Transcript Causes of Vaginal Discharge Including Sexually

Causes of Vaginal Discharge
Including Sexually Transmitted Infections
This is a nursing training
presentation.
Some of the images are
sensitive in nature and reflect
graphic disease processes.
It may be inappropriate for
certain audiences.
Learning Objectives
Describe common causes of vaginitis
Provide education on risks, symptoms, treatment, and
prevention strategies for common vaginal infections
including those that are sexually transmitted
Understand the components of a good sexual history
Appropriately triage women who present with vaginal
discharge
Vaginitis
Most frequent reason American women
visit the provider
More than 10 million office visits per year
Many related to infections that are
transmitted by sexual contact
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Most Common Causes of Vaginitis
Overgrowth of vaginal flora
Sexually transmitted infections
Non-infectious causes
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The
Pelvic
Exam
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Pelvic Exam Supplies
Poll Question
Which items would you set out for a vaginitis exam?
A. Speculum, battery, pH paper, saline, KOH,
ThinPrep (Pap solution), cotton swabs
B. Speculum, battery, gloves, pH paper, culture set
C. Speculum, battery, gloves, cultures, pH paper,
KOH, saline, cotton swabs
D. None of the above
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Assessment of discharge
(color, viscosity, odor,
adherence to vaginal walls)
Visualization of cervix
to rule out cervicitis
Vaginitis
Exam
Lab tests (pregnancy,
pH, wet mount)
Opportunity for birth control
and Plan B discussions
STI Evaluation
HIV test
Hepatitis B screen
Chlamydia/gonorrhea culture
VDRL/RPR for syphilis
DNA probe (Affirm test)
Rapid antigen test
Consider Pap (if over 21 and due for Pap testing)
Poll Answer
Which items would you set out for a vaginitis exam?
A. Speculum, battery, pH paper, saline, KOH,
ThinPrep (Pap solution), cotton swabs
B. Speculum, battery, gloves, pH paper, culture set
C. Speculum, battery, gloves, cultures, pH paper,
KOH, saline, cotton swabs
D. None of the above
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Common Causes of Vaginitis
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Bacterial Vaginosis (BV)
• Lack of protective lactobacilli which
keep anaerobes (bad bacteria in
check)
• Present in 29% of women
• Most common cause of discharge,
although 50% of women are
asymptomatic
• ‘Fishy’ odor, milky-white discharge
• 30% of women have a recurrence in
3 months, 50% in 12
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Bacterial Vaginosis (BV)
• Women with BV may be at higher risk for:
– Acquiring STIs including HIV, gonorrhea, chlamydia,
and herpes
– Post-op infections after gynecologic procedures
– Pregnancy complications (premature rupture of
membranes, premature delivery, low‐birth weight)
– BV recurrence
• Often identified in female-female partnerships
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Patient Education for BV
• Caused by a lack of protective lactobacilli
• More likely to occur in situations where normal vaginal flora are
altered such as douching or use of intravaginal preparations
• Use prescription oral or intravaginal medication as directed
• OTC medicines for yeast and other vaginal products don’t work
• Recurrence in 3-12 mos is common; treating male partner will not
help
• Reduce risks:
– Abstinence, mutual monogamy, latex condoms, limit number of
sex partners
– Wash sex toys
– Avoid douches and deodorant sprays
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Vulvovaginal Candidiasis
(Yeast infection)
• 75% of women experience it, and half have recurrences
• Overgrowth of normal vaginal flora
• Itching, redness, burning, ‘cottage cheese discharge’, no odor
• Usually not sexually transmitted; often found when evaluating
for STIs
• Risk factors:
– Diabetes, antibiotics,
spermicides, douching,
contraceptive devices, HIV,
pregnancy, corticosteroids
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Patient Education for Candidiasis
• Lack of vaginal lactobacillus bacteria allows overgrowth of yeast
fungus
• Can be spread through oral-genital contact
• Associated with antibiotics, pregnancy, diabetes, impaired
immune system, douching, sexual activity
• Take medicine as directed
• Avoid douches or feminine sprays to treat or prevent recurrence
• Mineral oil in topical antifungal preparations may erode latex
condoms and diaphragms. Use plastic or polyethylene condoms.
• Reduce risks: abstinence, mutual monogamy, latex condoms,
limiting number of sex partners
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Sexually
Transmitted
Infections (STIs)
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Estimated number of new and existing
(total) sexually transmitted infections
United States, 2008
Syphilis Gonorrhea Hep B
117,000 270,000 422,000
50,627,400
HIV
Chlamydia Trich
908,000 1.6 mil
3.7 mil
59,569,500
HSV-2
24 mil
HPV
79 mil
TOTAL 110,197,000
CDC Fact Sheet. Incidence, prevalence, and cost of sexually transmitted infections
in the United States, Feb 2013.
Trichomoniasis
• Very common STI
• Itching, burning, redness, pain during
urination and intercourse
• Frothy, thin, malodorous, yellowgreen discharge, although 85% of
women are asymptomatic
• Can be transmitted between female partners
• Risk factors: multiple partners, low SES, hx of STIs
• Pregnancy complications: associated with premature rupture
of membranes, preterm delivery, and low birth weight
• Trichomonas infection in HIV‐infected women may enhance
HIV‐transmission to sexual partners
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Patient Education for Trichomonas
• Can last for years without treatment
• Metronidazole can trigger cramps, nausea, vomiting, headaches
and flushing if combined with alcohol
– Avoid alcohol use during treatment and 24 hrs after
– Some providers advise avoiding alcohol for up to 3 days after
• Metronidazole should not be taken in first trimester of pregnancy
• No sex until patient/partner(s) complete treatment
• Douching may worsen discharge
• Can recur. Re-evaluate if symptoms persist.
• Trichomonas may facilitate HIV transmission
• Reduce risks: abstinence, mutual monogamy, latex condoms,
limiting number of sex partners
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Cervicitis
• Inflammation of the cervix (not always
related to infection)
• Causes
− Chlamydia, gonorrhea most common
(treat for both)
− Foreign objects, radiation, malignancy
• Mucopurulent discharge, pain during intercourse, bloody
discharge or spotting between periods, burning upon urination if
urethra is also infected.
• Can spread to uterus, fallopian tubes, or ovaries, resulting in
pelvic inflammatory disease (PID)
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Gonorrhea
• Common in cervix and vagina
• Also grows in urethra, mouth, throat,
eyes, anus
• Painful urination, vaginal discharge,
bleeding between periods; 50% of
women asymptomatic
• Associated with ectopic pregnancy,
PID, infertility, Bartholin’s cyst
Gonorrhea Diagnosis and Treatment
• Diagnosis
− NAATs (Nucleic Acid Amplification Testing)
− Endocervical culture
• Treatment
– Dual antibiotic therapy
• Ceftriaxone as single IM dose, plus either azithromycin
orally in single dose or doxycycline twice daily x 7 days
– Retest at 3-6 mos or whenever the patient seeks care in next
12 mos
– Evaluate and treat partners
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Patient Education for Gonorrhea
• In 15% of infected women, untreated gonorrhea spreads to
fallopian tubes, where it can cause scarring and infertility
• Increases susceptibility to HIV infection
• Treated with two medications. Take oral medication as
directed.
• Some strains are resistant. Retest in 3-6 months. Return earlier
if symptoms persist.
• No sex until patient/partner(s) complete treatment
• Reduce risks: abstinence, mutual monogamy, latex condoms,
limiting number of sex partners
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Chlamydia
• 1.6 million new infections/year
• Found in cervix, urethra, throat,
rectum
• Frequent/urgent urination with
burning, vaginal discharge, light
bleeding post-intercourse, lower
abdominal pain; however, 75% of
women asymptomatic
• Associated with infertility, PID, ectopic pregnancy
• Perinatal transmission results in neonatal conjunctivitis in 30-50%
of exposed babies
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Chlamydia Screening
US Preventative Services Task Force recommends
screening asymptomatic women…
 Yearly for all sexually active women ≤ 24 years
 Yearly for sexually active women > 24 years with
risk factors
• African American, new male sex partner, two or more
partners in preceding year, inconsistent barrier
contraceptive use (condoms) and hx of prior STI
 All pregnant women at first prenatal visit
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Chlamydia Diagnosis and Treatment
• Diagnosis
– NAATs
– Endocervical swab
– Urine test
• Treatment
– Antibiotics (azithromycin 1 g orally in single dose or
doxycycline 100 mg orally twice daily x 7 days)
– Retest at 3 mos or when patient seeks care in next 12 mos
– Evaluate and treat partners
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Patient Education for Chlamydia
• If untreated, can lead to tubal pregnancy, chronic pelvic pain,
infertility
− 30% of women develop PID
− 50,000 become infertile yearly due to untreated chlamydia
and gonorrhea
• Complete medication as directed
• No sex until patient/partner(s) complete treatment
• Women should be screened at least once a year if < 25 or if at
high risk or if become pregnant
• Pregnant women may need repeat testing 3 wks after treatment
• Reduce risks: abstinence, mutual monogamy, latex condoms,
limiting number of sex partners
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Genital Herpes Simplex Virus (HSV)
• 25% of population has serological evidence
• HSV-2 is genital, most common (1 in 4 women, 1 in 5 men 15-45)
• Transmission
– Kissing, skin-to-skin contact, vaginal/oral/anal sex
– Can be transmitted when symptoms are not present
• Outbreaks can occur 4-5 times/year; most frequent in first year
• C-section at delivery to prevent newborn infection
• After resolution, asymptomatic intermittent viral shedding occurs
even in absence of genital lesions
• Complications: most common cause of viral encephalitis; 3rd most
common cause of sexually transmitted proctitis
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Primary outbreak occurs 1 wk after contact
• Fever, chills, headache, painful lymph nodes
in groin
• Pain or itch usually precedes blisters/skin
ulcers
• 75% of patients with primary genital HSV
infection are asymptomatic.
Granulating ulcer
Initial lesions
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Genital
Herpes
Herpes Cervicitis
Genital Herpes
• Diagnosis
− Often inaccurate if based on H&P
− Viral culture for active lesions
− PCR (polymerase chain reaction) to detect asymptomatic virus
shedding
− Direct fluorescent antibody for clinical specimens (can
determine herpes subtype )
• Treatment
− Antiviral meds treat primary herpes/suppress recurrent
outbreaks (daily antivirals can decrease recurrences by 70-80%
for patients with 6+ episodes/year)
− Topical treatments do not work
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Partner
check!
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Patient Education for Genital Herpes
•
•
•
•
•
•
No cure. Symptoms may recur; recurrence varies by person.
First attack is usually worst; 40% never have second outbreak.
Outbreaks can be related to menses, intercourse, sunbathing, stress
Inform all partners; abstain from sex when symptomatic
Can be transmitted without symptoms; use latex condoms
People with herpes more likely to become infected if exposed to HIV
through sex; people with HIV + herpes more likely to spread HIV
• Take meds to prevent symptoms from returning/make recurrences
less severe
• Topical treatments don’t work; analgesics help painful lesions
• Inform provider if you become pregnant
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Syphilis
Stage 1: Primary
• Chancre or ulcer
Stage 2: Secondary
• Skin rash
• Lymphadenopathy
Stage 3: Tertiary
• Years later, neurologic
infection through body
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40,000 new cases/year caused by
bacterium Trepomema pallidum
Condyloma lata lesions (secondary syphilis)
Syphilis Diagnosis and Treatment
• Diagnosis
– Venereal Disease Research Laboratory (VDRL) and RPR
(Rapid Plasma Reagin)
– Treponemal test (FTA-ABS ) can confirm diagnosis
• Treatment
− Early infections: single-dose benzathine penicillin
− Late latent infections of unknown duration: benzathine
penicillin in 3 doses each at 1 wk intervals
− Clinical and serological follow-up tests at 6 mos and 12 mos
post-treatment
− Treat partners presumptively
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Patient Education for Syphilis
• Comply with medication instructions
• Return for 6 and 12 month follow-up appts
• No sex until patient/partner(s) complete treatment
• Pregnant women should have a blood test for syphilis to prevent
passing infection to the baby
• People with syphilis more likely to become infected if exposed to
HIV through sex; people with HIV + syphilis more likely to spread
HIV to others
• Reduce risks: abstinence, mutual monogamy, latex condoms,
limiting number of sex partners
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HPV-Related Genital Warts
• Caused by human papillomavirus
(HPV) subtypes 6 and 11
• Benign but very contagious
• Pink or flesh-colored, raised/flat
spots resemble cauliflower
• Inside/outside vagina or anus, on
nearby skin, on cervix, lips, mouth,
tongue, throat
• Women can be infected and not
have symptoms
• Can take 6 mos to develop
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HPV-Related Genital Warts
Treatment:
• Creams
– Polophyllin TCA, Aldara or
imiquimod 5%
• Cryosurgery, laser therapy,
electro-cauterization, surgical
excision
• Examine partners and treat if
warranted
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HPV Cervical Condyloma
• If cervix is
infected, follow
with Pap smears
every 3-6 mos
after first
treatment
• Remember HPV
vaccine for
females ages
9-26
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Patient Education for Genital Warts
• Even though warts may be removed, viral infection can't be cured
• Warts often return; they are benign but very infectious
• No sex until patient/partner(s) complete treatment
• Get regular Pap smears
• Best prevention is abstinence or sex with only one uninfected
partner; condoms help prevent infection, but don’t cover all
affected skin
• Gardasil immunization for uninfected partners <27 years of age
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HPV Infection
Rectal condylomas
sometimes require
surgery
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25% of patients with first episode of genital ulceration
have no detectable cause despite full diagnostic eval…
Genital Ulcers
Painless ulcers - think syphilis, but herpes
can also present this way
Multiple ulcers - think herpes, but could
also be syphilis
Diagnosis based on only a history and
physical is often inadequate
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Herpes patient: initial visit and 4 days later when
ulcers have begun to heal with medication
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Poll Question
HIV testing is accurate immediately after
exposure to the virus.
A. True
B. False
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Poll Question
HIV testing is accurate immediately after exposure to the virus.
A. True
B. False
Most people develop detectable antibodies 2-8 wks after exposure
(avg 25 days); 97% develop antibodies in first 3 mos.
Some take longer. In very rare cases, it can take up to 6 mos to
develop antibodies to HIV. Therefore, if initial negative HIV test
was done in first 3 mos after possible exposure, CDC recommends
considering repeat testing >3 mos after exposure to account for
possibility of false-negative result.
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Human Immunodeficiency Virus (HIV)
• CDC recommends screening everyone for HIV, any time at any
site at least once, and yearly for anyone at risk
• Women are 4x more likely to contract HIV through vaginal sex
with infected men, than men are to contract HIV through vaginal
sex with infected women
• Growing problem for women: Black/Hispanic women represent
<29% of US women, but account for 79% of female AIDS cases
• Patient education
− Viral infection, not curable at this time
− Transmitted by vaginal/anal/oral sex, needle sharing,
occupational exposure, transplant, artificial insemination, and
contaminated transfusions
− Best prevention is abstinence or sex with only one uninfected
partner. Condoms help prevent infection.
Hepatitis B
Encourage
vaccination for
prevention:
3 shots over 6 mos
Patient education:
− Preventable with vaccine
− Adult recovery rate is 95%
− Transmitted via intercourse, contaminated blood, occupational
exposure
− Can survive for 7 days outside the body
− Don’t share needles, razors, toothbrushes, nail clippers,
earrings
− Reduce risks: abstinence, mutual monogamy, latex condoms,
limiting number of sex partners
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The Sexual History
and Prevention Counseling
This next section comes from the CDC publication,
A Guide to Taking a Sexual History.
A booklet version of it is on the CDC website…
http://www.cdc.gov/std/see/HealthCareProviders/SexualHistory.pdf
VETERANS HEALTH ADMINISTRATION
Think of sharing these questions with your
provider…
Start the sexual hx by normalizing the discussion
1. I am going to ask you a few questions about your sexual health
and sexual practices. I understand that these questions are
very personal, but they are important for your overall health.
2. Just so you know, we ask these questions to all adult patients,
regardless of age, gender, or marital status. These questions
are as important as the questions about other areas of your
physical and mental health.
Add… Like the rest of our visit, this information is kept in strict
confidence. Do you have any questions before we begin?
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Sexual History
Providers should utilize the “Five P’s”
1. Partners
• Are your sex partners men, women, or both?
• In the past 2 months, how many sex partners have you had?
• In the past 12 months, how many sex partners have you had?
One partner in last 12 mos: ask about length of relationship and
partner’s risk factors (current or past sex partners, drug use)
More than one partner in last 12 mos: explore more specific risk factors
(condom use, or non-use, and partners’ risk factors)
VETERANS HEALTH ADMINISTRATION
Sexual History
Providers should utilize the “Five P’s”
1. Partners
2. Prevention of pregnancy
3. Protection from STIs
4. Practices
5. Past history of STIs
VETERANS HEALTH ADMINISTRATION
When questioning
and counseling, use
a nonjudgmental
and caring manner
Be aware of factors that increase the
risk for an STI…
Illicit drug use
Unprotected sex
Young age
Unmarried
Multiple sexual
partners
Prior STI
VETERANS HEALTH ADMINISTRATION
Contact with sex
workers
New sex partner
in past 60 days
No vaccination
(HPV, hepatitis)
Summary of STI Screening for Women
• HIV: Screen all women ≤ 65 regardless of risk at least once;
annual screen for those at increased risk
• HPV: Encourage vaccination for all women ≤ 26
• Chlamydia: Screen all women ≤ 24, and any at high risk
• Trichomonas and Gonorrhea and Syphilis: Screen women at risk
– Consider screening all women under ≤ 24 for gonorrhea
• Hepatitis B: Consider vaccinating women at risk
* At risk = Multiple current partners, new partner,
inconsistent condom use, sex while under the influence
of alcohol or drugs, sex in exchange for money or drugs.
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STI Summary
• STIs cost US health care system $17
billion/year
• Young people represent only 25% of
sexually experienced population, but
account for nearly half of new STIs
• Less than half of people who should
be screened actually receive
recommended STI screening services
• Providers are required to report
gonorrhea, chlamydia, and syphilis to
local or state public health authorities
─ Nursing can help track/report
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Case Study
A call comes in from a woman
veteran who complains of new
vaginal discharge.
What questions would you ask?
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Helpful References
• CDC. A Guide to Taking a Sexual History.
http://www.cdc.gov/std/see/HealthCareProviders/SexualHistory.pdf
• CDC. Self Study STD Modules/Vaginitis
http://www2a.cdc.gov/stdtraining/self-study/vaginitis.asp
• CDC. Sexually transmitted diseases treatment guidelines 2010.
http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf
• Seattle STD/HIV Prevention Training Center. The Practitioner’s Handbook
for the Management of Sexually Transmitted Disease.
http://www.stdhandbook.org/
• Workowski KA, Berman SM. Centers for Disease Control and Prevention
sexually transmitted diseases treatment guidelines. Clin Infect Dis.
2007;44(s3):S73-6
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