Document 64825

Dr. Dave Fuller and Dr. Chris Sanderson
Taken from the RCH handbook: Sonia Grover
* Previous issues available on the GPAG website…….*
Vaginal discharge:
Most newborn girls have some mucoid white vaginal discharge. This is normal and disappears by about 3 months of
This is the most common gynaecological problem in childhood, usually occurring in girls aged between 2 years and
the start of puberty. The vaginal skin in childhood is thin and atrophic. Overgrowth of mixed bowel flora occurs in this
environment and the resultant discharge can be an irritant to the vulva area, which is also atrophic. The moist
environment between the opposed skin surfaces may also be exacerbated by urine dribbling, particularly in an obese
young girl.
Erythema/irritation of the labia and perineal skin.
Itch and dysuria may also be present.
+ offensive vaginal discharge.
Investigations are usually not required. If urinary symptoms are present, check the urine to exclude urinary tract
infection (UTI).
Explanation and reassurance.
Vinegar (1 cup white vinegar in a shallow bath)
Simple soothing, barrier cream to the labial area (e.g. zinc-castor oil or nappy rash cream).
Toileting/hygiene advice: avoid potential irritants such as soaps and bubble bath.
Rarely, if the problem persists, further action maybe required. The natural history is for recurrences to occur up until
the age where oestrogenisation begins.
If a heavy discharge persists or marked skin inflammation beyond labial contact surfaces is present, take swabs
from the perineum in case of an overgrowth of one organism (e.g. group A Streptococcus) and treat it with the
appropriate antibiotics (usual culture findings are mixed coliforms).
Do not take vaginal swabs, as it is painful and distressing. If swabs for culture are required, introital area swabs are
If itch/irritation is the main complaint, consider pinworms.
If eczema occurs elsewhere on the body, this can be superimposed on the irritated skin. Combined treatment of the
vulvovaginitis (as above) and hydrocortisone may be indicated.
Foreign bodies are a potential cause for a persistent, unresolving, often blood-stained discharge. An examination
under anaesthesia with vaginoscopy is required to exclude this.
Although this is rare, consider sexual abuse if other indicators are present.
Thrush is rare in prepubertal girls unless there has been significant antibiotic use. Thrush thrives in an oestrogenised
environment, not in the atrophic setting.
Dr. Michael Roberts and Dr. Deb Friedman
Vaginal discharge is a common cause for presentation
within General Practice. In reproductive aged women, a
normal physiological vaginal discharge consists of 1 to 4
mL fluid (per 24 hours), which is white or transparent and
mostly odourless. The discharge may become more
noticeable at times of pregnancy, with the use of oestrogen
and progestogen based contraceptives and at the
mid-cycle with ovulation. The pH of normal vaginal
secretions is acidic at 4.0 to 4.5, and is hostile to the
growth of pathogens.
The normal microbiology of the vagina contains abundant
lactobacillus, diphtheroids and Staphylococcus
epidermidis. Age, phase of menstrual cycle, sexual activity,
contraceptive choice, pregnancy, presence of necrotic
tissue (i.e. retained products of conception), foreign bodies,
use of hygienic products, douches and antibiotics can all
disrupt the normal vaginal ecosystem. Overall, bacterial
vaginosis, candida vulvovaginitis, and trichomoniasis
account for more than 90% of cases of vaginitis.
Among sexually active young adults and adolescents, STIs
must be considered as the cause for vaginal discharge. In
these cases, treatment of partners is vital;
Chlamydia: Commonly asymptomatic but may be
associated with a non-specific discharge. Chlamydia is
treated with doxycycline or azithromycin.
Trichomonas: The discharge may be frothy, malodorous,
creamy, green, bloody, pruritic or asymptomatic. Physical
examination often reveals erythema of the vulva and
vaginal mucosa. Treatment is with metronidazole.
Next Issue Look out for…..
risk factors for STI, represent “imbalances” or
“overgrowths” of normally present flora. Such as:
Bacterial vaginosis (BV): Caused by many different
bacteria; Gardnerella vaginalis, Mycoplasma hominis,
Prevotella, Bacteroides, anaerobic Peptostreptococcus & Fusobacterium spp. Risk factors include multiple or new sexual partners, douching, and cigarette
smoking, but can occur in women who have never had
vaginal intercourse. There is a high occurrence of BV
and concordance of flora in women who have sex with
women. The discharge is usually grey, thin, nonirritating and malodorous (fishy). Up to 30% of women
may have this at any particular time and it may resolve
spontaneously over months so treatment is usually
only advised if symptomatic. Treatment is oral or
intravaginal metronidazole or clindamycin.
Candida (aka “thrush”). Not an STI. There is often no
discharge, just pruritis, dysuria, and dyspareunia. If
present, the discharge is white and creamy or cheesy.
It is odourless and associated with an erythematous,
irritated and pruritic vulva. Recurrent candida
warrants the exclusion of anaemia (especially iron
deficiency), diabetes, immunosuppression, and the
co-existence of infection with herpes simplex virus.
Candida can be treated with topical antifungals or oral
Candida under the microscope:
Gonorrhoea: Commonly asymptomatic but may have a
gray-white or yellow, thick purulent discharge. Treatment
with stat IM Ceftriaxone is preferred, as some resistance
has emerged to ciprofloxacin.
Condyloma acuminata, or genital warts can also cause
vaginal discharge, pruritis, burning and pain. Clinicians
should inspect the genitalia for evidence of macroscopic
Note: Vaginal pessaries should never be prescribed to prepubertal girls.
Chlamydia, Gonorrhoea and Syphilis
The commonest causes of vaginal discharge seen in
general practice among adult women, above 25, without
Rarely, Group A Streptococcus (GAS) causes
vulvovaginitis in mothers who are colonised with GAS.
This condition presents with acute onset of frankly
purulent discharge accompanied by pruritis, irritation,
erythema, and labial oedema. It can be treated with
Cont. Page 2
From page 1
In the post-menopausal age group, vaginal discharge is less common and requires careful assessment and
investigation. Vulvovaginal candidiasis is less common in postmenopausal women, unless they are taking estrogen
therapy. Discharge may be due to atrophic vaginitis and respond well to hormone replacement therapy or topical
oestrogen therapy but cervical and uterine pathology (neoplasm) need to be considered and excluded. Atrophic
vaginitis can also occur in pre-menopausal women in the postpartum period, during lactation, and as a complication
of antioestrogenic drugs, and responds well to topical oestrogen.
Other non-infectious causes of vaginal discharge, or vaginitis must also be considered once infection has been
excluded. In particular, irritants (scented panty liners, perfumes, soaps), allergens (latex condoms, seminal fluid),
fistulas, and genital tract lesions (ectropion, polyps, granulation tissue, or neoplasia). A foreign body can be
associated with chronic vaginal discharge, bleeding or spotting, and a foul smelling odour. Removal of the foreign
body is generally adequate treatment.
Diagnostic Approach– Dr. Deb Friedman and Dr. Owen Harris
Perform a speculum examination to exclude foreign body or genital tract lesions, and collect a cervical swab and
then sample vaginal discharge from vaginal vault. Use a blue or black cotton-tipped swab with transport media. A
low vaginal swab can be collected without the use of a speculum, and can be useful for detecting candida. Within
the microbiology laboratory, the following will be performed:
1. “Wet Prep”. Smelling ("whiffing") the slide immediately after applying KOH can detect the fishy (amine) odour
of BV. Microscopy can identify clue cells (Gardnerella vaginalis), yeast or motile trichomonads. Wet prep is
performed as early as possible, and specimens should be sent directly to the laboratory ideally within a few
2. Vaginal culture. For Candida. 10-20% of women are colonized with candida; therefore culture should not be
routinely performed. Culture also has no role in the diagnosis of BV, as it is polymicrobial, and G.vaginalis is
detected in up to 60 % of healthy asymptomatic women.
3. Cervical culture: Especially among women with a history of high-risk behaviour and purulent vaginal discharge.
Can assist in detecting trichomonas.
Chlamydia and Gonorrhoea will be covered in greater detail in the October edition of GOCATS.
Clue cells found in Bacterial Vaginosis:
Dr. Deb Friedman
Sexually transmitted infections (STIs) are a major public health problem in all countries. If untreated, STIs can result in
chronic pelvic infection, infertility, cancer of the cervix, and increased risk of acquiring HIV.
A proportion of STIs will be detected when patients present with certain symptoms, such as vaginal discharge, urethral
discharge, or genital ulcers. However, this will not assist in reducing the transmission of STIs from those patients with
asymptomatic disease. Targeted screening of asymptomatic patients in specified risk groups is important.
The decision about who to screen should be based on an assessment of their risk for STI. The following factors place
patients at greater risk for STI:
Adolescent & young adult age group
New sex partner in the past 2 months
Multiple sexual partners
History of previous STI
Drug use
Meeting partners on the internet
Contact with sex workers
Therefore the most important first step is to take a sexual history, including information about age at first sex, new
sexual partners, multiple sexual partners, types of sexual exposures, previous STIs & frequency of condom usage.
The most important of these questions is that of new sex partners which is a risk factor for STI.
Among patients with risk factors for STI, counseling and screening should be undertaken. Among sexually active
women under the age of 25 years, (especially those with a new partner, multiple partners and inconsistent condom
usage) cervical swabs and urine should be collected annually to screen for Gonorrhoea, Chlamydia & Trichomonas.
2-yearly Pap smears should also screen for HPV. Women older than 25 who are at high risk should also be screened.
Patients with risk factors such as commercial sex workers, multiple sexual partners, another STI & drug users should
have blood collected to screen for HIV, hepatitis B & syphilis. Young women should receive HPV vaccination, while
non-immune high-risk patients should be vaccinated against hepatitis B.
Young sexually active men should be screened via urethral or urine specimens for Chlamydia. Men who have sex with
men should be screened annually for HIV and syphilis, and should have urine or urethral specimens collected to
screen for Gonorrhoea, & Chlamydia. Rectal and pharyngeal cultures may be collected to screen for Gonorrhoea
among patients with a history of oral-genital & receptive anal intercourse.
Patients with newly diagnosed chlamydial, gonococcal, or trichomonas infections should be rescreened in 3 months for
new asymptomatic infections. Regardless of symptoms, sexual partners should be evaluated, tested, and treated if
they had sexual contact with the index patient during the 60 days preceding onset of symptoms or diagnosis of
Chlamydia. If a GP is unable to complete all contact tracing phone 9347 1899 for assistance.
All GPs should be aware of the requirement for 4 year olds to receive their vaccinations within the first month after
their birthday. Previously, children were not considered overdue if they were vaccinated by the age of 5 years,
however, now ACIR considers that children are overdue for vaccination after the age of 4 years and 1 month. It is
acceptable to vaccinate preschool children after the age of 3 years and 6 months.
GPs are encouraged to develop innovative ways to remind parents about 4 year old immunisations, such as
preemptive birthday cards, which can be downloaded from under ‘our services’,
‘prevention and early intervention’, ‘immunisation’.
2009 has seen more than 1800 cases of whooping cough diagnosed in Victoria, and 86 cases in the City of Greater
Geelong. Children under the age of 1 year are most at risk for adverse outcomes (apnoea and pneumonia) secondary
to Pertussis infection. Ordinarily, in our society, whooping cough is transmitted by infected adults whose immunity has
waned, therefore, doctors are advised to ensure that infants are vaccinated as per the recommended schedule, and
that parents, any other close carers or susceptible adult patients receive a whooping cough booster (combined with
diphtheria and tetanus vaccine), as soon as possible. In addition, doctors must maintain a high degree of suspicion
for possible cases of whooping cough among patients with prolonged cough. Currently, free Boostrix is available for 3
months for new parents of infants born after June 15th 2009. Grandparents, and other non-immune adults are
currently not funded to receive free Boostrix, but should be encouraged to get vaccinated nonetheless.