Vaginal Discharge in STDs: Syndromic Approach

Introduction:

The present assignment is to discuss about the topic “Syndromic Management of Vaginal Discharge in sexually transmitted disease (STD)” based on the existing scientific evidences till date.

Vaginal Discharge

Vaginal Discharge (VD) is a common symptomatic manifestation of the clinical condition associated with STD and due to vaginitis, the inflammation of vagina marked by the features of inflammatory responses and the variation of the ecological environment of the vagina1. Understanding the complexities surrounding VD can benefit from healthcare dissertation help, enabling a thorough exploration of its underlying causes and implications for patient care.

The signs and symptoms for a specific etiopathogenesis:

VD is a prominent symptom of STD and it is characterised by the profuse purulent discharge, yellow in colour for infection with Trichomonas, fishy in odour, with or without symptoms of itching, erythema of vulvovagina, dyspareunia and dysuria1.

Cause of VD

Infection is the most common cause for VD along with vaginitis. Infection with parasite Trichomonas vaginalis (TV) is evident to be the most prevalent one of nearly 70% followed by Bacterial Vaginosis (BV) which includes the STD causing bacteria and candidiasis of the vagina (VC). Other pathophysiological conditions that can also contribute to VD are cervicitis, atrophic vaginitis, desquamative inflammatory vaginitis (DIV), mucoid ectopy and psychosexual problems that may cause VD along with burning sensation in vulva 1, 2.

Associated Risk Factors:

The following risk factors are exposure of foreign substance to vagina, having multiple sexual partners, poor personal hygiene, the atrophic alterations observed within vagina of women who have reached menopause, irritation induced by any chemicals, excretory products like urine and feces and psychological problems for instance depression can cause recurrent episodes of VD3.

Diagnosis:

The most common misconception that is prevalent in the clinical field is the association of vaginal discharge to infection of vagina. Evidences are available that have stated only two third of the cases of VD is related to infection of vagina5. Similarly a study with a population size of 381 participants demonstrated that 19% were suffering from mucopurulent cervicitis, and another 19% had no possible infection of vagina5. The diagnoses of the other pathophysiological conditions are considered to be crucial4. For the assessment of vaginitis as the cause of VD the specialist should consider the history of the patient, cautious examination of the body parts, appropriate examinations of vagina and the other microbiological laboratory examination such as pH of vagina, potassium hydroxide assessment, vaginal pool wet mount, vaginal swab test, gram staining of the discharge and examination of fresh discharge samples under microscope for confirmation4 and nucleic acid amplification test (NAAT) is recommended with urine sample along with specific detection kit for specific STD organisms.

Syndromic Management

Syndromic management refers to the systematic management approach based on evidences that utilizes the algorithms and flowchart of clinical relevance and which can be applied the healthcare providers even in poor resource settings for appropriate treatment of sexually transmitted diseases (STI) 6.

The treatment guidelines for VD due to Vulvovaginal Candidiasis (VVC):

The first line therapies prescribed to treat the condition include Butoconazole 2% cream, 5 g intravaginally for 1 day, Clotrimazole 500-mg vaginal tablet for 1 day, Terconazole 0.4% cream, 5 g intravaginally for 7 days, Terconazole 0.8% cream 5 g intravaginally for 3 days and Terconazole 80 mg vaginal suppository, 1 suppository for 3 days. Fluconazole 150 mg, 1 tablet should be administered orally. For the management of recurrent episodes of VVC, azole therapy administered topically for the period of 7-14 days or Fluconazole 100–200 mg for the period of 3 days taken orally at Day 1, 4, 7 is recommended. The therapeutic regimen for maintenance is Fluconazole of dosage 100-mg, 150-mg, or 200-mg dose need to be administered weekly followed by clotrimazole 200 twice weekly administered topically and Clotrimazole 500-mg, a vaginal suppository administered weekly for overall 6 months4.

These are the treatment regimens provided for patients with uncomplicated infections. For patients infected with strains of non albicans, CDC recommends the administration of azole agents either orally or topically as a replacement of fluconazole for an extended course regimen. If the therapy does not provide desirable results then boric acid capsules 600mg intravaginal should be prescribed every day for total 2 – 3 weeks4, 7.

Treatment management of VD due to Trichomonas Vaginalis infection:

Two recommended regimens are there:

Metronidazole either 2 g as single dose or 500 mg administered twice each day for the period of 1 week. CDC approved tinidazole for the treatment with oral application of 2g for 7 days and it is considered in case of resistance developed against metronidazole or in case of recurrence. This is recommended by CDC only for patients with culture positive infections. Moreover patients who are resistant to nitroimidazole evidence based treatment with paromomycin applied intravaginally can be considered by the specialist 4, 7.

Treatment management of VD due to Bacterial Vaginosis (BV):

The first line therapy includes metronidazole, 500 mg to be administered orally twice every day for total 7 days. It is considered to be the gold therapy4.

The other alternative regimens include clindamycin 300 mg for 7 days orally (bid) along with topical applications of antibacterial therapies that involves the administration of clindamycin cream 2% (intravaginal), 5g at bed time administered intravaginally for 1 week, metronidazole gel 0.75%, 5 g, administered intravaginally for total period of 5 days, clindamycin ovules, 100 mg administration of 1 ovule intravaginally at the bed time for total 3 days4, 7. However working group of CDC on BV reported that higher recurrence of episodes with application of topical agents in comparison to metronidazole therapy administered orally for four weeks. For pregnant cases, CDC recommended metronidazole at dosage of 500 mg (bid) / 250 mg for three times (tid) / clindamycin dosage of 300 mg (bid) to be administered orally for a period of 1 week. Relapse of infection was observed among 30% of the cases. In those cases, CDC recommended metronidazole gel 0.75% to be applied intravaginal during bed time for total 10 days 4, 7.

References:

Nwankwo TO, Aniebue UU, Umeh UA. Syndromic diagnosis in evaluation of women with symptoms of vaginitis. Current infectious disease reports. 2017 Jan 1;19(1):3.

Sherrard J, Wilson J, Donders G, Mendling W, Jensen JS. 2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge. International journal of STD & AIDS. 2018 Nov;29(13):1258-72.

Mashburn J. Etiology, diagnosis, and management of vaginitis. Journal of midwifery & women's health. 2006 Nov 1;51(6):423-30.

Quan M. Vaginitis: diagnosis and management. Postgraduate medicine. 2010 Nov 1;122(6):117-27.

Landers DV, Wiesenfeld HC, Heine RP, Krohn MA, Hillier SL. Predictive value of the clinical diagnosis of lower genital tract infection in women. American journal of obstetrics and gynecology. 2004 Apr 1;190(4):1004-8.

Zemouri C, Wi TE, Kiarie J, Seuc A, Mogasale V, Latif A, Broutet N. The performance of the vaginal discharge syndromic management in treating vaginal and cervical infection: a systematic review and meta-analysis. PloS one. 2016;11(10).

Vishwanath S, Talwar V, Prasad R, Coyaji K, Elias CJ, de Zoysa I. Syndromic management of vaginal discharge among women in a reproductive health clinic in India. Sexually transmitted infections. 2000 Aug 1;76(4):303-6.

Hainer BL, Gibson MV. Vaginitis: diagnosis and treatment. American family physician. 2011 Apr 1;83(7):807-15.