Vaginal Discharge, Pelvic Pain, and Dyspareunia

Hx taking with vaginal discharge

- Ask about: timing of onset, color, odor, presence of blood, irritation - Candida tends to be thick, itchy, white discharge while bacterial vginosis is grey, fishy-smelling - Allergic reactions usually itch - Urinary symptoms can be present with STI - Lower abdominal pain, backage and dyspareunia suggest PID - Older age suggests malignancy rather than infection - Date of menopause and last cervical smear - Any ring pessaries (should be changed every 6 months) - History of hysterectomy or obstructed labor; thinking fistula (tends to be constant discharge which is actually urine) - Hx of DM = candida - Current method of contraception, new partner - Recent antibiotics; think infection

NGU

- Characterised by discharge and/or dysuria but may be asymptomatic - Diag by > 5 polymorphonuclear leucocytes (PMNLs)/1000x in urethral smear - positive urine leukocyte esterase test - C. trachomatis or M. genitalium in up to 50% ( range 30-80%) - In a further 20% an undiagnosed C.trachomatis or M. genitalium is found in the partner if he/she is tested. - Urinary tract infection may account for 6.0%

Chlamydia

- Chlamydia trachomatis (serovars D-K) - Obligate intracellular Gram negative bacteria - C trachomatis is the most common curable STI - Prevalence: 1 : 10 in 20-24 yr old - IP: 14-21 days Symptoms and signs - Asymptomatic in over 50% - Urethral discharge; clear, grey mucoid or mucopurulent - Dysuria - Rectal infection usually asymptomatic but can present with discharge and proctitis - Pharyngeal infection is usually asymptomatic & uncommon Complications: - Conjunctivitis -Epididymo-orchitis - Sexually Acquired Reactive Arthritis (SARA) or Reiter's syndrome Diagnosis by - Urine NAATs or urethral swab NAATs - Culture & EIA less sensitive so not used these days Rx : Same as for NGU

Follow up of urethritis

- Compliance with treatment - Resolution of symptoms - to take a sexual history to explore the possibility of reinfection - Test of cure: culture tests >72 hr after completion of Rx and NAATs after 2 weeks Partner notification and health promotion - Male patients with symptomatic urethral infection should notify all partners with whom they had sexual contact within the preceding 2 weeks or their last partner if longer ago. - Patients with infection at other sites or asymptomatic infection should notify all partners within the preceding 3 months.

Examination with discharge

- General, abdominal, speculum and bimanual - Look for signs of systemic infection (tachycardia, pyrexia, local lymphadenopathy) - Look for signs of malignancy (cachexia, general lymphadenopathy) - Abdominal palpation to exclude local tenderness; may indicate PID or abdominal mass] - Tenderness on bimanual suggest PID - Speculum; look for discharge, inflammation, ulceration, FB and local tumors

Urethritis

- Inflammation of urethra that may or may not be associated with urethral discharge. - Gonococcal or non (chalnydai, mycoplasma, HSV, CMV, adenoviruses..) - It involves local mucous membrane epithelial cell damage or invasion by an infectious agent (bacterial, viral, or fungal) followed by inflammatory changes including accumulation of leukocytes and chemical mediators (antibodies, cytokines, and interleukins) with resultant swelling, discharge, and pain. - Sx: mostly both discharge and dysuria but can be either, or other symptoms - Urethritis usually resolves without complication, even if untreated, yet it can result in urethral stricture, stenosis, or abscess formation in rare cases. Urethritis can occur in a continuum with concomitant seminal vesiculitis and epididymitis.

Ectropion?

- It used to be called cervical erosion. - In many women cells from the inside the cervical canal, known as glandular cells (columnar epithelium) are present on the outside surface of the cervix. - The area where the glandular cells meet the squamous epithelial cells is called transformation zone. - This are may appear to bleed more easily and may produce more mucus. - Therefore ectropion may cause discharge/bleeding or pain during sex.

Gonococcal urethritis

- Neisseria Gonorrhoea, gram -ve diplococcus - Incubation period: 2-5 days - Primary site of infection is mucous membrane - Transmission by direct inoculation - Male to female = 50-90% - Female to male = 20% single exposure, 60-80% after 4 exposures

Paget's disease of vulva

- Paget's disease of the vulva is uncommon; it is usually seen in postmenopausal women. - The aetiology is unknown, although the lesion is thought to be of glandular origin. - In 25% of cases, there is an underlying adenocarcinoma (breast, urinary, genital or colonic). - Paget's disease of the vulva can be unifocal or multi- ocal and the lesions are typically clearly defined, scaly, erythematous plaques with varying degrees of ulceration and leucoplakia. - Lesions can be unifocal or multifocal and are typi- cally clearly defined, scaly, erythematous plaques with varying degrees of ulceration and leucoplakia. - The main symptom is pruritus and the diagnosis is made histologically. - Treatment is surgical using laser ablation or local excision and up to one-third will recur. - Although associated with adenocarcinoma, malignant change within the lesion is rare.

Signs of urethritis

- Profuse purulent discharge - Mucopurulent discharge - Damp meatus - Meatitis - Balanitis - Local complications: epididymal tenderness/swelling - "Normal"

Examination with pelvic pain and dyspareunia

- Pyrexia and tachycardia are associated with PID. - Rupture of an ovarian cyst can cause intraperitoneal bleed- ing and, subsequently, hypotension with tachycardia. A ruptured ectopic pregnancy would also present with these signs. - Exclude abdo mass, cachexia and amenia - Site of abdominal pain should be elicited, signs of peritonism (guarding, rebound tenderness)... On bimanual pelvic examination - Generalized tenderness, including uterine, is more common with PID. - This condition is also associated with cervical excitation (cervical motion tenderness) which indicates peritonism. - The tenderness may be unilateral with an ovarian cyst or an ectopic pregnancy. - A common site for endometriosis is the pouch of Douglas, and tender nodules can be palpated in the posterior fornix. - Pevlic mass 1) Tubo-ovarian abscess 2) Ovarian cyst 3) Endometriotic cyst 4) Fibroid 5) Ectopic pregnancy - Uterus feels tender and bulky with adenomyosis - Fixed, tender, retroverted uterus could be due to endometriosis NB - cervical os may be open if patient is miscarrying

Recurrent urethritis

- Re-infection, - Therapeutic failure - "Venereophobia": repeatedly milking the urethra (negative by white blood cell or Gram stain criteria) Any treatment of chronic NGU should cover M. genitalium and T. Vaginalis i.e. Azithromycin 500mg stat then 250mg for the next 4 days plus Metronidazole 400 mg twice daily for 5 days

Hx taking with pelvic pain/dyspareunia

- SOCRATES for pain - Associated sx: N+V, vaginal discharge or irritation - Relation of pain to menstrual cycle or to bowel habit - Ovarian cyst = acute, worse on one side, N/V, radiates to upper thighs. Must dx quickly. - Mittelschermz: must know timing of cycle to Dx - Endometriosis typically starts up to 2 weeks prior to menses and is usually relieved when bleeding starts. - PID pain is felt across entire abdomen, hx of fever - Date of LMP to exclude pregnancy/miscarriage/ectopic - Last cervical smear - Recent gynae procedures (think PID) - A history of sexually transmitted disease, previous PID or pelvic surgery could result in adhesion formation - Recent childbirth is a common cause of superficial dyspareunia, particularly if suturing of vaginal lacerations or episiotomy was necessary - A postmenopausal patient who has not been using hormone replacement therapy may have superficial dyspareunia secondary to atrophic changes. - Current use of contraception must be checked, both to exclude pregnancy and to determine the risk of PID - Sexual history; factors for vaginismus

Lichen planus

- This is a common skin condition which may occur anywhere on the body. - It usually affects mucosal surfaces, most commonly seen in the mouth, and can affect all ages. - Clinically, flat-topped purpuric plaques and papules are seen, with a fine white reticular pattern. - It is more commonly associated with pain than with pruritis. - The aetiology is unknown, but it may have an auto-immune component. - Treatment is aimed at managing symptoms and is predominantly based on topical or oral corticosteroids.

Vulval intraepithelial neoplasia

- This is a relatively uncommon condition, although the incidence is increasing in young women. - HPV 16 possibly etiology. - Histologically, neoplastic cells are contained within the basement membrane and the degree of dysplasia is divided into mild, moderate and severe (VIN 1, VIN 2 and VIN 3, respectively). - Symptoms include pruritus, pain, soreness and palpable lesions, but many are asymptomatic and found incidentally. - VIN lesions are variable and can be papular (similar to genital warts) or macular with irregular borders. Pigmentation (brown or black) is common and leucoplakia and ulceration can occur. - Invasive squamous carcinoma of the vulva usually appears as an exophytic tumour, often with surface ulceration. - Lesions can be papular (like genital warts) or macular with irregular borders. They can be red, brown or black (pigmented), or white (leucoplakia) and ulceration might be present. - Unifocal lesions are more common postmenopausally. - The diagnosis is made histologically from vulval biopsies. - Treatment is usually surgical, either by ablating the lesion with laser or cryotherapy or by local excision. - VIN will recur in up to 80% of treated women and as the risk of malignant change is small, especially in younger women, major mutilating surgery should be avoided. - Surgical treatment is recommended when the risk of malignant change is increased: • in excessively hyperkeratotic lesions in postmenopausal women • in the immunosuppressed. - If the severity of dysplasia is seen to worsen on serial biopsy excision should be considered. - Where conservative treatment is planned, topical steroids may give symp- tomatic relief.

Physiological discharge

- This is called physiological leucorrhea, and usually consists of 1-4ml per 24 hours. - It is typically transparent, mucousy white to yellowish, its typically odourless but may be slightly malodorous. - Lactobacilli in the normal vaginal flora maintain acidity in vaginal discharge by producing hydrogen peroxide and lactic acid, the ph of normal leucorrhoea in reproductive woman is 4.0-4.5 which creates a hostile environment for pathogens to grow. In premenarchal or post menopausal woman with low oestrogen levels, vaginal ph may be a bit higher 4.7 or more - It varies with changing estrogen levels associated with the luteal phase of the menstrual cycle and pregnancy. Sex and ectopy as well. Possible causes are - Vestibular gland secretions - Vaginal transudate - Cervical mucus - Residual menstrual fluid Pathological causes need to be excluded.

Sx of mycoplasma genitalium

- Urethral discharge, purulent or mucopurulent - Dysuria - Urethral pruritus - Haematuria or haemospermia - Painful intercourse or ejaculation Urinary frequency and urgency typically are absent. If present, either should suggest prostatitis or cystitis

Ix of vulval problems

- Where systemic disease is suspected, relevant investigations include thyroid and liver function, renal function and glucose tolerance. - Urinalysis might reveal the presence of haematuria, proteinurea and glycosuria. - Bacteriological swabs should be taken to exclude yeast infection and sexually active women should be screened for STDs. - Although certain vulval conditions have a typical appearance, many are difficult to distinguish. The mainstay of diagnosis of vulval dystrophies, dermatoses and neoplasms is histological. - Punch biopsies of the vulva can be performed under local anaesthetic in the outpatient setting, with or without a colposcope. - Discrete lesions can be excised in their entirety under general anaesthesia. - Hysteroscopy may be needed to exclude endometrial pathology if there is a history of PM bleeding

Most common causes of vulval skin disorders

- lichen sclerosus - lichen planus - dermatitis - vulval candidiasis. Dermatological conditions which can affect the vulva include psoriasis and eczema. Infective causes of vulval changes include STDs, warts, herpes, scabies and threadworms. Systemic causes include diabetes, renal failure and Crohn's disease.

Lichen sclerosis

- most common of the vulval dystrophy. - usually develops in PM women, although any age group can be affected, including prepubertal girls - aetiology is unknown - whole of the vulva and perianal region may be affected. - affected skin is typically thin, shiny and can have leucoplakia or erythroplakia (due to inflammation) - anatomical changes include shrinkage or loss of the labia minora and shrinkage of the introitus. - adhesions can fuse the labia together. - lichen sclerosus can affect the perineum and perianal region. Symptoms include discomfort, dyspareunia and itching, leading to bleeding and skin splitting. The labia minora may fuse laterally and the introitus may narrow. Diagnosis is made histologically from vulval biopsies, which classically show - subepithelial haemorrhage (ecchymoses) - inflammation Treatment is aimed at relieving the itching and soreness and, as this is a chronic relapsing condition, is usually intermittent: • Simple emollient creams can relieve mild symptoms. • Short courses of potent topical steroids might be needed. • The recommended second-line treatment is topical tacrolimus, with follow-up at a specialist clinic. • Testosterone cream is sometimes used, but probably acts more as an emollient than hormonally. Complications are unusual and include anatomical changes and the risk of malignancy. Anatomical changes can cause dyspareunia and, if fusion of the labia occurs in the midline, difficulty in micturition, which might require separation of the labia. Long-term follow-up of women with lichen sclerosus is important as up to 5% will develop squamous carcinoma of the vulva.

Squamous carcinoma of vulva

- to be discussed later?

DDx of deep dyspareunia

1) Congenital - Incomplete vaginal atresia - Vaginal septum 2) Infection - PID 3) Post-surgery - Relating to childbirth - Pelvic floor repair 4) Pelvic disease - Endometriosis - Fibroids - Ovarian cyst/tumors 5) Psychosexual - Vaginismus

DDx of superficial dyspareunia

1) Congenital - Vaginal atresia - Vaginal septum 2) Infection - Vulvulovaginitis 3) Postsurgery - Relating to childbirth - Pelvic floor repair 4) Vulval disease - Bartholin's cyst - Vulval dystrophies - Carcinoma of the vuvla 5) Psychosexual - Vaginismus 6) Atrophic changes - Post menopausal

DDx of vaginal discharge

1) Infective - STI: chlamydia trachomatis, trichomonas vaginalis, neisseria gonorrhea - Infection not ST: candida albicans, bacterial vaginosis 2) Inflammatory - Allergy to soap/contraceptives - Atrophic changes - Post op granulation tissue 3) Malignancy - Vulval carcinoma - Cervical carcinoma - Uterine carcinoma 4) Foreign body - Retained tampon/condom - Ring pessaries 5) Fistula - From bowel, bladder and ureter to vagina

Investigations for vaginal discharge

1) Microbiological swabs - Vulval/high vaginal swab (HVS); for candida albicans and trichomonas vaginalis - Endocervical/urethra swabs for chlamydia trachomatis and neisseria gonorrhea 2) MSU - Infection 3) Cervical cytology 4) Endometrial sampling/hysteroscopy 5) Pelvic ultrasound 6) Laporoscopy - PID - Pelvic malignancy

Treatment of urethritis

1st line Rx - Ceftriaxone 500mg IM as a single dose and - 1gm Azithromycin orally Alternative Rx ( all with 1gm Azithromycin) - Cefixime 400mg oral as a single dose - Spectinomycin 2gm IM as a single dose - Cefotaxime 500mg IM as a single dose - or Cefoxitin 2g IM as a single dose plus probenecid 1g oral Quinolones-↑ resistance - Ciprofloxacin 500mg oral as a single dose - Ofloxacin 400mg oral as a single dose Azithromycin 2gm orally can be given but intolerance due to side effects Advice to abstain from sexual intercourse until they and their partner(s) have completed treatment

DDx pelvic pain

Acute 1) PID 2) Tubo-ovarian abscess - Post termination - Post IUCD insertion - Post hysteroscopy 3) Early pregnancy complications - Miscarriage - Ectopic pregnancy 4) Gynaecological malignancy 5) Ovarian cyst - Rupture - Hemorrhage - Torsion 6) Fibroid necrosis 7) Ovulation pain (mittelschmerz) 8) Abscess - Bartholin's cyst - Labial 9) UTI or renal calculi 10) Appendicitis Chronic 1) Adenomyosis 2) Endometriosis 3) Adhesion - Gynae surgery - PID - Appendicitis 4) Gynae malignancy 5) GI pathology - Diverticulitis - IBS

Mycoplasma genitalium

Association of M. Genitalium with urethritis Acute - 10-30% ; assoc with inflammatory discharge Chronic - 20-40% -Difficult to culture -Diagnosis by molecular methodology Molecular probes PCR

Treatment of NGU

Azithromycin 1gm orally, single dose or Doxycycline 100mg bd x 7 days Or Ofloxacin 200mg bd x 7 days

Symptoms of vulval disease

Common sx include pain and pruritis. Causes can be classified as follows: • Vulval dystrophy • Neoplasia • Dermatological • Infection. Common skin changes include changes in texture and colour. Generalized dermatological conditions and systemic illness may present with vulval symptom.

Dysuria in men

Dysuria may be caused by anything that causes inflammation of the urethral mucosa. Infection is the most common cause. - < 35yrs of age cause more likely to be an STI - > 35 yrs of age cause more likely to be UTI due to coliforms. In older men infection is more likely to be due to stasis secondary to BPH

How can we classify vulval dystrophies and how do they generally present

Histologically, the vulval dystrophies are divided into atrophic and hypertrophic or a mixed picture of both. Atrophic vulval dystrophy is better known as lichen sclerosus. Lichen planus.

Hx and Ex with vulval disease

History - Younger: infection - Older: dystrophies and cancers - Acute onset: infection - Hx of PM bleeding: cancer - Symptoms of yeast and herpetic infections may worsen premenstrually - Contact dermatitis: recent changes in soap or stuff - Discharge: infection - Presence of systemic skin disorders - History of atopy and symptoms suggestive of DM, renal and liver failure - FH of autoimmune conditions Examination - Skin surfaces prone to derm conditions - Signs of chronic renal/liver failure - Vaginal and cervical examination - Look for inguinal lymphadenopathy - Generalized vulvitis, vaginal discharge and ulcers suggest an infective cause, although ulceration should alert the examiner to the possibility of malignancy. - Genital warts might be seen on the vulva, perianally, in the vagina or on the cervix. - Labial fusion, adhesions, stenosis of the introitus, leucoplakia and atrophic changes are frequent signs of lichen sclerosus. The lesions of hyperplastic dystrophy can be localized or extensive, and typically show thickening of the affected skin with variable colour change. Thickened plaques of leucoplakia might be present.

Investigating urethritis

Microscopy of gram stained genital specimen - 90% sensitive in symptomatic patients Urethral swab - culture Direct plating on to culture plates (Thayer Martin or modified New York selective medium, Incubated at 370C in a CO2 incubator) OR Send swab in Amies's or Stuart's transport medium Urine NAATs Other sites: Rectal and Pharyngeal swabs

Define chronic pelvic pain

Pain that lasts 6 months or more

Physiological vs. pathological causes of discharge in men

Physiological - Pro-semen - Prostatorrhoea - Nocturnal emission Pathological - Infectious; gonococcal or non gonococcal - Prostatitis - Sensitivity to chemicals - Trauma ex. catheterization and instrumentation

How do we classify dyspareunia

Superficial: at the area of the vulva and introitus Deep: within the pevlis

Rx of mycoplasma genitalium

Tetracyclines -40-80% effective Azithromycin - 1 gm 80% effective - 1.5 gm > 95% effective ( 500 mg stat then 250mg daily for 4 days) Quinolones - moxifloxacin- 2nd line (Hepato toxic)

Dermatological conditions affecting the vulva

The typical raised, erythematous, scaly lesions of psoriasis can occur on the vulva, although here they might appear smooth and without the scaling. The presence of psoriasis elsewhere on the body will suggest the diagnosis, which can be confirmed histologically. Treatment is with topical steroids, but the relapse rate is high. Eczema of the vulva is rare. More commonly, eczematous reactions occur due to contact with irritant sub- stances such as soaps and detergents. Treatment is by identifying and removing the source of irritation and topical steroids.

Review: vulval anatomy

The vulva extends from the mons pubis anteriorly to the perineum posteriorly and the labia majora laterally. The whole surface of the vulva up to the inner aspect of the labia minora is covered by stratified, keratinized squamous epithelium with a superficial cornified layer. The cornified layer is absent in the vagina and there is a decreasing degree of keratinization.

Reiter's syndrome

Triad of -urethritis -arthritis & -conjunctivitis -+ with or without other cutaneous or mucous membrane lesions such as, keratoderma blennorrhagica, circinate balanitis, uveitis, oral ulceration, cardiac or neurological involvement. Aetiology is multifactorial: - Infective - Immunological - Genetic factors - More common in men (1-2% of men with sexually acquired NGU. - C trachomatis, N.gonorrhoea, - Enteric infection (Shigella flexneri, yersinia enterocolitica, Salmonella spp. And Compylobactor spp.) - HLA-B27