of female infertility. Rectal infection, due to local spread, occurs in women and is usually asymptomatic, as is pharyngeal infection.

Conjunctival infection is seen in neonates born to infected mothers and is one cause of ophthalmia neonatorum.

Disseminated GC leads to arthritis (usually monoarticular or pauciarticular) and characteristic papular or pustular rash with an erythematous base in association with fever and malaise. It is more common in women.

Diagnosis

  • Gram-stain
  • Culture
  • Nucleic acid amplification tests (NAATs) using urine specimens
  • Blood culture and synovial fluid investigations (in cases of disseminated GC)
  • Tests for coexisting pathogens such as Chlamydia, Trichomonas and syphilis

Treatment

  • Oral therapy with either cefixime or ceftriaxone intramuscularly
  • Longer courses of antibiotics are required for complicated infections
  • All sexual contacts should be examined and treated as necessary

Trichomoniasis

Trichomonas vaginalis (TV) is a flagellated protozoon which is predominantly sexually transmitted. It is able to attach to squamous epithelium and can infect the vagina and urethra. Trichomonas may be acquired perinatally in babies born to infected mothers.

Clinical features

Infected women may, unusually, be asymptomatic. Commonly the major complaints are of vaginal discharge which is offensive and of local irritation. Men usually present as the asymptomatic sexual partners of infected women, although they may complain of urethral discharge, irritation or urinary frequency.

Examination often reveals a frothy yellowish vaginal discharge and erythematous vaginal walls. The cervix may have multiple small haemorrhagic areas which lead to the description 'strawberry cervix'. Trichomonas infection in pregnancy has been associated with preterm delivery and low birth-weight.

Diagnosis

  • Phase-contrast, dark-ground microscopy
  • Culture
  • Polymerase chain reactions

Treatment

  • Metronidazole orally
  • Topical therapy with intravaginal tinidazole
  • Male partners should be treated, especially as they are likely to be asymptomatic and more difficult to detect

Urethritis

Urethritis is usually characterized in men by a discharge from the urethra, dysuria and varying degrees of discomfort within the penis. In 10-15% of cases there are no symptoms. A wide array of etiologies can give rise to the clinical picture which is divided into two broad bands: gonococcal or non-gonococcal urethritis (NGU).

Trichomonas vaginalis, Mycoplasma genitilium, Ureaplasma urealyticum and Bacteroides spp. are responsible for a proportion of cases. HSV can cause urethritis in about 30% of cases of primary infection, considerably fewer in recurrent episodes. Other causes include syphilitic chancres and warts within the urethra. Non-sexually transmitted NGU may be due to urinary tract infections, prostatic infection, foreign bodies and strictures.

Clinical features

The urethral discharge is often mucoid and worse in the mornings. Crusting at the meatus or stains on underwear occur. Dysuria is common but not universal. Discomfort or itch within the penis may be present.

Diagnosis

  • Gram stained
  • Cultures

Treatment

  • Oral doxycycline or azithromycin
  • Sexual partners must be traced and treated

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