Leukorrhea

ชั�ยพงศ์� ตั้�งสิ�ทธิ�ธิรรม ทอแสิง ชัโยวรรณ

Leukorrhea

• Increased vaginal discharge• Physiologic/Pathologic

Normal Vaginal Discharge

• Creamy white discharge– Vulvar secretion

• Bartholin glands• Sweat glands• Sebaceous glands• Skene glands

– Vagina– Cervix– Endometrial glands– Fallopian tubes

Normal Vaginal Discharge

• Increased when– Ovulation—endocervical glands– Premenstrual phase– Pregnancy– Sexual excitement—Bartholin’s glands

• pH < 4.5

Physiological Vaginal Discharge

– Newborns– Puberty– Congestion of pelvic organs– Cervical ectopian– Contraceptives– Vaginal douche

Pathological Vaginal Discharge

– Vaginitis in infancy and childhood– Senile vaginitis (Atrophic vaginitis)– Candidiasis– Bacterial vaginosis– Trichomonas vaginitis– Mucopurulent cervicitis– Foreign bodies– Neoplasm– Urinary and fecal discharge

Vaginitis in infancy and childhood

• Low immunity• Age 1-5 years• Infection/Foreign body/Tumor• Wet smear, Gram stain, culture, speculum• Treatment– Rest– antibiotics – estrogen

Atrophic vaginitis

• Postmenopause• Decreased estrogen– Vaginal wall thining– Decreased acidic environment

• Yellow/Green/Bloody• Pruritic/Painful• Dysuria• Dyspareunia/Postcoital bleeding• Vaginal wall thining, colpitis macularis, patchy

ulceration, adhesive vaginitis

Atrophic vaginitis

• PAP smear, Gram stain, culture• +- Cervical biopsy, Fractional curettage• Treatment: – Antibiotics– estrogen (local/systemic)

Candidiasis

• Yeast cells/Pseudohyphae• Inflammation and curd-like discharge• Predisposing factors– Diabetes– Obesity– Pregnancy– Antibiotics– Contraceptives– Low immunity– Premenstrual period

Candidiasis

• KOH preparation, Gram stain (positive)• Subouraud’s/Nicerson’s media culture• Treatment:

– Uncomplicated• Clotrimazole V.P. (100) Vg suppo OD 6days• Clotrimazole V.P. (200) Vg suppo OD 3days• Itraconazole (400) PO stat• Fluconazole (150) PO stat

– Complicated• Clotrimazole V.P. (100) Vg suppo OD 14 days then Clotrimazole V.P. (500) Vg

suppo weekly for 6 months• Repeat Fluconazole 3 days after then weekly for 6 months

• Partner?

Bacterial vaginosis

• Decreased amount of Lactobacilli Increased amount of anaerobes

• Low immunity, fatigue, frequent sexual intercourse, vaginal douche

• Mostly asymptomatic• Increased (foul-smelling) discharge

Bacterial vaginosis

• Amsel criteria (3/4)– Gray-white discharge– pH > 4.5– Clue cells– Whiff test

• Treatment:– Metronidazole (500) 1 tab PO bid pc 7 days– Clindamycin (300) 1 tab PO bid pc 7 days

Trichomonas vaginitis

• Anaerobic flagellated protozoa• Mainly sexually transmitted• Yellowish green/white discharge• Itchy• Dysuria, dyspareunia• Vaginal mucosa inflammation• colpitis macularis, strawberry cervix

Trichomonas vaginitis

• Wet smear, Gram stain to rule out gonococcal infection

• Treatment– Metronidazole (500) 1 tab PO bid pc 7 days– Clotrimazole V.P. (100) Vg suppo OD 6days

• Must also treat partners, no intercourse until resolved

Mucopurulent cervicitis

• Mucopurulent discharge• Dysuria• Vulval inflammation• N. gonorrhoeae, C. trachomatis, HSV• Gram stain intracellular gram negative

diplococci

Mucopurulent cervicitis

• Dual therapy• Gonococcal infection– Ceftriaxone 125 mg IM stat

• Chlamydial infection– Doxycycline (100) 1 tab PO bid pc 7 days– Azithromycin (1g) 1 tab PO stat

• Must also treat partners, no intercourse until resolved

Foreign Bodies

• Children• Adults—contraceptive devices, pessary,

swabs, tampons• Purulent vaginal discharge; foul-smelling,

bloody• Speculum; may use nasal or aural speculum• Removal then antiseptics

Neoplasm

• Benign/Malignant• Leukorrhea• purulent, foul-smelling, bloody if

infected/malignant

Urinary and fecal discharge

• Urinary discharge– Urethro-vaginal fistula– Vesico-vaginal fistula– Uretero-vaginal fistula

• Fecal discharge– Recto-vaginal fistula

Summary

• Physiologic• Pathologic– Vaginitis in infancy and childhood– Senile vaginitis (Atropic vaginitis)– Candidiasis– Bacterial vaginosis– Trichomonas vaginitis– Mucopurulent cervicitis– Foreign bodies– Neoplasm– Urinary and fecal discharge

THANK YOU