ABNORMAL VAGINAL DISCHARGE -ETIOPATHOGENESIS

Dr. G. Ruben raj

Vaginal discharge is the most common presenting

complaint of females attending op department.

Excessive vaginal discharge may be physiological or

Pathological.

DEFINITION :

Abnormal vaginal discharge (AVD) is defined as any

one of the three presentations,

1. Excessive vaginal discharge not associated with

menstruation; pre, mid and post period.

2. Offensive or malodorous discharge

3. Yellowish or mucopurulent discharge

PREVALANCE It has been estimated that

approximately 1/3 rd of female patients

may complain of Abnormal vaginal

discharge.

It can occur in females of all ages,from

neonatal to the post menopausal period

and it is quite common during pregnancy.

Many clinics have reported that 70%

of pregnant women manifest Abnormal

vaginal discharge due to lower genital

tract infection.

NORMAL DISCHARGE

Floccular in consistency

Whitish and non malodourous

Normal pH is acidic ranging from 3.5

to 4.5 due to Lactobacilli which convert

glycogen to lactic acid

Secondary fermentation of

endocervical mucus by vaginal flora also

contribute to low pH.

Cellular contents of discharge are composed of sloughed cells of cervical

columnar and vaginal squamous epithelium.

Bulk of discharge consists of serous vaginal transudate and lubricating

cervical mucus

VULVO VAGINAL SOURCE

Vaginal canal being ectodermal origin consists of stratified

squamous epithelium.

There are no sweat,sebaceous and other types of secretory

glands in vaginal epithelium.

Upper end is formed by portio vaginalis of cervix

Caudal end is formed by vulva lined by squamous

Epi. containing secretory,sweat and sebaceous gland

Vaginal fluid is largely derived from serum trasudate in vaginal beds

that seeps from capillaries through intercellular channels.Small amount is

derived from Bartholins glands,endometrium and fallopian tubes.

CONTENT -

cellular debris,transudate consisting primarily of water &

electrolytes,facultative micro organisms,fatty acids,proteins and

carbohydrates.

Contd...

Cervical source:

Cervix is the principal source of

vaginal secretion.

The stratified squamous epithelium of

the portio vaginalis changes in to high

columnar at the external os which lines

the cervical canal and cervical glands as

well.

The cervical glands secrete thick and

Viscid mucus

Cervical glands are of simple and

Tubulo alveolar type..

UTERUS AND FALLOPIAN TUBES

Though uterus is lined by highly

secretory columnar epithelium,they

contribute less to the normal vaginal

secretion.

The secretion of the glands undergo

cyclic activity in the elaboration of

glycogen and other nutritive substances in

preparation for pregnancy each month

Tubes normally contribute nothing to

vaginal secretion.

In rare instance of a hydro salphinx

resulting from salphingitis,the tubal

secretions may be expelled through

vagina,in the form of watery discharge.

VAGINAL MICRO ORGANISMS :

The vaginal eco system is a complex environmental condition,consisting of

inter relationships among the endogenous microflora,metabolic products of

microflora,host oestrogen and the pH.

Vaginal infection and inflammation

occurs when vaginal eco system is

altered.

When the balance of micro organism

changes,potentially pathogenic

organisms that are part of normal flora

proliferates and lead on to overt

infection.

Besides lacto bacillus,other organisms in vaginal flora includes—

Bacteroids,Beta haemolytic and non haemlytic stretococci,Candida albicans,

Diptheroids,enterococci,E.coli,mobiluncus,M.hominis,Peptostreptococci spp,

Staph.epidermidis and Ureaplasma urealyticum.

Contd...

VAGINAL ECO SYSTEM

NON INFECTIVE LEUKORRHEA :

Non infective leukorrhea should be considered as the diagnosis when

following criteria are fulfilled.

ENDO CERVICAL SECRETIONS:

Absence of visible mucopus

Absence of microscopic mucopus

Contd...

Vaginal secretion :

Absence of trichomonad motility,

Absence of filamentous elements,

Clue cells less than 20% of vaginal epithelial cells,

Numerous lactobacilli

Polymorpho nuclear leukocytes: Epithelial cell ratio is

1:1 or less

If all seven criteria are fulfilled, vaginal and cervical infections can be safely

excluded.

CAUSES FOR VAGINAL DISCHARGE

PHYSIOLOGICAL :

AGE-DEPENDENCE :

1.NEONATE AND INFANT

2.PRE-PUBERTY

3.CHILD BEARING

4.POST MENOPAUSAL

--

CONTD.

EXCESSIVE SECRETION :1.PREGNANCY

2.SEXUAL AROUSAL

PATHOLOGICAL :

A) NON-INFECTIVE

CHEMICAL IRRITATION –Antiseptics,bath additives

deodorants,detergent spermicides,douches,

perfumed soaps.

-CONTD..

FOREIGN BODIES

IUCD,RETAINED MATERIALS,RETAINED

TAMPONS RETAINED SHEATHS

GYNAECOLOGICAL CONDITIONS

ENDOCERVICAL POLYP,FISTULAE,RADIATION

EFFECTS,POST-OPERATIVE AND TUMOURS

OTHERS : MEDICATION,NUTRITION AND SEXUAL PRACTICE

INFECTIVE CAUSES

CERVICITIS1.HERPES GENITALIS

2.MUCOPURULENT CERVICITIS— a) Gonococcal

b) Non gonococcal- Chlamydia

positive and Chlamydia negative

VAGINITIS

1.BACTERIAL VAGINOSIS

2.VAGINAL CANDIDIASIS

3.VAGINAL TRICHOMONIASIS

AGE DEPENDANT PHYSIOLOGICAL CONDITION :

NEONATE AND INFANTS:

Neonatal vagina is lined by st.squamous

epithelium due to influence of maternal oestrogen.

After 1 month to puberty lined by cuboidal

epithelium [PH -7.0].Neonatal physiological discharge results from

maternal estrogen action on vaginal epithelium.

Maternal estrogen is metabolised in 3-4 weeks.

SUSCEPTIBILITY TO INFECTIONS :

EARLY NEONATE Vaginal epithelium susceptible to

T.vaginalis and C.albicans due to peri

natal transmission.

Resistant to N.gonorrhea and

C.trachomatis.

OLDER INFANTS Susceptible--N.gonorrhea&C.trachomatis

Resistant to Candida.

EARLY NEONATE

OLDER INFANTS

PRE-PUBERTY :

Pre puberty physiological discharge is a hall mark

of

Impending onset of menarche

Due to unopposed secretion of estrogen the

ovaries stimulates vaginal and cervical secretions

leading to discharge

It is thin and mucoid and soils under

garments.This discharge may be interpreted as

infection.

It ultimately subsides with the onset of cyclic

progesterone activity.

CHILD BEARING AGE :Causes for increased vaginal secretion during child bearing

age is as follows:

1.Mid cycle stimulation of endo cervical

glands by oestrogen

2. EXOGENOUS-Semen of recent

ejaculation

3. Mid cycle discharge is sufficient to

keep the vagina

moist and usually does not stain the under garments.It may

be associated with

Mittelshmerz or mid cycle unilateral pelvic discomfort.

POST MENOPAUSAL PERIOD

There is atropy of vaginal epithelium due to diminished

estrogen secretion

Thin,serous discharge,occasionally blood

stained and associated with itching and burning.

Small areas of granulation and ulceration along

with slight vaginal bleeding may develop.

Most common cause of

Abnormalvaginaldischarge is Atropic vulvovaginitis.

EXCESSIVE SECRETION

PREGNANCY

o Physiological discharge,floccular in

characteristics,may exceed

1ml of amount on speculum examination.

o Occurs due to increased vascularity,congestion of

pelvic organs

and cervical hyperplasia.

SEXUAL AROUSAL

o In non pregnant women,sexual arousal results in increased

discharge,due to secretion from Bartholins glands.

NON-INFECTIVE CONDITIONS CAUSING AVD

CHEMICAL IRRITANTS

Antiseptics,deodarants,detergent

spermicides,douches and perfumed soaps-

Chemical induced vulvovaginitis

Allergic reaction raraely cause discharge,often

associated with local reaction.

MANAGEMENT- Avoiding irritants and saline baths.

...contd

Long term use of tampons and multiple douching should

generally be avoided

, as they increase the discharge due to drying effect and

alteration of vaginal flora

Commercial preparations leads to abnormal shift in

vaginal flora.

Douching should be generally avoided.But if patient persists

mild vinegar solution and water could be used.

FOREIGN BODIES :

Foreign bodies—cotton wool from tampons often becomes entained with

thread of IUCD and act as source of infection.

Retained tampons & broken sheath may result in persistent infection

producing copious,foul smelling discharge

It is necessary to remove the foreign body and then the vaginal flora will

rapidly return to normal.

GYNAECOLOGICAL CONDITIONS :

DISCHARGE CAUSE

Mucoid and blood tinged Endo cervical polyp

Profuse watery discharge with Uro genital fistula

out mucoid element---Urine

Clear discharge,slight bloody Vaginal vault Granulation tissue

Secretion[following Hysterectomy]

Heavy vaginal discharge Benign tumours

Frank bleeding Malignant tumours

Purulent discharge Bacterial infections

MEDICATION AND SEXUAL PRACTICE

Alternative medicinal drugs,over the counter medicinal products and nitritive

compounds may be associated with infective or non infective discharge

Examples include oral and vaginal metronidazole lead to an increase inlacto

bacilli which persists for 1 month after therapy and Intra vaginal Clindamycin

has caused a decrease in lacto bacilli 1 week post-therapy.

Sexual activities and change in sexual partners may alter the normal vagina

Flora leading to vaginal discharge.