CHAPTER 10
Diseases of the Vagina
LEUCORRHEA
Definition - excessive secretion of normal vaginal discharge
The term leucorrhea should fulfil the following criteria:
1. Excess secretion is evident from persistent vulval moistness or staining of the undergarments (brownish
yellow on drying) or need to wear a vulval pad
2. Non-purulent and non-offensive
3. Non-irritant (never causes pruritus)
Causes
1. Physiological
a. At birth – due to effect of placental estrogen on genital organs
b. At puberty – due to increased vascularity of pelvic organs
c. During ovulation – due to increased estrogen
d. Premenstrual – due to pelvic congestion and increased mucous secretion by hypertrophied
endometrial glands
e. During pregnancy – due to increased hormone levels
f. During sexual excitement – due to increased secretions from the bartholin’s glands.
2. Pathological
i. Cervical Leucorrhea - Non-infective cervical lesion may produce excessive secretion which pours out at
the vulva.
a. Cervical erosion
b. Chronic cervicitis
c. Mucus polyp
d. Ectropion
ii. Vaginal Leucorrhea - Increased vaginal transudation occurs in conditions associated with increased
pelvic congestion.
a. Uterine prolapse
b. Acquired retroverted uterus
c. Chronic pelvic inflammation
d. OCP’s
e. Vaginal adenosis
Diagnosis
1. The excessive discharge has got relevance with the above conditions
2. Discharge is non-offensive and non-irritant
3. General examination may reveal ill health
4. Vulval inspection reveals:
a. White or creamy discharge
b. No evidence of pruritus
5. Bimanual and speculum examinations reveal:
a. A negative pathology
b. Associated pelvic lesions causing cervical or vaginal leucorrhea
6. Microscopic examination of the discharge - pus cells are indicative of infection
7. If pus cells are detected, further investigations are carried out to identify the organism from the discharge.
Neoplasm and foreign body are excluded.
a. Hanging drop preparation
b. Gram stain
c. Culture
Treatment
1. Improvement of general health
2. Sympathetic attitude towards the ailments. Anxiety should be removed.
3. Cervical lesions - surgical treatment such as electrocautery, cryosurgery, trachelorrhaphy, etc.
4. Pelvic lesions - appropriate therapy specific for the pathology
5. OCP users may have to temporarily discontinue using it
6. Local hygiene has to be maintained meticulously.
TRICHOMONIASIS
Causative Organism - Trichomonas vaginalis (anaerobic, pear shaped flagellated protozoa)
Mode of Transmission
1. Sexual contact
2. Use of an infected person’s towels, bath or clothes
Clinical Features - 20% remain asymptomatic. Others develop symptoms 4-28 days following sexual contact
with an infected partner, or infected material.
1. Discharge - profuse, thin, creamy or slightly green in color, irritating and frothy
2. Vulva - evidences of pruritus and vulvitis
3. Vaginal walls - tender and angry looking. Also termed as strawberry vagina as multiple small punctate
strawberry spots are seen on the vaginal vault and portio vaginalis of the cervix
4. Urinary symptoms - dysuria, frequency, burning micturition
Investigations
1. Hanging drop preparation
2. Staining – with 1% brilliant cresyl violet
3. Culture of the discharge on Diamond’s media
Treatment
Oral
1. Metronidazole 200 mg orally T.I.D for 1 week, for both partners or 2gm single dose
2. Alternative drugs - Tinidazole, Secnidazole
Vaginal
1. Ornidazole 500 mg pessary
2. Clotrimazole 100 mg pessary for 1 week
CANDIDIASIS (MONILIASIS)
Causative Organism - Candida albicans
Predisposing Factors
1. It flourishes in an acidic medium with abundant supply of carbohydrate. Therefore, it is common in
pregnancy and diabetes.
2. Hormonal contraceptive pills
3. Prolonged use of antibiotics
Symptoms
1. Profuse, curdy discharge (odourless)
2. Intense pruritus
3. Vulval irritation
4. Dysuria
5. Burning sensation
Signs
1. Inflammation of the vulva- red and edematous
2. White patches of cheesy curdy material adherent to the vagina, which when removed leave multiple
petechiae-like hemorrhagic areas
3. Discharge is “cottage cheese like”
Investigations
1. Examination of KOH mount - candidal hyphae and buds stand out in prominence along with spores.
2. Discharge culture on Sabouraud’s medium - rounded colonies, 1-2 mm in diameter, within 48-72 hours,
with yeast-like odor
3. Discharge culture on Nickerson’ss medium - brown-black colonies in 48-72 hourss
Treatment
1. Advice regarding personal hygiene
ne
2. Avoidance of synthetic undergarments
ments
3. Finger nails should be clipped short
hort
4. Oral drugs
i. Fluconazole 150mg single dose
se
5. Vaginal
ies for 10
10-14 days
i. Nystatin - 1-2 vaginal pessaries
ii. Imidazole derivatives (Miconazole,
nazole, Clotrimazole, Terconazole) - vaginal pessaries
saries or creams
6. Treatment of the cause - control of diabetes, stoppage of OCP, etc.
NON-SPECIFIC
CIFIC VAGINITIS / BACTERIAL VAGINOSIS
In this group of disorders, a variety of mixed pathogens are recoverable on smear and
nd culture, e.g.
Staphylococcus, Streptococcus, E. coli,
col etc.
Etiology (Alteration in normal vaginal
al flora - decreased lactobacilli and increase in other bacteria)
1. Chemicals, drugs, contraceptivess
2. Douches, pessaries, tampons, foreign
reign bodies
3. Trauma
4. Operations - vaginal and cervicall
Diagnosis – based on the presence of 3 of the 4 signs
signs1. White milky adherent discharge..
2. pH > 4.5
n adding 10% KOH)
3. Whip test positive (fishy odour on
4. Clue cells on microscopy, these are vaginal epithelial cells whos
whose surface is stippled
ppled with coccobacillus
Treatment
al health
1. General - improvement of general
2. Local
a. Water dispersible buffered vaginal
ginal jelly - to correct the vaginal pH to 4.5
b. Bactericidal cream such as triple
ple sulpha
c. Antibiotic pessaries, if organism
m and sensitivity are known
d. Diathermy cauterization and conization - to eliminate infection in the genitall tract such as chronic
endocervicitis
ole, Azithromycin, and Seclonidazole
e. FAS-3 kit - contains Fluconazole,
SENILE VAGINITIS (ATROPHIC VAGINITIS)
Definition - vaginitis in postmenopausal women
Etiology -The basic underlying pathology is estrogen deficiency.
1. Menopause
2. Premature menopause
3. Prolonged lactation
4. Oophorectomy operation
Clinical Features
1. Dry vagina
2. Dyspareunia
3. Discharge - purulent, slightly blood-tinged
4. Urinary symptoms - dysuria, frequency
5. Vagina - inflamed and tender with excoriation of the mucosa
6. Low-grade chronic urethritis
7. Patchy granular vaginitis, the spots of which are red and bleed easily when swabbed.
8. Infection may spread upwards to cause senile endometritis and pyometra
Diagnosis - Senile endometritis may co-exist and carcinoma of the endometrium or cervix should be excluded
prior to therapy.
1. Examination under anesthesia
2. Diagnostic curettage
3. Cervical cytology or biopsy
Treatment
1. Estrogen - to improve the resistance of the vaginal epithelium, raise the glycogen content and lower the
vaginal pH
2. Ethinyl estradiol 0.01 mg daily for 3 weeks
3. Pessary containing estrogen
4. Vaginal cream containing estrogen
LONG
ESSAY
SHORT
ESSAY
SHORT
ANSWERS
PREVIOUS EXAMINATION QUESTIONS FROM THIS CHAPTER
1. Define leucorrhoea. Discuss the causes and management of white discharge per vagina.
2. How will you investigate & treat a case of 30 year old patient presenting with white discharge per vagina?
3. Define leucorrhoea. Mention its causes and describe its management.
1. Differential diagnosis of discharge per vagina and their management.
2. Evaluation of leucorrhoea.
3. Diagnosis and treatment of Trichomonias vaginalis infection.
4. Etiology, diagnosis and treatment of monilial vaginal infection.
5. Monilial vaginitis.
6. Senile vaginitis — diagnosis and management.
7. Vaginal trichomoniasis.
8. Diagnosis and treatment of vaginal candidiasis.
9. Differential diagnosis of discharge per vagina and their management.
10. Causes of leucorrhea in reproductive age group
1. Bacteria vaginosis diagnosis and treatment.
2. Differential diagnosis of mass per vagina.
3. Treatment of vulvovaginal moniliasis.
4. Management of candidiasis in gynecology.
5. Causes and management of vaginitis.
6. Treatment of vaginal trichomoniasis.