Vaginal Discharge
Vaginal Discharge: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
Vaginal discharge is abnormal except forphysiologic leukorrhea, which occurs during the first few weeksof life and with the onset of puberty.
Principal Causes of Vaginal Discharge
- Prepubertalonset
- Physiologicleukorrhea
- Vulvovaginitis
- Nonspecificcauses
- Specific infections
- Foreign body
- Pubertal and postpubertal onset
- Physiologicleukorrhea
- Vulvovaginitis
- Nonspecificcauses
- Specific infections
- Bacterialvaginosis
- Candida species
- Trichomonas vaginalis
- Herpes simplex virus
- Cervicitis
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Pelvic inflammatory disease
- Foreign body
Clinical Features and Diagnosis
Prepubertal Onset
Physiologic Leukorrhea
Maternalestrogen passes across placenta and stimulates hypertrophy of glycogen-containingvaginal squamous epithelial cells in the fetus.Decrease in serum estrogen after birthleads to shedding of these cells and production of whitish vaginaldischarge that may persist for a few weeks.Some neonates also may have associatedwithdrawal bleeding secondary to decreased estrogen stimulationof the endometrium. Vulvovaginitis
Nonspecific Causes
Most commoncause of vaginal discharge in prepubertal girls is nonspecific vaginitis, whichis usually due to poor perineal hygiene and contamination with mixedbowel flora.Chemical irritants (e.g., bubble bathpreparations, shampoos, and harsh soaps) also may cause vaginitis.Dysuria is sometimes associated finding. Specific Infections
Some neonatesacquire T. vaginalis during passage through birth canal, and whitish oryellowish vaginal discharge may persist beyond neonatal period.Seeing motile flagellated organism on wet mount (saline) confirmsdiagnosis.Infection with Candida species mayproduce whitish or yellowish discharge and vulvar inflammation.Risk factors include diabetes mellitus, use of broad-spectrum antibiotics,and immunodeficiency disorders. KOH preparation or culture of dischargeis diagnostic.Group A Streptococcus, S. aureus, H.influenzae, S. pneumoniae, and Shigella species may produce foul-smellingvaginal discharge. Diarrhea usually occurs with Shigella vaginitis,and in some cases vaginal discharge contains blood. Positive vaginalculture is diagnostic.E. vermicularis (pinworm) producesintense anal itching, particularly at night when worms move ontoperianal skin. Persistent scratching may produce secondary vulvovaginitis.Seeing white, threadlike worms, which are about 1 cm in length,or identifying eggs under microscope from cellophane tape preparationis diagnostic.In prepubertal females, infection withT. vaginalis, herpes simplex virus, N. gonorrhoeae, or C. trachomatisimplies sexual abuse until proven otherwise. Infections with thesepathogens are discussed in sections Pubertal and Postpubertal Onset: Vulvovaginitis,and Cervicitis. Foreign Body
Foreignbody in vagina causes foul-smelling discharge, which is often associated withpain or bleeding.Toilet paper, pins, beads, and pencilerasers are some of the objects that may be found.History and physical exam are usuallydiagnostic.Radiography of pelvis is useful, especiallyif foreign body is radiopaque. Exam under anesthesia may be necessaryin some cases. Pubertal and Postpubertal Onset
Physiologic Leukorrhea
Most commoncause of vaginal discharge in pubescent girls.Cyclic ovarian activity with increasedestrogen secretion produces glycogen-containing vaginal epithelium.Desquamated vaginal cells and mucus produce whitish discharge thatusually starts before menarche and may continue for several years.Wet preparation shows epithelial cellswith no evidence of inflammation. Vulvovaginitis
Nonspecific Causes
Contributing factors to nonspecific vulvovaginitisinclude poor hygiene, obesity, chemical irritants, and tight-fittingnylon underpants.
Specific Infections
Primary causes of vaginitis in adolescentsare bacterial vaginosis, Candida species, T. vaginalis, and herpessimplex virus. Because of changes in vaginal epithelium and colonizingflora in puberty, vagina is more resistant to infections causedby N. gonorrhoeae and C. trachomatis. In adolescents these 2 pathogenscause cervicitis rather than vaginitis.
Bacterial Vaginosis
Presenceof vaginal Gardnerella and Mobiluncus species does not necessarilysignify a sexually transmitted disease because these bacteria alsocan occur in sexually inactive girls.Presence of thin, white, homogenousdischarge; characteristic fishy odor when 1–2 drops of 10% KOHare added to specimen of vaginal discharge; neutral or alkalinevaginal pH; and appearance of small refractile bacteria coatingvaginal epithelial cells (clue cells) on saline wet mount or Gramstain confirm diagnosis. Candida Species
Infectionwith Candida species produces thick, cheesy pruritic discharge.Positive KOH preparation demonstratingyeast cells and mycelia or positive vaginal culture is diagnostic. Trichomonas vaginalis
Infectionwith T. vaginalis usually produces frothy, pale yellow to gray-greendischarge with musty odor.Although pathogen can survive on fomitevectors (damp clothes, towels), usual source of infection is throughdirect sexual contact.Presence of motile flagellated organismson wet mount is diagnostic. If wet mount is negative, positive cultureor polymerase chain reaction test confirms diagnosis. Herpes Simplex Virus
Infectionwith herpes simplex virus 1 (HSV-1) or HSV-2 may produce small painful vesiclesand ulcers on vulva, vagina, or cervix. Vaginal discharge, fever,and inguinal adenopathy also may occur.Herpetic infections can present asprimary genital infections or as recurrent episodes, especiallywith HSV-2.Fluorescent antibody staining of vesiclescrapings or positive culture from lesion confirms diagnosis. Cervicitis
Is an inflammationof the ectocervix, endocervix, or both. T. vaginalis, Candida species,and herpes simplex virus can cause ectocervicitis, whereas C. trachomatisand N. gonorrhoeae are most common pathogens causing endocervicitis.Typical clinical findings of cervicitisare mucopurulent discharge and inflamed cervix. Chlamydia trachomatis
Infectionis almost always acquired through sexual contact. It is most prevalentbacterial sexually transmitted disease in U.S. and frequently accompaniesgonococcal genital infections.Can be asymptomatic or produce mildcervical discharge. Associated findings include dysuria and urinaryfrequency.Positive endocervical culture or identificationby nucleic acid amplification tests is diagnostic. Neisseria gonorrhoeae
Transmissionoccurs by direct sexual contact.Cervix is inflamed and tender and vaginaldischarge is thick creamy yellow.Positive endocervical culture or identificationby nucleic acid amplification tests is diagnostic. Pelvic Inflammatory Disease
Is an infectionwith spread of organisms from vagina or cervix to endometrium (endometritis),fallopian tubes (salpingitis, tubal abscess), pelvic peritoneum(pelvic peritonitis), or contiguous structures (oophoritis, tuboovarianabscess).N. gonorrhoeae, C. trachomatis, andendogenous flora of lower genital tract including anaerobic bacteria(Bacteroides, Peptostreptococcus, Clostridium, and Actinomyces species)and facultative bacteria (E. coli, H. influenzae, Streptococcusspecies) are frequent pathogens.Cervical and vaginal discharge, lowerabdominal pain, cervical motion tenderness, adnexal tenderness,vomiting, and fever are common findings.Cervical culture for C. trachomatis,N. gonorrhoeae, and other aerobic and anaerobic bacteria shouldbe performed. Laparoscopy may be required to provide definitivediagnosis in equivocal cases. Foreign Body
In adolescents,most common foreign body is retained tampon.Discharge is foul smelling and oftenblood streaked.Foreign body can usually be visualizedby speculum exam. Diagnostic Approach
Nonspecificvulvovaginitis is most common cause of vaginal discharge in prepubertal girls.If discharge fails to improve with good perineal hygiene or if itis purulent, specific bacterial infection, sexually transmittedinfection, or foreign body should be suspected. Wet mounts (salineand KOH), Gram stain, and vaginal cultures should be performed.Exam under anesthesia may be necessary for suspected foreign body.In pubertal girls who are not sexuallyactive, most common causes of vaginal discharge are physiologicleukorrhea, bacterial vaginosis, and C. albicans. Wet preparations(saline and KOH) and Gram stain should be performed. Bacterial andfungal cultures also should be considered.In girls who are sexually active, thesame diagnoses described for pubertal nonsexually active femalesare possible, but sexually transmitted infections also are likely.In addition to wet preparations and Gram stain, cultures for C.trachomatis, N. gonorrhoeae, and other aerobic and anaerobic bacteria shouldbe performed. In some centers nucleic acid amplification technologyis available for detection of C. trachomatis and N. gonorrhoeaefrom endocervical and urine specimens. Laparoscopy may provide definitivediagnosis in suspected pelvic inflammatory disease with negativecervical cultures.If sexual abuse is suspected at anyage, vaginal, rectal, and throat cultures for N. gonorrhoeae andvaginal and rectal cultures for C. trachomatis should be performed,even in an asymptomatic child. HIV testing should be considered.So should pregnancy prophylaxis, which depends on whether menarche hasbeen reached and on nature of abuse. References
- Al-Salihi, et al. Neonatal trichomonasvaginalis. Report of three cases and review of the literature. Pediatrics1974;53:196–200.
- Blake DR, Woods ER. The future is here: noninvasivediagnosis of STDs. Contemp Pediatr 2001;18:71–87.
- DeMeo LR, et al. Evaluation of a deoxyribonucleic acidprobe for the detection of Trichomonas vaginalis in vaginal secretions.Am J Obstet Gynecol 1996;174:1339–1342.
- Emans SJH, et al. Pediatric and adolescent gynecology,4th ed. Philadelphia: Lippincott-Raven, 1998.
- Feigin RD, Cherry JD, eds. Textbook of pediatric infectiousdiseases, 4th ed. Philadelphia: WB Saunders, 1998.
- Long SS, et al., eds. Principles and practice of pediatricinfectious diseases. New York: Churchill Livingstone, 1997.
- Murphy TV, Nelson JD. Shigella vaginitis: report of38 patients and review of the literature. Pediatrics 1979;63:511–516.
- Paradise JE. Vaginal discharge. In: Fleisher G, LudwigS, eds. Textbook of pediatric emergency medicine, 4th ed, Philadelphia:Lippincott Williams & Wilkins, 2000:621–624.
Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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