$ %& !"# Dr. Dave Fuller and Dr. Chris Sanderson Taken from the RCH handbook: Sonia Grover * Previous issues available on the GPAG website…….* Vaginal discharge: Most newborn girls have some mucoid white vaginal discharge. This is normal and disappears by about 3 months of age. Vulvovaginitis: This is the most common gynaecological problem in childhood, usually occurring in girls aged between 2 years and the start of puberty. The vaginal skin in childhood is thin and atrophic. Overgrowth of mixed bowel flora occurs in this environment and the resultant discharge can be an irritant to the vulva area, which is also atrophic. The moist environment between the opposed skin surfaces may also be exacerbated by urine dribbling, particularly in an obese young girl. Presentation: Erythema/irritation of the labia and perineal skin. Itch and dysuria may also be present. + offensive vaginal discharge. Management: Investigations are usually not required. If urinary symptoms are present, check the urine to exclude urinary tract infection (UTI). • Explanation and reassurance. • Vinegar (1 cup white vinegar in a shallow bath) • Simple soothing, barrier cream to the labial area (e.g. zinc-castor oil or nappy rash cream). • Toileting/hygiene advice: avoid potential irritants such as soaps and bubble bath. Rarely, if the problem persists, further action maybe required. The natural history is for recurrences to occur up until the age where oestrogenisation begins. • If a heavy discharge persists or marked skin inflammation beyond labial contact surfaces is present, take swabs from the perineum in case of an overgrowth of one organism (e.g. group A Streptococcus) and treat it with the appropriate antibiotics (usual culture findings are mixed coliforms). • Do not take vaginal swabs, as it is painful and distressing. If swabs for culture are required, introital area swabs are adequate. • If itch/irritation is the main complaint, consider pinworms. • If eczema occurs elsewhere on the body, this can be superimposed on the irritated skin. Combined treatment of the vulvovaginitis (as above) and hydrocortisone may be indicated. • Foreign bodies are a potential cause for a persistent, unresolving, often blood-stained discharge. An examination under anaesthesia with vaginoscopy is required to exclude this. • Although this is rare, consider sexual abuse if other indicators are present. Thrush is rare in prepubertal girls unless there has been significant antibiotic use. Thrush thrives in an oestrogenised environment, not in the atrophic setting. Dr. Michael Roberts and Dr. Deb Friedman Vaginal discharge is a common cause for presentation within General Practice. In reproductive aged women, a normal physiological vaginal discharge consists of 1 to 4 mL fluid (per 24 hours), which is white or transparent and mostly odourless. The discharge may become more noticeable at times of pregnancy, with the use of oestrogen and progestogen based contraceptives and at the mid-cycle with ovulation. The pH of normal vaginal secretions is acidic at 4.0 to 4.5, and is hostile to the growth of pathogens. The normal microbiology of the vagina contains abundant lactobacillus, diphtheroids and Staphylococcus epidermidis. Age, phase of menstrual cycle, sexual activity, contraceptive choice, pregnancy, presence of necrotic tissue (i.e. retained products of conception), foreign bodies, use of hygienic products, douches and antibiotics can all disrupt the normal vaginal ecosystem. Overall, bacterial vaginosis, candida vulvovaginitis, and trichomoniasis account for more than 90% of cases of vaginitis. Among sexually active young adults and adolescents, STIs must be considered as the cause for vaginal discharge. In these cases, treatment of partners is vital; Chlamydia: Commonly asymptomatic but may be associated with a non-specific discharge. Chlamydia is treated with doxycycline or azithromycin. Trichomonas: The discharge may be frothy, malodorous, creamy, green, bloody, pruritic or asymptomatic. Physical examination often reveals erythema of the vulva and vaginal mucosa. Treatment is with metronidazole. Next Issue Look out for….. ! "! risk factors for STI, represent “imbalances” or “overgrowths” of normally present flora. Such as: Bacterial vaginosis (BV): Caused by many different bacteria; Gardnerella vaginalis, Mycoplasma hominis, Prevotella, Bacteroides, anaerobic Peptostreptococcus & Fusobacterium spp. Risk factors include multiple or new sexual partners, douching, and cigarette smoking, but can occur in women who have never had vaginal intercourse. There is a high occurrence of BV and concordance of flora in women who have sex with women. The discharge is usually grey, thin, nonirritating and malodorous (fishy). Up to 30% of women may have this at any particular time and it may resolve spontaneously over months so treatment is usually only advised if symptomatic. Treatment is oral or intravaginal metronidazole or clindamycin. Candida (aka “thrush”). Not an STI. There is often no discharge, just pruritis, dysuria, and dyspareunia. If present, the discharge is white and creamy or cheesy. It is odourless and associated with an erythematous, irritated and pruritic vulva. Recurrent candida warrants the exclusion of anaemia (especially iron deficiency), diabetes, immunosuppression, and the co-existence of infection with herpes simplex virus. Candida can be treated with topical antifungals or oral fluconazole. Candida under the microscope: Gonorrhoea: Commonly asymptomatic but may have a gray-white or yellow, thick purulent discharge. Treatment with stat IM Ceftriaxone is preferred, as some resistance has emerged to ciprofloxacin. Condyloma acuminata, or genital warts can also cause vaginal discharge, pruritis, burning and pain. Clinicians should inspect the genitalia for evidence of macroscopic warts. Note: Vaginal pessaries should never be prescribed to prepubertal girls. Chlamydia, Gonorrhoea and Syphilis '(() The commonest causes of vaginal discharge seen in general practice among adult women, above 25, without Rarely, Group A Streptococcus (GAS) causes vulvovaginitis in mothers who are colonised with GAS. This condition presents with acute onset of frankly purulent discharge accompanied by pruritis, irritation, erythema, and labial oedema. It can be treated with penicillin. Cont. Page 2 $ **# From page 1 In the post-menopausal age group, vaginal discharge is less common and requires careful assessment and investigation. Vulvovaginal candidiasis is less common in postmenopausal women, unless they are taking estrogen therapy. Discharge may be due to atrophic vaginitis and respond well to hormone replacement therapy or topical oestrogen therapy but cervical and uterine pathology (neoplasm) need to be considered and excluded. Atrophic vaginitis can also occur in pre-menopausal women in the postpartum period, during lactation, and as a complication of antioestrogenic drugs, and responds well to topical oestrogen. Other non-infectious causes of vaginal discharge, or vaginitis must also be considered once infection has been excluded. In particular, irritants (scented panty liners, perfumes, soaps), allergens (latex condoms, seminal fluid), fistulas, and genital tract lesions (ectropion, polyps, granulation tissue, or neoplasia). A foreign body can be associated with chronic vaginal discharge, bleeding or spotting, and a foul smelling odour. Removal of the foreign body is generally adequate treatment. Diagnostic Approach– Dr. Deb Friedman and Dr. Owen Harris Perform a speculum examination to exclude foreign body or genital tract lesions, and collect a cervical swab and then sample vaginal discharge from vaginal vault. Use a blue or black cotton-tipped swab with transport media. A low vaginal swab can be collected without the use of a speculum, and can be useful for detecting candida. Within the microbiology laboratory, the following will be performed: 1. “Wet Prep”. Smelling ("whiffing") the slide immediately after applying KOH can detect the fishy (amine) odour of BV. Microscopy can identify clue cells (Gardnerella vaginalis), yeast or motile trichomonads. Wet prep is performed as early as possible, and specimens should be sent directly to the laboratory ideally within a few hours. 2. Vaginal culture. For Candida. 10-20% of women are colonized with candida; therefore culture should not be routinely performed. Culture also has no role in the diagnosis of BV, as it is polymicrobial, and G.vaginalis is detected in up to 60 % of healthy asymptomatic women. 3. Cervical culture: Especially among women with a history of high-risk behaviour and purulent vaginal discharge. Can assist in detecting trichomonas. Chlamydia and Gonorrhoea will be covered in greater detail in the October edition of GOCATS. Clue cells found in Bacterial Vaginosis: Dr. Deb Friedman Sexually transmitted infections (STIs) are a major public health problem in all countries. If untreated, STIs can result in chronic pelvic infection, infertility, cancer of the cervix, and increased risk of acquiring HIV. A proportion of STIs will be detected when patients present with certain symptoms, such as vaginal discharge, urethral discharge, or genital ulcers. However, this will not assist in reducing the transmission of STIs from those patients with asymptomatic disease. Targeted screening of asymptomatic patients in specified risk groups is important. The decision about who to screen should be based on an assessment of their risk for STI. The following factors place patients at greater risk for STI: Adolescent & young adult age group Unmarried New sex partner in the past 2 months Multiple sexual partners History of previous STI Drug use Meeting partners on the internet Contact with sex workers Therefore the most important first step is to take a sexual history, including information about age at first sex, new sexual partners, multiple sexual partners, types of sexual exposures, previous STIs & frequency of condom usage. The most important of these questions is that of new sex partners which is a risk factor for STI. Among patients with risk factors for STI, counseling and screening should be undertaken. Among sexually active women under the age of 25 years, (especially those with a new partner, multiple partners and inconsistent condom usage) cervical swabs and urine should be collected annually to screen for Gonorrhoea, Chlamydia & Trichomonas. 2-yearly Pap smears should also screen for HPV. Women older than 25 who are at high risk should also be screened. Patients with risk factors such as commercial sex workers, multiple sexual partners, another STI & drug users should have blood collected to screen for HIV, hepatitis B & syphilis. Young women should receive HPV vaccination, while non-immune high-risk patients should be vaccinated against hepatitis B. Young sexually active men should be screened via urethral or urine specimens for Chlamydia. Men who have sex with men should be screened annually for HIV and syphilis, and should have urine or urethral specimens collected to screen for Gonorrhoea, & Chlamydia. Rectal and pharyngeal cultures may be collected to screen for Gonorrhoea among patients with a history of oral-genital & receptive anal intercourse. Patients with newly diagnosed chlamydial, gonococcal, or trichomonas infections should be rescreened in 3 months for new asymptomatic infections. Regardless of symptoms, sexual partners should be evaluated, tested, and treated if they had sexual contact with the index patient during the 60 days preceding onset of symptoms or diagnosis of Chlamydia. If a GP is unable to complete all contact tracing phone 9347 1899 for assistance. + !" , All GPs should be aware of the requirement for 4 year olds to receive their vaccinations within the first month after their birthday. Previously, children were not considered overdue if they were vaccinated by the age of 5 years, however, now ACIR considers that children are overdue for vaccination after the age of 4 years and 1 month. It is acceptable to vaccinate preschool children after the age of 3 years and 6 months. GPs are encouraged to develop innovative ways to remind parents about 4 year old immunisations, such as preemptive birthday cards, which can be downloaded from www.gpageelong.com.au under ‘our services’, ‘prevention and early intervention’, ‘immunisation’. , 2009 has seen more than 1800 cases of whooping cough diagnosed in Victoria, and 86 cases in the City of Greater Geelong. Children under the age of 1 year are most at risk for adverse outcomes (apnoea and pneumonia) secondary to Pertussis infection. Ordinarily, in our society, whooping cough is transmitted by infected adults whose immunity has waned, therefore, doctors are advised to ensure that infants are vaccinated as per the recommended schedule, and that parents, any other close carers or susceptible adult patients receive a whooping cough booster (combined with diphtheria and tetanus vaccine), as soon as possible. In addition, doctors must maintain a high degree of suspicion for possible cases of whooping cough among patients with prolonged cough. Currently, free Boostrix is available for 3 months for new parents of infants born after June 15th 2009. Grandparents, and other non-immune adults are currently not funded to receive free Boostrix, but should be encouraged to get vaccinated nonetheless.