Tracy Coningham (BPharm), Lee Baker (Dip Pharm)

Lower genital tract disorders are not uncommon in females and occur in most women at least once in their lives and in many women, numerous times. These conditions may involve the mucosa of the vagina (vaginitis), the vulva or external genitalia (vulvitis) or both (vulvo-vaginitis). Itching, burning and tissue inflammation are the usual symptoms often accompanied by a vaginal discharge with an abnormal consistency, volume, odour and colour. Vaginal discharge is, however, also a normal phenomenon in a woman’s life and varies in quantity and characteristics depending on the stage in the reproductive cycle.

A normal discharge:

• Is clear or cloudy white, but may leave a yellowish mark after drying on the underwear.
• Has no marked or unpleasant odour.
• Does not cause vulvo-vaginal irritation.
• Varies in volume depending on the individual and her response to situations.

In the normal, healthy vagina, glycogen-rich cells line the mucosa. Commensal bacteria in the vagina’s flora cause fermentation of this glycogen to produce acids. This process is particularly active during the reproductive years. These acids are essential to maintain the vaginal pH at approximately 3.5-4.0 in order to discourage the growth of pathogens.

An increase in the pH of the vagina predisposes a female patient to infection. A rise in pH may be triggered by menstruation, antibiotics, sexual activity, pregnancy, use of oral contraceptives, postmenopausal oestrogen deficiency and infections.

Diagnosis
For an accurate diagnosis, medical examinations and laboratory tests need to be conducted, but symptoms are also a relatively good assessment. The presence of redness, irritation, itching or discomfort of the vulva and/or vagina with an abnormal discharge are indicative of vulvo-vaginitis. Other necessary, tell-tale questions include when in the menstrual cycle the discharge occurs, whether the discharge is continuous or sporadic, presence of pain, previous response to treatment and whether the patient is currently sexually active.

Causes throughout the years
Discharges have various causes throughout the reproductive life of a female.

• Newborn baby – sterile mucoid discharge caused by maternal oestrogen which lasts for approximately 10 days. Slight bleeding may occur as a result of oestrogen withdrawel.
• Children – E. coli is the most common pathogen involved usually due to poor hygiene, relatively high vaginal pH and immature anatomy. Vulval inflammation is the most common symptom.
• Women in reproductive years – may be caused by any number of organisms, namely Candida albicans (fungus), Trichomonas vaginalis (protozoa), Gardnerella vaginalis (bacteria), or a combination thereof, but may also be caused by the Herpes virus or Neisseria gonorrhoeae. Vulval inflammation occurs secondary to a vaginal infection and rarely occurs alone.
• Post-menopausal women and hysterec-tomised women – infections are most likely to be caused by bacteria or fungi. A natural rise in pH along with oestrogen deficiency resulting in thinning vulvar skin and vaginal mucosa predisposing the women to infection. Vulval inflammation is common without vaginal involvement.

Warning signs
A vaginal discharge in a child, especially if bloody, may be caused by a foreign object or a malignancy and requires immediate attention.

A watery discharge, especially if bloody, in women in the reproductive years may be due to cancer of the cervix, vagina or endometrium or endometriosis. Vaginal bleeding after inter-course may be indicative of polyps and also requires medical attention.

Lower abdominal pain is not usually associated with these types of infections and may be indicative of pelvic inflammatory disease.

Vulval itching over an extended period may be due to human papillomavirus infection or a malignancy.

Common infective causes
1.  Bacterial vaginosis
This condition may be suspected when the patient has a profuse, non-irritating, grey-white, sticky discharge with an unpleasant “fishy” odour. The odour typically intensifies on contact with alkali substances such as semen or soap. Local itching and discomfort may also occur, but are not marked.

In the absence or depletion of the acid-forming bacteria, Lactobacillus, Gardnerella vaginalis proliferates and produces amino acids. These amino acids are split by other bacteria which also proliferate at this time and form amines which are basic and cause an increase in the pH to 4.5. This increase in pH causes the cells in the vaginal mucosa to shed and produce the characteristic foul smelling discharge.

The drug of choice for treatment is metronidazole (Flagyl®), preferably given as a single dose of 2g. It may also be given over a 7 day period as 400mg three times per day. As an alternative, clindamycin vaginal cream (Dalacin VC®) used daily for 7 days may be used but unfortunately may initiate a flare of candidiasis in 10% of patients. It is not necessary to treat the male partner. Povidone-iodine (Betadine®) douche or gel may also be used for symptomatic relief.

2.  Vaginal candidosis (thrush)
Candida species are commensals in the female genital tract and do not cause a problem unless proliferation occurs.

Characteristic “cottage cheese” discharge with a severe vulvo-vaginal itch makes diagnosis fairly simple. Regular recurrence in susceptible patients makes self-diagnosis possible. Other symptoms include swelling and redness of the vaginal tissues. The itch is classically worse at night, may be associated with anal pruritis and there may be white spots on the actual tissues. There is not normally an associated odour and the discharge clings to the vaginal wall. Urinating may be uncomfortable and more frequent than usual, and discomfort during sexual intercourse is common. A classic tell-tale sign is worsening of symptoms in the premenstrual week. It is important to remember that some females do not experience any symptoms at all and others may only present with one or two.

One of the most important points to bear in mind when treating a vulvo-vaginitis is the “ping-pong” effect i.e. passing the infection back and forth between partners unknowingly. This is because the partner may not experience any symptoms but may harbour the organisms. For this reason, it is essential that both partners are treated at the same time. Thrush is a classic infection for the “ping-pong” phenomenon and should be managed accordingly.

The initial drugs of choice are either clotrimazole (Canesten®) or miconazole (Gyno-Daktarin®) applied and inserted into the vagina either as pessaries, vaginal tablets or cream. Both of these are non-prescription medications. Treatment should be continued for 2 weeks to prevent recurrence. Another option is povidone-iodine gel or douche. Prescription options include oral fluconazole (Diflucan®) or itraconazole (Sporonox®) or oral or vaginal ketoconazole (Nizoral®, Nizovules®).

Recurrent cases may necessitate monthly treatment with one clotrimazole vaginal tablet per month or ketoconazole 200mg/day for 5 days of the month or a single fluconazole 150mg capsule per month.

3.  Trichomonal vaginitis
In this common, protozoal infection, a foamy, profuse, greenish-yellow discharge is present accompanied by a severe itch, swelling of the vulva and foul odour. Coitus is painful and bleeding may occur. Urinary frequency and pain on urination may also be present. On examination, the pH is between 5.0 and 7.5 and there appear to be red patches on the cervix and vaginal walls known as “strawberry cervix”. Symptoms often appear shortly after a menstrual period. This disease is easily spread sexually, affecting both men and women equally with the result that both partners should be treated.

First-line therapy is metronidazole 2g as a single dose. Recurrent cases are treated with 2-3g of metronidazole daily for 7 days. Povidone-iodine douche or gel or clotrimazole vaginal tablets may be used for symptomatic relief.

The use of condoms is strongly recommended to prevent re-infection.

Other causes

• More than 40% of women with vaginal symptoms do not fall into any of the above categories and differential diagnoses include urinary tract infections and cervicitis.
• Apart from infectious causes, other instigating agents may include soaps, bubble bath, non-cotton underwear, tight-fitting pants and foreign bodies e.g. tampons or intra-uterine devices.
• Lifestyle factors may also play a role such as fatigue, nervousness, poor diet and illness.
• Antibiotics, steroids, diabetes, immuno-compromised patients e.g. AIDS, menstrua-tion and pregnancy are all common causes.

General Treatment
If the condition is simply a copious, but otherwise, normal discharge, douching with water occasionally may be sufficient to reduce the volume. All other discharges need specific treatment to target the responsible pathogen. To control symptoms of discomfort and itching, intermediate measures such as a vinegar and water douche or a bath with a few drops of tea tree oil may be used. Sitting in a sitz bath or applying cool compresses will relieve itching and discomfort. Daily douching, especially with medication, is discouraged as this practice predisposes a patient to pelvic inflammatory disease.

If the labia are stuck together as a result of a previous infection, oestrogen cream applied for 7-10 days will solve this problem.

If the pruritis is definitely due to non-infective causes, a hydrocortisone cream of 1% or less may be applied and/or antihistamine tablets may be taken.

If oestrogen deficiency has been implicated, hormone replacement therapy is indicated, either applied topically such as Premarin® vaginal cream (conjugated oestrogens) or systemically via a transdermal patch, gel or an oral tablet.

A very important point to remember is that the vaginal mucosa is rich in blood vessels thereby providing a favourable site for absorption of topically applied medication. As a result of this, vaginal preparations may cause systemic side-effects especially if the mucosa is damaged.

Conclusion
Vulvo-vaginitis is a fairly common inflammatory condition with severity ranging from mild irritation to unrelenting symptoms causing debilitation. The presence of a vaginal discharge need not necessarily indicate infection and may simply be a reflection of the stage in the reproductive cycle. Preventative measures such as dietary modifications, diabetic monitoring, supplementation with Lactobacillus and avoidance of tight clothes have been researched with varying success rates. The key to management of vaginal discharge is accurate diagnosis of the responsible pathogen followed by appropriate therapy with antibiotics, antifungals, anti-protozoals or anti-virals.

REFERENCES:
Plusfile – Vulvo-vaginitis 1991 Module 4
Merck Manual of Medical Information – Home Edition
Betadine® Femtalk
Vaginal Thrush brochure – Janssen-Cilag
Mims Disease Review
Manual of Family Practice