Vaginal Discharge Solution
Vaginal cuff cellulitis is a common complication following both abdominal and vaginal hysterectomy. Symptoms and signs usually present between postoperative days 3 and 5, and may begin in the hospital, or just after discharge. Patients often complain of lower abdominal pain, pelvic pain, back pain, fever, and abnormal vaginal discharge. Induration, tenderness of the vaginal cuff, and possibly a purulent discharge or labial edema or erythema are prominent during the pelvic examination. The white blood cell count is usually elevated.
Infection ranges from asymptomatic carrier state to severe, acute inflammatory disease. A vaginal discharge is reported by 50 to 75 percent of patients. It may vary in character from the classic picture of a yellow-green frothy discharge, seen in 20 to 30 percent of patients, to a gray discharge to scant or no discharge. Other symptoms include vulvovaginal soreness and irritation (25 to 50 percent) pruritis, which may be severe (25 to 50 percent) dysuria (25 percent) and malodorous discharge (25 percent). A sense of vulvovaginal fullness may be intense or mild. As many as half of symptomatic women complain of some degree of dyspareunia. Symptoms may be more severe before, during, or after menstruation when the vaginal pH is more alkaline. Lower abdominal pain is rare and should alert the physician to the possibility of other diseases.
The signs and symptoms of early cervical carcinoma include watery vaginal discharge, intermittent spotting, and postcoital bleeding. Diagnosis often can be made with cytologic screening, colposcopically directed biopsy, or biopsy of a gross or palpable lesion. In cases of suspected microinvasion and early-stage cervical carcinoma, cone biopsy of the cervix is indicated to evaluate the possibility of invasion or to define the depth and extent of microinvasion. Cold knife cone biopsy provides the most accurate evaluation of the margins.
VAGINAL FOREIGN BODY Vaginal foreign bodies classically present with intermittent bloody, foul-smelling vaginal discharge. Small wads of toilet paper are most commonly found. Foreign bodies should be suspected when the posterior wall of the lower half of the vagina cannot be visualized when the child is in the crawling position (see Fig i98 2S) or knee-chest position (cannonball position). Toilet paper is not palpable on rectal examination, although other foreign bodies such as erasers, beads, and nuts can sometimes be appreciated. Radiographs are usually not helpful. Frequently, the object may be removed by gentle vaginal irrigation with warm water or by milking the vagina of any hard objects during rectal exam. Foreign bodies that cannot be removed by simple measures may require examination and removal under anesthesia.
LICHEN SCLEROSIS ATROPHICA Although uncommon in prepubertal girls, lichen sclerosis is being increasingly recognized by emergency physicians and pediatricians. This increased recognition is in some measure a reflection of increased concern about and awareness of sexual abuse and the subsequently increased frequency of perineal examination of prepubertal girls. The affected girl complains of itch, irritation, dysuria, perineal and or perianal pain, and bleeding. There may be a coexistent vaginal discharge. As perianal pain persists, the girl may develop problems with painful defecation, stool retention, constipation, and encopresis.
Virginal patients with menstrual cramps, mittelschmerz, or vaginal discharge do not require a full pelvic examination, because a rectovaginal examination is generally sufficient. In the case of trauma and abnormal vaginal bleeding, a vaginal examination is necessary. It can generally be tolerated by adolescents with intact hymen if a narrow Pederson-type or Huffman speculum is used. Conscious sedation or full anesthesia may be required, depending on psychological response of the patient and the circumstances surrounding the injury or the extent of the injury or disease.
PHYSICAL EXAMINATION48,1 H The physical exam should be performed thoroughly and compassionately. A female chaperone should be present if the examining physician is a man. Document a general medical examination, including vital signs and level of consciousness. Bruises, lacerations, or other signs of trauma should be described in detail a body map may be useful. As many as 290 percent of rape survivors will have nongenital injuries. - H.2,13 The examiner should carefully inspect the victim's face, oral cavity, neck, breasts, wrist, thighs, and buttocks. Areas of tenderness should also be recorded. A pelvic examination should be performed, noting any vaginal discharge or genital lacerations or abrasions. Toluidine blue can be used to detect small vulvar lacerations. 4 Lacerations expose the deeper dermis, containing nuclei that absorb this stain. Prior to inserting the speculum, the dye is applied to the posterior fourchette with gauze and wiped away with lubricating jelly. A linear...
CLINICAL FEATURES Vesicovaginal fistulas may occur after total abdominal hysterectomy. Patients present 10 to 14 days after surgery with a watery vaginal discharge. The diagnosis can be confirmed by inserting a cotton tampon into the vagina and then instilling methylene blue or indigo carmine dye via a transurethral catheter. If the tampon stains blue, a vesicovaginal fistula is present. If no staining occurs, a ureterovaginal fistula must be ruled out by injecting 5 mL of indigo carmine dye intravenously. If a ureterovaginal fistula is present, the tampon should stain blue within 20 min.
Children and adolescents may insert objects intravaginally during periods of genital exploration or sexual stimulation. In young girls, the most commonly inserted foreign bodies are rolled-up pieces of toilet paper, toys, and small household objects. 1 In adolescents and adult women, it is often a forgotten tampon or sponge contraceptive. Foreign objects left in place for more than 48 h can cause severe localized infections due to Escherichia coli, anaerobes, or overgrowth of other vaginal flora. Patients present with a foul-smelling and or bloody vaginal discharge. The only treatment necessary for vaginitis secondary to the presence of a foreign body is removal of the object.1 In most cases, the vaginal discharge and odor will disappear without further therapy within several days.
There is a relatively small literature relating to reproductive tract infections in men and women. In part this is because these topics are extremely sensitive and in many cultures associated with shame and social stigma. While the incidence of reproductive tract infections and other conditions in developing countries is substantial, many women do not seek treatment from the formal health sector for these problems, or else postpone treatment until the condition is acute. Work conducted in Vietnam (Gammeltoft, 1999 Whittaker, 2002), in Thailand (Boonmongkon Nichter & Pylypa, 2001 Whittaker, 2000), and among Vietnamese migrants (Kendall, 1987), concentrates upon the ethnophysiology of vaginal discharge and its relationship to ideas of strength, humoral balance, and cleanliness. The presence of vaginal discharge may be associated with a dirty womb and may be believed to indicate a transgression against the moral order. Sobo's (1993a, 1993b) study of
After the HSG, you may have minor cramps and discomfort for a few days. It is also normal to have slight vaginal discharge. Your doctor may recommend that you continue pain medication to minimize your discomfort. You may also be given a prescription for antibiotics, if your medical history indicates that you are at increased risk for infection. The antibiotics are a preventive measure to reduce the chance of developing a pelvic infection from the HSG procedure itself. Risks and complications with the HSG procedure are rare. However, be sure to call your doctor if you experience heavy bleeding or extreme discomfort or cramping pain.
A diagnosis of cervicitis, typically due to Neisseria gonorrhoeae or Chlamydia trachomatis, must always be considered in women with purulent vaginal discharge. The presence of high-risk behavior or any sexually transmitted disease requires screening for HIV, hepatitis B, and other STDs.
Pelvic inflammatory disease may present with abdominal pain, fever, and leukocytosis. The disease is usually found in young women. A careful pelvic examination should be carried out in all female patients with lower abdominal pain. A history of irregular menses and the finding of vaginal discharge should aid in the diagnosis.
A 17-year-old girl presents to the city sexual health clinic with vaginal discharge. She has a new boyfriend and is 'on the pill' she and her partner do not use condoms as their relationship is monogamous . On examination, she has mild lower abdominal tenderness to palpation, cervicitis, and cervical discharge. There is cervical motion tenderness and left adnexal tenderness on bimanual examination. Her 17-year-old boyfriend has accompanied her to the clinic and is assessed separately he reports a small amount of urethral discharge and mild dysuria. Examination reveals copious urethral discharge with meatal edema. A Gram stain of discharge reveals Gram-negative intracellular diplococci. You review the literature to determine the following.
Primary genital episode genital HSV is characterized by multiple painful vesicles in clusters. They may be associated with pruritus, dysuria, vaginal discharge, and tender regional adenopathy. Fever, malaise, and myalgia often occur one to two days prior to the appearance of lesions. The lesions may last four to five days prior to crusting. The skin will reepithelialize in about 10 days. Viral shedding may last for 10 to 12 days after reepithelialization.
In a multicenter study, including 2322 women, the Pearl Index of efficacy in compliant patients was 0.8. Irregular bleeding was uncommon (5.5 of cycles), and withdrawal bleeding occurred in 98.5 of cycles. Compliance was 86 , with 15 of women discontinuing treatment because of an adverse event, most commonly device-related discomfort, headache, or vaginal discharge vaginitis. Only 2.5 of discontinuations were device related.
The clinical symptoms of UTI in an adult are dysuria, frequency, and lower abdominal pain. However, the correlation between symptoms and the presence of infection is inexact as only 50 to 60 percent of women with dysuria have significant bacteriuria.24 Internal dysuria, a burning suprapubic pain during urination associated with bladder tenderness, is more associated with UTIs as compared to external dysuria, the burning sensation as urine passes over inflamed perineal tissue. In females, external dysuria or a history of vaginal discharge is more associated with vaginitis, cervicitis, or pelvic inflammatory disease than with a UTI.
In newborn females, the placental transfer of estradiol and gonadotropin is responsible for a mucoid or blood-tinged vaginal discharge, minor breast development, and vaginal flora similar to that in adult women. Uterine bleeding secondary to estrogen withdrawal may occur in the first 6 weeks of life in normal neonates. Bleeding after this time is always abnormal and requires investigation.
Ten years of age tends to be the lower limit for menarche, and the mean age in North America is 12.5 years. Most children develop secondary breast changes 2 years prior to the onset of menarche. At the time of ovarian stimulation, a white or yellow vaginal discharge, which is both nonodorous and nonirritating, may appear. Early cycles are anovulatory and irregular, but unlike adult anovulatory cycles, bleeding is generally not excessive. The hypothalamic pituitary axis takes 1 to 5 years to reach full maturity, and the average time to establish ovulatory cycles is 2 years after menarche.
Health care providers should maintain a low threshold for the diagnosis of PID, and sexually active young women with lower abdominal, adnexal, and cervical motion tenderness should receive empiric treatment. The specificity of these clinical criteria can be enhanced by the presence of fever, abnormal cervical vaginal discharge, elevated ESR and or serum C-reactive protein, and the demonstration of cervical gonorrhea or chlamydia infection.
Victims of prior child sexual abuse are frequently difficult for inexperienced physicians to assess because of an unfamiliarity with the normal prepubertal genital examination.11 Children who have been sexually abused are brought to the emergency department because of a disclosure about the abuse or because of other symptoms such as those referrable to the genitourinary tract, including vaginal discharge, vaginal bleeding, dysuria, urinary tract infections, or urethral discharge behavior disturbances, including excessive masturbation, genital fondling, or other sexually oriented or provocative behavior encopresis regression nightmares and unrelated complaints.12 Approximately 15 percent of children diagnosed in an emergency department as victims of sexual abuse in one report had unrelated complaints such as abdominal pain, asthma, and sore throat. Physical findings indicative of a sexually transmitted disease should also be noted, including a vaginal discharge, warts consistent with...
Sexually transmitted pathogens cause several common syndromes. Infection with Neisseria gonorrhoea or Chlamydia trachomatis frequently results in urethritis, cervicitis, or the constellation of symptoms and signs that suggest the presence of pelvic inflammatory disease. HSV, Treponema pallidum, and Haemophilus ducreyi are common agents of ulcerative genital disease, while vaginal discharge is commonly caused by infection with Trichomonas vaginalis or Candida spp. or by bacterial vaginosis. tests (i.e. pH testing, whiff test, microscopic evaluation of 'wet preps') also appears limited when compared with more comprehensive laboratory-based evaluations.30 In a study performed in 153 women presenting to a clinic in Israel with vaginal discharge, only the finding of vaginal pH 4-5 was associated with infection by a particular pathogen (yeast) the positive predictive value of low vaginal pH for vaginal candidiasis was 68 . A recent review evaluated studies of syndromic diagnosis and...
Vulvovaginitis is inflammation of the vulva and vaginal tissues. It is usually characterized by a vaginal discharge and or vulvar itching and irritation. A vaginal odor may be present. It accounts for 10 million visits to physicians per year in the United States, and is the most common gynecologic complaint in prepubertal girls. 1 The three most frequent infectious causes are trichomoniasis (caused by Trichomonas vaginalis), bacterial vaginosis (BV caused by replacement of normal flora by overgrowth of anaerobes and Gardnerella vaginalis), and candidiasis (usually caused by Candida albicans).2 BV is the most common cause of vaginal discharge or malodor. Polymicrobial infection in women with vaginitis is not uncommon. Vulvovaginal candidiasis, contact vaginitis, and atrophic vaginitis may occur in virgins and after menopause, but other forms of infectious vulvovaginitis are generally found only in sexually active women. 2
Cervical cancer, in decreasing order, most often presents with postmenopausal bleeding, abnormal vaginal bleeding, postcoital bleeding, vaginal discharge, pain, or leg swelling. Diagnosis must be made by cervical biopsy. Often, on speculum examination, a mass or ulcerative lesion is seen on the cervix. A Pap smear must never be done if a suspicious lesion is seen Instead, the gynecologic consultant should be called to perform a biopsy, cone biopsy, or loup electrosurgical excision procedure (LEEP).
Lower abdominal pain is the most frequent presenting complaint in PID. Other symptoms may include abnormal vaginal discharge, vaginal bleeding, post-coital bleeding, dyspareunia, irritative voiding symptoms, fever, malaise, nausea, and vomiting. PID may be minimally symptomatic or asymptomatic.9