GENITAL DISCHARGES IN THE FEMALE

By

Maj. M. P. Vora, M.B.B.S., D.V.D.

Bombay

Current Medical Practice

A monthly journal devoted to modern medicine and surgery

Vol.No.15, No.6 of June 1971

Pages: 801-805

Some genital disorder requiring investigation and treatment is common in females. It may be a discharge, pruritis, warty growth, ulcer or psycho-sexual problem. Many of these conditions are related to sexual activity, but this may be marital contacts only. Among these, a genital discharge is the commonest complaint. In these cases, the venereal origin is likely to be masked by various conditions, which may be obvious at first sight. If such cases are routinely examined with adequate care and skilled facilities for venereal origin it will help to eliminate the reservoir of infection and reduce the morbidity rate of V.D.; moreover, this will save many patients from unnecessary medications. In fact, it should be a matter of utmost concern to exclude or clinch the venereal infection at the beginning. However, the investigation should be carried out without the associated implication that the condition is necessarily transmitted sexually. The genital discharge, often the sole compliant may be due to many and varied causes. Gonococcal origin is first to be considered in every case. But to prove its existence is often difficult when there is a mixed infection. Precise diagnosis without adequate bacteriological investigation is impossible; for such a discharge in an identical way may be due to various causes. On no account should a suspected case of venereal disease be treated with chemotherapy without confirmation of the diagnosis. Such a procedure makes the recovery of the causative organism impossible and may seriously jeopardize the patient’s chance of complete cure in the shortest period. Without precise diagnosis, it is impossible to advice on the management of any sexual partner married or otherwise. The social significance of venereal infection should not be under-estimated; particularly when an extra-marital contact is denied or when marital relation has taken place within the supposed incubation period.

The causes of genital discharges may be divided into groups:

• Inflammatory,
• Constitutional,
• Neoplastic,
• Adventitious and
• Miscellaneous.

• The inflammatory discharges may further be subdivided:-

• Bacterial
• Specific - gonorrhoea, syphilis - primary, secondary or tertiary, chancroid, lymphogranuloma venereum, granuloma inguinale, tuberculosis and diphtheria.
• Non-specific - Pyogenic staphylococci, streptococci, pneumococci, B.coli, enterococci diphtheroids.
• Fungal - Moniliasis, rhinosporidiasis.
• Viral - herpes genitalis.
• Protozoal - trichomonas vaginalis, leishmania brazilians, amoebiasis.
• Parasitic - pediculosis pubis, scabies.
• Metazoal - schistosomia haemotobian
• Traumatic - foreign bodies such as the ring pessary, loop, I.U.D. retained sanitary pad etc.
• Chemicals - strong antiseptic douche, allergic to certain constituents of contraceptic paste or jellies.

• Constitutional

• Physiological, 2. Pathological and 3. Systemic diseases.

• Physiological leucorrhoea may occur in association with an increased ovarian activity or an excess oestrogen secretion. Self abuse or frequent sexual stimulation without gratification may leads to this complaint. A vaginal discharge among those whose duty involves constant standing on feet or overwork may be observed in nurses and waitresses. Anaemia and constipation are concomitant factors. Such discharges are mucoid in nature and contain large number of epithelial cells, few pus cells and no germs. Culture for gonococci, candida albicans and trichomonas vaginalis are negative. The vaginal mucosa is healthy in appearance. After appropriate examination and tests reassurance is all that is needed in these cases.

• Pathological changes following physiological process are cervical lacerations, uterine displacement, post-menopausal vaginitis, senile vaginitis etc.

• Systemic diseases - exanthemata, fevers, anaemia, pelvic congestion, nutritional deficiency, drug intoxication , allergy, psycho-sexual difficulties, contact dermatitis or sensitization, impetiginous or infective dermatitis, infected scabies, pediculosis pubis, thread worm infestation of the bowel, schistosomia haemotobian etc.

• Neoplastic - benign or malignant growths of the vulva, vagina, cervix, venereal warts, carcinoma, polyps etc.

• Adventitious - sinuses and fistulae due to various causes, vesico-vaginal fistulae, recto-vaginal fistulae etc.

• Miscellaneous -a static vaginal discharge.

In these cases, a proper clinical examination and necessary laboratory tests are of utmost importance. The patient should present herself without cleaning the parts and passing urine for at least 6 to 8 hours. Good light is essential. The lithotomy position is most convenient. Note the clinical findings; palpate the lower abdomen, suprapubic area and inguinal lymph nodes. Inspect the vulva, separate the labia, inspect the urethral orifice, vaginal introitus, openings of the Bartholin’s and Skene’s ducts, palpate the urethra and Bartholin’s glands, investigate the rectum, by using Cuscos’s bivalve vaginal speculum, inspect the cervix, the vaginal walls, fornices, collect samples of secretion from various sites, make smears for examination, and take a drop of secretion from posterior vaginal fornix of the vagina for the dark-field examination for T.vaginalis. For recovery of gonococci, smears from the urethra, Bartholin’s duct, Skene’s duct, the cervix, and the rectum are likely to be rewarding. Note the reaction of the discharge. Bimanual examination of the uterus and adnexa is done and note if there is any tenderness or swelling in the lateral fornices of the vagina.

If the first examination does not elicit adequate evidence, one has to use provocation. The provocatives are used as a routine in most cases. They are (a) glycerine tampon or (b) fresh silver nitrate solution, 1% for the urethra and 5% to the cervix. The patient is examined 24 hours and samples collected for bacteriological examination, on two successive days.

The conditions which give rise to genital discharge are varied; the commonest among them are:-

Gonorrhoea

In the majority of cases, an uncomplicated gonorrhoea in the female is asymptomatic. A female contact of gonorrhoea may show no naked-eye evidence of the disease and yet give a positive smear, culture or antifluorescent evidence. Most females (whether primary or secondary contacts) attend a clinic only when their male partners have discovered their own infection. Gonococcal cervicitis may give rise to vaginal discharge. The coincidence of T.vaginalis, candida albicans or other bacterial infection is observed in many cases; and this makes difficult the demonstration of gonococci in the discharge till the secondary infection is cleared. In some cases, this may require a number of repeated searches by smear, culture and fluorescent antibody technique. In the course of time, involvement of the urethra, the cervix, the endocervix, Skene’s ducts, Bartholin’s glands and their ducts the posterior fornix of the vagina and the rectum is common. In view of the common association of gonorrhoea with other infections, a routine examination to exclude them is a necessity. A person infected with either syphilis or gonorrhoea is infectious even during the incubation period i.e. before any signs and symptoms develop. It is also important to trace , investigate and treat contacts of an established case; but this is often neglected.

Cervicitis

The trauma of childbirth associated with infection by various organisms is common, leading to erosion of the cervix. This can give rise to the complaint. An attempt to clear the secondary infection and to reduce the area of erosion by chemical or electrical cautery - are initiated.

Trichomonas vaginalis

This is a common inhabitant of the vagina and may be found without any inflammation. Often it is associated with acute vaginitis and vulvitis. It may be acquired venereally in most cases; at times, sexual transmission is not likely. The condition may be symptomatic or asymptomatic. When it flares up into a clinical vaginitis, probably as the result of super-infection, it gives rise to profuse, frothy muco-purulent discharge alkaline in reaction; “raw beef”, “strawberry” or “flea-bitten” appearance of the vaginal mucosa is a characteristic feature. The endocervix is normal. Examination of the fresh discharge reveals typical, living, active, motile flagellate organisms in a wet preparation on dark-field microscopy. Smears are devoid of gonococci. Examination of the sexual partner is considered necessary. Combination of tests by smear and culture is more effective in diagnosis. “Non-specific” genital infection and vaginal thrush due to Candida albicans are often associated.

Moniliasis

This has become common during the last few years on account of the use of broad-spectrum antibiotics and contraceptive pills. Diabetes and the pregnant state make one easily susceptible to fungal attacks. The condition may be with or without symptoms. It may give rise to local irritation, dyspareunia, pruritis vulvae and acute vaginitis with intolerable itching. The vaginal discharge is scanty, caseous or inspissated and highly acidic in reaction; white curdy patches on the vaginal walls are visible. It may involve the vagina, the vaginal portion of the cervix and the perivulval skin. The endocervix and ducts of Skene’s and Bartholin’s glands remain unaffected. Microscopic examination of the sample of the discharge shows candida albicans or yeast-like organism and a large number of Doderlein’s bacilli. It may cause balano-posthitis in the male sexual partner. In all cases of candida albicans, it is important to test the urine for sugar and to look for evidence of nutritional deficiency or hypoparathyroidism.

Non-specific vulvo-vaginitis

This may be due to variety of organisms. It is an inflammatory condition in a susceptible person occurring sometime after sexual contact with some partner. It may follow the first act of coitus or a new sexual relationship. Many times, the cause may remain undiscovered. Certain causes such as chronic local uncleanliness and poor personal hygiene predispose to contagiousness. The signs and symptoms may be trivial or very severe. Local irritation, dysuria, vulval redness and oedema and vaginal discharge may be present. It is of utmost importance to establish whether the condition is due to the gonococcus or not. Slides and cultures for bacteriological examination must be taken from the interior of the vagina, urethra, cervix and the rectum. The vaginal discharge is purulent, scanty or profuse, alkaline in reaction and devoid of Doderlein’s bacilli. Warty growths irritation, itching and proctitis may be complained. The urethra, cervix, endocervix, Bartholin’s glands and the rectum may be involved. The condition may be associated with T.vaginalis, Moniliasis and gonorrhoea.

Traumatic vaginitis

This may be due to numerous causes. Foreign bodies in the vagina will sooner or later cause profuse watery foul smelling discharge. Foreign bodies may be a condom, tampon, cotton-wool, ring-pessary, or intra-uterine loop. Chemical vaginitis may be observed in persons who are sensitive to one of the constituents of a contraceptive cream or jelly. Strong antiseptic solution for douching may be the cause. Even douching the vagina plain water tends to interfere with normal physiology and protection.

Other causes of vaginal discharge have already been mentioned at the beginning. At times, a complaint of a genital discharge is found to be associated with normal vaginal discharge. This may be due to a fear of malignancy, sexual adventure or fear of venereal disease following a sexual relation with a new partner or unfaithful husband.

Treatment

For these conditions of diverse origin, an accurate diagnosis followed by the specific treatment can only be a logical procedure. Systemic medication should be supplemented by other forms of local treatment. Personal hygiene and local cleanliness should be promoted by various measures such as daily careful swabbing of the parts and use of vaginal tablets or pessaries.

An acute fresh gonococcal infection requires an effective penicillin blood level of 2 to 3 µg. per ml, continuously maintained for at least three days. To achieve this objective, one of the following schedules is recommended.

• a mixture of 1million units of benzyl penicillin-G and 1.2 million units of benzyl procain penicillin-G I.M.
• 1 gm. of benzyl probenicide orally followed one hour later by 5m.u. of crystalline penicillin-G I.M.
• a mixture of benzyl procain penicillin-G and benzathine penicillin 2.5 m.u. I.M. in a single injection. If penicillin sensitivity is detected, other antibiotics should be employed. Cephaloridine or Kanamycine 2g. in 5 ml. I.M. daily or Ampicillin 500 mg. orally four times a day.

For T. vaginalis, Metronidazole (‘Flagyl’) 200 mg. T.D.S. orally for 7 days is advised. A course may be repeated after a week’s interval. Another useful drug is Nifuratal (Magmilor).

For monilial infection, Nystatin (‘Mycostatin’) oral tablet (500,000 units) one T.D.S. is continued for at least 48 hours after the clinical cure is observed. Nystatin vaginal tablet is inserted deep into the vagina once or twice daily for about 2 weeks. This provides specific therapy and helps restoration of normal bacterial flora. For urethral instillation Nystatin 1000 units per ml. pr 12.5 to 25 mg amphotericin-B in 5 ml. aqua sterile and 2.5 ml of 5% dextrose solution- is used. The urethral opening should be sealed for 15 minutes following instillation.

For ‘non-specific’ infection, terramycin, tetracycline, erythromycin or Methacycline 500 mg. four times a day orally till clinical cure is obtained.

Follow-up

Every case needs to be observed for a period of 3 to 6 months during which clinical examination and laboratory tests, at regular intervals, have to be carried out. The serologic tests for syphilis should not be omitted either at the beginning or at the end.

Table showing differential points of common inflammatory genital discharges in the female is given on the next page.