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Abnormal vaginal discharge etiopathogenesis

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Abnormal vaginal discharge etiopathogenesis

  1. 1. ABNORMAL VAGINAL DISCHARGE - ETIOPATHOGENESIS Dr. G. Ruben raj
  2. 2. 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
  3. 3. 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.
  4. 4. 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.
  5. 5.  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.
  6. 6.  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...
  7. 7. 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..
  8. 8. 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.
  9. 9. 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.
  10. 10.  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...
  11. 11. VAGINAL ECO SYSTEM
  12. 12. 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
  13. 13. 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.
  14. 14. CAUSES FOR VAGINAL DISCHARGE PHYSIOLOGICAL : AGE-DEPENDENCE : 1.NEONATE AND INFANT 2.PRE-PUBERTY 3.CHILD BEARING 4.POST MENOPAUSAL -- CONTD.
  15. 15. EXCESSIVE SECRETION : 1.PREGNANCY 2.SEXUAL AROUSAL PATHOLOGICAL : A) NON-INFECTIVE CHEMICAL IRRITATION –Antiseptics,bath additives deodorants,detergent spermicides,douches, perfumed soaps. -CONTD..
  16. 16. 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
  17. 17. INFECTIVE CAUSES CERVICITIS 1.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
  18. 18. 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.
  19. 19. 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
  20. 20. 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.
  21. 21. 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.
  22. 22. 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.
  23. 23. 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.
  24. 24. 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.
  25. 25. ...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.
  26. 26. 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.
  27. 27. 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
  28. 28. 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.

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