How little we know about vaginal ecosystem and loss of battle by defense mechanism--> PID?? Here is ABC of white discharge :-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 suspicious of some common but drug resistant infections & uncommon investigation .It’s an challenge for the Gynaecologist as well!
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.
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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-
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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.
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