What causes Leucorrhoea-Persistent long term annoying with or without pruritus vulvae, may or may not be associated with Urinary symptoms

White Discharge- A menace for Woman. Leucorrhoea-Persistent long term annoying with or without pruritus vulvae, may or may not be associated with Urinary symptoms .This symptom  of vaginal discharge is strongly suspicous of some common but drug resistant infections & uncommon investigation

 

 

•     It’s an challenge for the Gynaecologist as well!

•     Dr. S K Pal. M.S (Gynae)

Vaginal Ecosystem & Immune system of vaginal Mucosa and Vaginal Fluid is the least discussed topic.

•     Why and how entry of offending bacteria, parasites and viruses inside the vaginal canal are continuously prevented is still remains an enigma to  even the Gnaecologists of repute.

What are the normal vaginal Flora???

•       Let us talk about most commonly discussed bacteria- i.e. Lacto Bacilli.

•       1) There are about 100 species of L B.

•       2) They principally produce Lactic Acid as well as Hydrogen Peroxide.

•       .

What are the Defensins

•       3)Defensins: Usually neutrophils and Macrophages of body  excretes this substances to fight against any invading organism. At vaginal fluid the  normally Lact. Bacilli also synthesize such antibacterial substances to kill against invading organisms

What are normally liberated by Lact. Bacilli???

•       IV) Bacteriocins. These are group of anti-bacterial substances (chemical)which are produced by one strain of bacteria which are harmful against another strain of the same family.

How the defense system is normally maintained?

•       It is already known that 1) L. Acid, 2)  H2O2, 3) Defensins, & 4) Bacteriocins . Are important both in prevention of overgrowth of pathogenic bact & their proliferation.

•        

•       But one should also think of about pH of vaginal fluid- which is normally   3.5-4.5.à This high pH is key supervisor in preventing  growth of anaerobic organisms. 

Is she oestrogen-deficient clinically?

•       The population and work force of L. Bacilli depend much on estrogen.

•       If the women concerned is oestrogen deficient her conc. of L. Bacilli, H2O2  and Lac. Acid.   in vagina will be less.

•       As such, she  will be a candidate for recurrent  BACTEIAL VAGINOSIS.

 

Where are the sources of normal virginal secretions?

•       After attaining adulthood--Vagina is almost always most. Where from the fluid comesà Vaginal mucosa do not contain any glands to secrete any fluid.

What are the normal & usual sources of vaginal secretions?

•       Sources are:- Transudates from vaginal  walls, cervical secretions, Endometrial and tubal fluids, secretions from sebaceous glands, sweat glands, Skene glands of ext. urethra, Bartholdi glands.

•       Any such gland can pour much- cause annoyance to the woman concerned.

 

Qualities of Normal Vaginal Fluid- What is Normal Discharge

•       White, Thin, flocculent, without any smell/ pruritus. It contains many micro-organisms and their metabolic products that are excreted in the fluid.

•       Normally there is a bio-film of normal commensal  (Doderlein   bacilli)  in the vaginal mucosaà prevents entry of bacteria into the mucosa.

Reproductive Hormones are the key regulators of amount, character of Discharge.

•       The microscopical  examinations are done:-

•       1) Wet mount preparations.- one/two drops of vaginal . Fluid are taken and put on glass slide and a cover slip is put- seen without any stain-

•       1

Hanging Drop Preparations-At OPD/ at Clinics.

•       1) Flagellate organisms:- Trichomonas infections.

•       2) Hyphae- Monilial infections- Fungal vaginitis.

 

We often hear the term Bacterial Vaginosis.

•       It is a mixed infection caused by some specific organisms e.g. Gardnerella  Vaginalis, Mobiluncus, Mycobact hominis, and Bacteroid  species .

•       This term was coined by Spiegel in 1983.

•       It causes white homogenous discharge sticking to vaginal walls.

•       It is possibly the most common cause of vaginal discharge seen amongst reproductive age group.

Bacterial Vaginosis.- How to diagnose?

•       Clinically- the entire vaginal  wall is covered / painted/ coated by a thick white discharge.  KOH  test:-Fishy smell- 10% KOH test at your clinic

•       Microscopy- Gm stain-  CLUE  cells.,

•       Ansell's Criteria, Nugent Scoring system.

What is KOH test?

•       In cases of Bacterial Vaginosis – if a small amount of KOH solution is added then there will be fishy smell from the vaginal fluid   treated with KOH solution- Diagnostic of BV.

What are the most rarely performed Tests?

•       1) Gas Liquid Chromatography.

•       2)Culture of Vaginal Fluid – Aerobic and anaerobic culture often with sensitivity tests

•       3) PCR Technique is becoming increasingly popular..

What next microscopically??

•       Gm Stain:- Lacto bacilli, Doderlein Bacilli, Diff cocci, Supllemenation. Desquamated vaginal cells and pus cells which must not exceed 1  HPF.

 

•       What  are CLUE  Cells ? – These are big vaginal desquamated cells on the surface of which there many small bacteria sticking.- seen in Bacterial Vaginosis.

When we should be worried- call abnormal vaginal discharge???

•       Persistently  heavy,  Malodorous, purulent, blood   pruritus,  cause much irritation/ cause pain or one has to wear a vulvae pad. For excessive  normal secretion.

•       These are the situation one has to investigate and treat.

“Whites”- is a term / expression by patients.

•       Excessive discharge falls under two basic groups:-

•       A) Noninfective- Excessive normal secretion- designated by lay public as leucorrhoea.

•       B) Infective:- pathological- a matter of concern- may be caused by a variety of organisms.

•       One has to elicit history, Sometimes too much Lab tests  to arrive at a definitive diagnosis.

What are the common causes of whites?

•       1) Trichomoniasis.

•       2/ Candida albicans- diabetes, Oral pill intake, antibiotics prolonged use, sometimes resistant type Candida- most difficult to diagnose and treat.

•       3) Chlamydial Trachomatis.

What are the less common causes of Whites?

•       5) Gardnerella vaginalis infection.

•       6) N Gonorrhoeae.

•       7)  HSV(Herpes simplex Virus).

Other but uncommon causes of Whites?

•       9) E. Histolytica- often not considered.

•       10) E. Coli.

•       11)  Staphylococci. Mycobacterium family, Cl. Welchi, Streptococcus.

What are the rare causes of whites?

•    Senile vaginitis, Allergic, Foreign body, Worm infestations, Benign and Malig neoplasms.

Abnormal micro organisms in birth canal can cause HPV infections and ectropion  & many cervical Pathologies.

•     If access to cervical canal by the offending organisms are openà then many bact will have an open access to endocervixà Chr. Cervicitis.

Persistent Whites.

•       This damages the natural defense mechanism,    will continue to exist in endo cervix promotes development of persistent infection. Later difficult to eradicate.

•       HPV  may occasionally persist in cervix epithelium if defense mechanism is lost.

 

Vaginal Micro-organisms and Obstetric Catastrophe.

•       IVF specialists are very serious on this ailment:-My dear forum members:- We have to keep in mind that Ill effects of abnormal vaginal microflora  can yield to:-

•       1) Habitual abortion.

•       2) Preterm Labour

•       3) Puerperal  sepsis.

•       4) Post C S  secondary hemorrhage.

•       IVF specialist are very serious about this ailment of ecosystem of vagina prior to mock transfer even.

How to  prevent BV in Pregnancy?

•       A) Care of the perineum- by different locally applicable antiseptics./ Personal hygiene.

•       B) routine suppl. Of probiotics from 20 weeks of gestation prevents proliferation of pathognomic bacteria and release of cytokines which  cause preterm wreaking of fibroblasts of amniotic membranes,