Vaginal discharge and itching

CHAPTER 34 Vaginal discharge and itching


Vaginitis is an inflammation of the vagina that can cause vaginal discharge. Vaginal infections are common in postpubertal women. Trichomonas vaginalis, Candida, and bacterial vaginosis (BV) (the epithelium is not inflamed with this syndrome) account for 95% of all vaginal infections in U.S. women. Often patients have more than one infection at a given time.


Some studies suggest that pregnant women with BV have premature rupture of membranes and early delivery. The most common cervical infections are Chlamydia trachomatis, Neisseria gonorrhoeae, and herpes simplex. Postmenopausal women often have discharge related to atrophic vaginitis, caused by the deficiency of estrogen in the vaginal tissues.


Vulvar itching, burning, and a foul odor often accompany vaginal discharge. Pubic lice, scabies, pinworms, and genital warts (condylomata acuminata) can all cause itching. Common foreign bodies found in the vagina of adults are lost or forgotten tampons, which can produce a foul-smelling discharge.


Chemical vaginitis in a young girl is usually caused by sensitivity to bubble bath, whereas in the adolescent or woman it occurs because of the use of scented douches, lubricants, or hygiene sprays. Vulvovaginitis is one of the most common gynecological disorders in girls as a result of their hypoestrogenic state and their perineal hygiene, which is often poor. The vaginal mucosa is thin and less resistant to infectious organisms. The postmenopausal woman can experience these same symptoms with estrogen deficiency.


In childhood and adolescence, reports of vulvar itching, soreness, or vaginal discharge are common. The lack of estrogen stimulation; neutral pH of the vaginal secretions; lack of protective thick labia and pubic hair; and daily living habits (e.g., wiping, clothing, play equipment, environment, and baths), lead to this complaint.



Diagnostic reasoning: focused history





What kind of vaginitis might this be?



Key questions




image What are the amount, color, and consistency of your discharge?


image Do you have itching, swelling, or redness?


image Is there an odor?




Characteristics of discharge


Copious amounts of greenish, offensive-smelling discharge are most consistent with T. vaginalis. Mucopurulent or purulent discharges are associated with gonorrhea and Chlamydia. A moderate amount of white, curd-like discharge is consistent with Candida vulvovaginitis. BV typically produces a discharge that is thin and either white, green, gray, or brownish. Although characteristic symptoms associated with each type of vaginal discharge can be helpful in arriving at a diagnosis, they are not diagnostic in and of themselves. Microscopic examination of the vaginal discharge is more sensitive than the clinical picture in confirming the diagnosis (Figure 34-1).


image

FIGURE 34-1 Microscopic differential diagnosis of vaginal infections. A, Clue cells (epithelial cells with clumps of bacteria) are evident in bacterial vaginosis. B, Budding, branching hyphae characterize candidiasis. C, Motile trichomonads are seen with trichomoniasis.


(From Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 3, St Louis, 1997, Mosby-Wolfe.)



Itching, swelling, and redness


Vaginitis causes inflammation of the tissues, resulting in erythema and edema. Because of the inflammatory process, the amount of discharge will produce a concomitant amount of swelling and redness of the vulva and vagina. Itching is consistently present with candidiasis. Scratching can lead to excoriations and satellite lesions. BV does not involve the inflammatory process and results in discharge with little vulvovaginal erythema and edema.



Odor


A fishy odor caused by the release of amines from organic acids is prominent with BV. It is accentuated by the addition of potassium hydroxide (KOH) to the wet mount slide and is considered a positive “whiff” test. Odor commonly accompanies trichomonal infections. Retained tampons or other foreign bodies can also cause a foul odor.





Is this likely a sexually transmitted infection?



Key questions



image Are you sexually active? Do you have multiple partners? Do you have a new partner?


image Have you had sex against your will? If a child: You might ask, “Has anyone touched your private parts?”


image What form of protection do you use? How often do you use protection?


image Have you or your partner(s) ever been tested or treated for a sexually transmitted infection (STI)?


image Do you have any rashes, blisters, sores, lumps, or bumps in the genital area?



Sexual history


Early-age onset of sexual activity, multiple partners, and nonuse of barrier contraceptives, particularly condoms, increases the risk of vaginal infection. STIs are common in women of childbearing age (12 to 50 years) who have acquired a new partner. The patient who frequently changes sexual partners or participates in risky sexual practices (e.g., rectal intercourse without a condom) is at high risk for STIs.


Do not ignore the possibility of an STI in older women or children. An older woman may be sexually active, for example, after a divorce or widowhood. Also, 50% of all children with an STI have been found to be sexually abused. T. vaginalis is rare in children but can be transmitted to the neonate from an infected mother.



Recent treatment for a sexually transmitted infection


Recent treatment for an STI may indicate treatment failure, a coinfection that was not covered by the prescribed drug, or recent exposure.



Lesions


Vesicles usually indicate herpes infection. Patients typically notice them on the external labia and report that they itch or burn. Condylomata lata, condylomata acuminata, and molluscum contagiosum are all papular lesions found on the labia, perineum, and anal regions. Molluscum contagiosum, when occurring in the genital area, may extend to include the inner thighs. Typically, condylomata acuminata (genital warts) are rough, verrucous lesions that are usually located inferiorly from fossa navicularis to the fourchette and the perineal area. A painless ulcer suggests syphilis and classically appears as a solitary lesion. However, there can be more than one chancre, especially if the patient is immunocompromised.





Can this be vaginitis that is not related to an sti?



Key questions



image Have you ever been told that you have diabetes or Cushing syndrome or that you are positive for HIV infection?


image Have you been ill recently?


image Are you taking antibiotics, hormones, or oral contraceptive pills?


image Have you received chemotherapy?


image Does the itching seem to be worse at night?


image Can you describe some of your recent activities?


image Is the patient premenarche?



Immunocompromised states


Refractory fungal vulvovaginitis may indicate undiagnosed diabetes or an immunocompromised state.



Recent illness


Chickenpox, scarlet fever, and measles can cause vaginitis.



Medications or chemotherapy


Birth control pills, corticosteroids, antibiotics, and chemotherapy are associated with candidal vulvovaginitis. Oral contraceptives can alter the vaginal pH, and antibiotics can alter the normal vaginal flora; both predispose to fungal infection. Corticosteroids and chemotherapy can produce an immunocompromised state and provide the opportunity for fungal infection.



Night itching


Pinworms are intestinal parasites that inhabit the rectum or colon and emerge to lay eggs in the skinfolds of the anus. Perianal pruritus, especially at night, along with pain or itching of genitals is common (Figure 34-2).


image

FIGURE 34-2 Pinworms (Enterobius vermicularis). On this wet mount, a mature worm is shown surrounded by eggs (A), which are shown more clearly at higher power (B).


(From Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 3, St Louis, 1997, Mosby-Wolfe.)



Activities


Riding a bicycle, using pools or hot tubs, or wearing tight-fitting pants or pantyhose can lead to heat and moisture in the genital area, causing mechanical irritation and such infections as candidiasis or BV.



Premenarche


Girls who have not yet reached menarche are prone to vulvovaginal infections because of a nonestrogenized vagina and the lack of labial development and hair growth.





Is this condition acute, recurring, or chronic?



Key questions



image How long have you had these symptoms?


image Are they getting better or worse?


image Have you ever had these symptoms before?


image How many episodes have you had in the past year?


image Are the episodes related to any particular activity or time?



Chronology of symptoms


The occurrence of vaginal discharge after having a new sex partner suggests an acute condition, such as a sexually transmitted infection. Symptoms associated with use of condoms or spermicidal jelly suggest sensitivity to the product. If the discharge occurs monthly, becoming worse after menses, suspect a chronic condition, such as vulvovaginitis candidiasis. Recurrent episodes related to bathing activities point to chemical irritation.





If this is acute, could it be related to a previous infection?



Key questions



image Have you been tested and treated for this condition recently?


image What medication was prescribed?


image Did you take all of the medication?


image What other prescriptions were you taking at that time?


image Have you taken any over-the-counter medications?



Adequate diagnosis


Diagnoses made clinically on the basis of the color or appearance of discharge may be incorrect, or a concomitant vaginal infection may have been missed. However, self-diagnosis and treatment are common, especially with the over-the-counter medicines for “yeast infection.”



Adequate treatment


Most medications that are prescribed are not taken exactly as directed. Women may stop using their vaginal medications when menses begins and resume after it ends. This practice can lead to treatment failure. They may also discontinue the therapeutic agent early, as soon as relief from symptoms takes place or a drug side effect is experienced (e.g., the metallic taste of metronidazole). Drug interactions may account for inadequate therapy, or there may be the need to alter dietary regimen (e.g., abstain from alcoholic beverages).





If this is chronic, what should i suspect?



Key questions



image Do any family members or sexual partners have recurrent vaginal or urinary tract infections? Do they have any itching, rashes, sores, lumps, or bumps?


image Do you have a new or untreated partner?


image What are your sexual practices (e.g., vaginal, oral, and/or anal sex)?


image How many yeast infections have you had in the past year?



Transmission


Caregivers, parents, and siblings can spread infections, such as candidiasis, molluscum contagiosum, herpes, lice, and pinworms to children through poor hygiene practices. Autoinoculation is also possible, especially for herpes, genital warts, and molluscum contagiosum.



New or untreated partner


The most common cause of reinfection is intercourse with a new or untreated partner.



Sexual practices


Possible infection reservoirs are oral and anal cavities, which may need to be cultured for herpes or gonorrhea. Additionally, materials used during intercourse may need to be disinfected (e.g., diaphragm). Less common modes of transmission include shared intimate clothing.

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Apr 10, 2017 | Posted by in NURSING | Comments Off on Vaginal discharge and itching

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