快樂小藥師 Im pharmacist nichts glücklich

[EXCERPTS]

A 29 year old woman complains of a one week history of thick, white, odourless vaginal discharge and vulval pruritus. There was no dyspareunia or abnormal vaginal bleeding. On examination, the abdomen is not tender, the vulva seems normal, and speculum examination reveals thick white discharge.

What you should cover

• Characteristics of the discharge—Onset, duration, colour, odour, consistency (a discharge that is heavier, thicker, or more offensive than usual is abnormal), cyclical changes, exacerbating factors (such as after intercourse) (see table for details).

Table: Characteristics of different causes of abnormal vaginal discharge

• Any associated symptoms—Itch, dyspareunia, abdominal pain; abnormal vaginal bleeding or pyrexia is more likely to indicate sexually transmitted infection (see table).
• Sexual history—Is patient at increased risk of sexually transmitted infection (age <25 years, new sexual partner or more than one sexual partner in past year, previous sexually transmitted infection)?
• Contraceptive use can affect vaginal discharge.
• Pregnancy can affect vaginal discharge and is an important factor in patient management.
• Concurrent medications and previous treatments used such as antibiotics, corticosteroids, over the counter drugs such as clotrimazole.
• Medical conditions such as diabetes, immunocompromised state.
• Non-infective causes of discharge such as allergic reaction, known cervical ectopy or polyps, genital tract malignancy, foreign body (such as tampons)
• Elicit any patient concerns and expectations

The most common causes of vaginal discharge are physiological, bacterial vaginosis, and candidiasis.

What you should do

Examination

Always offer examination, but, if the patient declines, treatment for candidiasis or bacterial vaginosis may be given without examination if the risk of sexually transmitted infection is low and there are no symptoms indicative of upper genital tract infection.

• Abdominal palpation for tenderness or mass (may indicate malignancy).
• Inspect the vulva for discharge, erythema, ulcers, other lesions or skin changes (see table).
• Bimanual pelvic examination for adnexal or uterine tenderness or mass, and for cervical motion tenderness (this can indicate pelvic inflammatory disease).
• Speculum examination to inspect vaginal walls, cervix, and characteristics of discharge. Although not mandatory, vaginal pH can be checked by using a swab to collect discharge from the lateral vaginal wall and rubbing on to narrow range pH paper. This can help discriminate between bacterial vaginosis, trichomoniasis,and candidiasis. Take endocervical swabs if there is risk of sexually transmitted infection and send off for nucleic acid amplification testing. High vaginal swabs are of limited diagnostic value except in pregnancy, post-instrumentation, failed treatment, recurrent symptoms, or to confirm candidiasis. This can also be an opportunity to carry out cervical screening.

Alternatively, you can advise the patient to attend the local genitourinary medicine clinic for the above examinations if she is at risk of sexually transmitted infection.

Management

When to consider referral to genitourinary medicine

• Gonorrhoea, trichomoniasis, or pelvic inflammatory disease is suspected, although treatment should be started
• Partner notification is required
• Diagnostic uncertainty
• Recurrent or persistent symptoms.

Infective (non-sexually transmitted infection)

• Bacterial vaginosis—Treat even in the absence of a positive HVS. It is important to treat in pregnancy as it can cause complications. Metronidazole 400 mg twice daily for 5-7 days or intravaginal therapies may be used. In recurrence, use oral metronidazole for 3 days at start and end of menstruation. Always counsel about alcohol with metronidazole.
• Candidiasis—Vaginal and oral azole antifungals are equally effective but avoid oral treatment in pregnancy. In recurrence, an induction and maintenance regimen may be used for six months. 
  

Infective (sexually transmitted infection)

• Always offer an annual chlamydia screen to sexually active women aged <25 years.
• Offer blood tests for HIV infection and syphilis.
• Chlamydia—Treat with either a single dose of azithromycin 1 g or twice daily dose of doxycycline 100 mg for seven days.
• Gonorrhoea—Uncomplicated infections should be treated with an intramuscular injection of ceftriaxone 500 mg and oral azithromycin 1 g, both as single doses. Everyone should have a test of cure.

Personal hygiene and advice

• Advise patient to avoid douches, perfumed products, and tight synthetic clothing.
• Educate patient about normal vaginal discharge.