VAGINAL DISCHARGE

PATHOPHYSIOLOGY
VAGINAL DISCHARGE

NURKHOLIS HARAHAP
2208260132
 PELVIC
INFLAMMATORY DISEASE
 PELVIC INFLAMMATORY DISEASE
Infection of the female upper genital organs

RISK FACTOR ETIOLOGY

• Promiscuity • Gonorrhea -> N. gonorrhoeae
• History of sexually transmitted infections • Non-Gonorrhea: Chlamydia trachomatis,
• History of sexual abuse Gardnerella vaginalis, Mycoplasma of man,
• Biopsy of internal genital masses Mycoplasma genitalium, Ureaplasma urealyticum,
• Curettage HSV type 2, Trichomonas vaginalis,
• Hysteroscopy CMV,Haemophilus influenzae, Streptococcus
• Conception (IUD) agalactia, Escherecia coli etc
• Unprotected sex
• Young age
 CLINICAL MANIFESTATIONS
• Lower abdominal pain
• Pelvic pain
• Fever, nausea, vomiting
• Abnormal vaginal discharge
• Abnormal uterine bleeding
PATHOPHYSIOLOGY
 PHYSICAL EXAMINATION
• Inspection: Abnormal Vaginal discharge
• Palpation: Cervical rocking pain, tenderness
uterus and adnexa

SUPPORTING INVESTIGATION
• Whole blood: Leukocytosis, increased ESR
• Increased C reactive protein
• Transvaginal ultrasound, MRI
• Endometrial biopsy
• Laparoscopy
• Microscopic vaginal discharge
 TREATMENT
NON PHARMACOLOGY
• Maintain genital hygiene
• Good nutrition
• Get enough hydration
• Avoid use vaginal cleanser
PHARMACOLOGY
Antibiotics (depending on etiology)
• Outpatient :
Ceftriaxone 250 mg IM SD + Doxycycline
2x100mg for 14 days +/- Metronidazole 2x500
mg 14 days
• Inpatient:
Cefotetan 2 gr IV/12 hours or cefoxitin 2 gr
IV/6 hours + Doxycycline 2x100 mg
Symptomatic
 COMPLICATION PROGNOSIS
• Pelvic pain chronic Early Diagnosis and Treatment: Prompt
• Infertility recognition and treatment of PID are crucial in
• Ectopic Pragnancy preventing complications. Antibiotics are
• Abscess ovarian tubo usually prescribed to treat the infection, and
the sooner treatment begins, the better the
prognosis.
 EDUCATION
• Explain that PID is caused by a bacterial infection, which often stems from sexually
transmitted infections such as chlamydia and gonorrhea
• Antibiotics are the primary treatment for PID and how important it is to follow the
instructions for using prescribed antibiotics.
• The importance of using condoms to prevent sexually transmitted infections that can
cause PID.
• Maintain genital hygiene, good nutrition, adequate hydration, avoid use vaginal
cleanser.
SERVICITIS
 SERVICITIS
Inflammation of the uterine cervix

ETIOLOGY
a. Non-Infections b. Infections
• Local trauma (tampons, cervical cap, IUD thread,
• Neisseria gonorrhoeae
pessary ring, diaphragm)
• Chlamydia trachomatis
• Radiation
• Herpes simplex virus
• Irritation due to chemicals (vaginal cleanser,
• Trichomonas vaginalis
latex)
• Systemic inflammation (Bechet syndrome)
• Malignancy
 RISK FACTOR CLINICAL MANIFESTATIONS

• Promiscuity • Asymptomatic
• Young age • Vaginal discharge
• Urban • Dysuria, dyspareunia
• Poor economic status • Abnormal vaginal bleeding
• Use of alcohol and drugs • Genital skin lesions (clustered vesicles, ulcer)
• Burning, itching sensation in the genitals
PATHOPHYSIOLOGY
 PHYSICAL EXAMINATION
• External genitalia inspection : Skin lesions (clustered vesicles, ulcers)
• Inspection: vaginal discharge (N.Gonorrhoeae -> mucopurulent, Chlamydia
trachomatis-> mucoid, Trichomonas vaginalis-> foamy greenish yellow discharge,
foul odor), Strawberry cervix (Trichomonas vaginalis), vesicles/ulcers/erythema on
the portio (Herpes simplex)
• Bimanual examination: Cervical enlargement, cervical/portio swaying pain
 SUPPORTING INVESTIGATION
• NAAT (Nucleic acid amplification testing)
• Microscopic -> NACL (Trichomonas vaginalis) wet preparation, Staining gram
(Bacteria), Tzank test (Herpes simplex)
 N. Gonorrheae

• Microscopies: Diplococcus Gram – intracellular

• Culture: Thayer Martin Medium
 Chlamydia trachomatis

Intracellular obligate Gram-negative bacteria, do not contain peptidoglycan and N-acetyl

muramic acid, measuring 0.2-1 m and only can reproduce inside eukaryotic cells
 TREATMENT

NON PHARMACOLOGY
• Maintain genital hygiene
• Good nutrition
• Get enough hydration
• Avoid use vaginal cleanser
TREATMENT

HERPES SIMPLEX
Acyclovir, 5x200 mg/day, orally, for 7 days, OR
Acyclovir 3x400 mg/day for 7 days OR
Valacyclovir, 2x500 mg/day, orally, for 7 day,

TRIKOMONIASIS
• Metronidazole 2 gr SD 2
• Metronidazole 2 x 500 mg 7 days
 COMPLICATION AND PROGNOSIS
• Infertility: If left untreated, cervicitis can cause inflammation that damages cervical tissue and
can even affect fertility in women.
• Risk of Chronic Pelvic Disease: Chronic or frequently recurring cervicitis can increase the
risk of inflammation of other pelvic organs, such as the uterus, fallopian tubes, or ovaries
 EDUCATION
• Avoid making cervicitis worse or triggering, such as chemicals in soap or detergent,
certain condoms, or other allergens.
• keep the genital area clean in a gentle and non-irritating way, such as using warm
water and neutral soap, without fragrances or harsh chemicals.
• Recommend wearing underwear made from sweat-wicking and loose-fitting
materials, which can help retain moisture and reduce irritation
• the importance of using condoms in every sexual intercourse to prevent transmission
of sexually transmitted infections that can cause or worsen cervicitis.
 Prevention
Prevention efforts are divided into several levels according to travel
disease. It is known that there are 3 main levels of disease prevention, namely:
• prevention first level (primary prevention),
• secondary level prevention (secondary prevention),
• and third level prevention (tertiary prevention).
VULVOVAGINALIS
CANDIDIASIS
 VULVOVAGINALIS CANDIDIASIS
Mucosal infections vagina and/or vulva (non-keratinized epithelium) caused by the
fungus Candida species

ETIOLOGY RISK FACTOR

• Candida albicans • IUD users
• Use of towels together
• Immunosuppression
• Diabetes mellitus
• Hormonal changes (e.g. pregnancy)
• Use of broad spectrum antibiotic therapy
• Obesity.
 CLINICAL MANIFESTATIONS

• itching on vulva area

• hot sensation in the vulva area
• pain when urinating (disuria)
• momentary pain sexual intercourse (dyspareuniae)
• abnormal vaginal discharge = white liquid yellowish
lump-shaped (cottage cheese-like)
PATHOPHYSIOLOGY
 PHYSICAL EXAMINATION
Inspection: hyperemia on labia minora, vaginal introitus, and abnormalities in severe
cases there are signs inflammation in the vulva area accompanied by edema (swelling)
and redness (erythema). There are erosions, ulcers shallow on the labia minora and
around the vaginal introitus. Spots were found yellowish white on labia minora, fluor
albus milky white with yellowish white lumps like cheese sticking to the vaginal walls
 SUPPORTING INVESTIGATION

the presence of cells yeast or budding yeast cells), blastospores, and pseudohyphae
(pseudohyphae)a lot.
 TREATMENT

NON PHARMACOLOGY PHARMACOLOGY

• Maintain hygiene or cleanliness of the
genital organs,
• Avoid intercourse sexual intercourse while
undergoing therapy,
• The patient's sexual partner does not need
to be given therapy if you do not
experience clinical symptoms.
• Reduce levels of anxiety and depression
 COMPLICATION AND PROGNOSIS
Candidiasi vulvovaginal indicates a good prognosis good with a cure rate of 80-95%. However,
vulvovaginal candidiasis recurred can occur in less than five percent of women Healthy. So the
risk of repeated cases is relate closely related to the patient's risk factors
 EDUCATION
• Maintain hygiene or cleanliness of the genital organs,
• Avoid intercourse sexual intercourse while undergoing therapy,
• The patient's sexual partner does not need to be given therapy if you do not
experience clinical symptoms.
• Reduce levels of anxiety and depression
BACTERIAL VAGINOSIS
 BACTERIAL VAGINOSIS
Polymicrobial syndrome due to disorders balance of normal vaginal bacterial flora

ETIOLOGY RISK FACTOR

• Gardnerella vaginalis
• IUD users
• Use of towels together
• Immunosuppression
• Diabetes mellitus
• Hormonal changes (e.g. pregnancy)
• Use of broad spectrum antibiotic therapy
• Obesity.
 CLINICAL MANIFESTATIONS

• colored vaginal discharge white and/or gray with a fishy odor

• dyspareunia
PATHOPHYSIOLOGY
 PHYSICAL EXAMINATION

Spuculum :
• vaginal discharge increased, homogeneous gray color, low or normal viscosity, odor,
and rarely foams.
• vaginal discharge adheres tothe vaginal walls appear as a thin layer or diffuse sheen,
pH of vaginal secretions ranges between 4.5-5.5. Symptoms of inflammation
generally there are none. There is erythema on vagina or vulva or petechiae on
vaginal wall.
 SUPPORTING INVESTIGATION

With a microscope, on preparation Wet vaginal secretions with saline solution physiology shows few
or no leukocytes, numerous epithelial cells and the presence of coccobacill group. There is a clue cell
(cell vaginal epithelium covered with coccobacilli so the cell boundaries are not clear) is
pathognomonic
 SUPPORTING INVESTIGATION
• To establish a diagnosis, 3 of the 4 AMSEL criteria are required:
(1) Homogeneous, white, noninflammatory secretions
that lines the walls of vaina;
(2) Wet preparation examination with saline
shows the presence of clue cells;
(3) pH vaginal discharge above 4.5;
(4) “whiff test” (vaginal fluid smells like fish after
addition of potassium hydroxide solution KOH] 10%) positive
 TREATMENT

NON PHARMACOLOGY PHARMACOLOGY

• Maintain hygiene or cleanliness of the
genital organs,
• Avoid intercourse sexual intercourse while
undergoing therapy,
• The patient's sexual partner does not need
to be given therapy if you do not
experience clinical symptoms.
• Reduce levels of anxiety and depression
 COMPLICATION AND PROGNOSIS
Untreated or recurring BV can increase the risk of complications such as upper reproductive tract
infections, pregnancy complications, and an increased risk of sexually transmitted infections.
 EDUCATION
• Maintain hygiene or cleanliness of the genital organs,
• Avoid intercourse sexual intercourse while undergoing therapy,
• The patient's sexual partner does not need to be given therapy if you do not
experience clinical symptoms.
• Reduce levels of anxiety and depression
 VAGINOSIS
TRIKOMONIASIS
 VAGINOSIS TRIKOMONIASIS
parasitic infections in the form of pathogenic protozoa in the ducts lower genitourinary tract of
women and men which can cause it to happen sexually transmitted infections

ETIOLOGY RISK FACTOR

• T. Vaginalis • IUD users
• Use of towels together
• Immunosuppression
• Diabetes mellitus
• Hormonal changes (e.g. pregnancy)
• Use of broad spectrum antibiotic therapy
• Obesity.
 CLINICAL MANIFESTATIONS

• vaginal discharge of yellowish hijua color, foamy like soapy water, and itching in the
genitalia organs
• Disuria
• Dyspareunia
• strawberry servic
PATHOPHYSIOLOGY
 SUPPORTING INVESTIGATION

In this microscopic examination, we will find a picture of the morphology of Trichomonas vaginalis
and also the movement of the trophozoid Trichomonas vaginalis that stomps.
 SUPPORTING INVESTIGATION
• To establish a diagnosis, 3 of the 4 AMSEL criteria are required:
(1) yellow-green, foamy, sticky and abundant
(2) Microskopis, Tricomonas, Leukocytes>10 Wide Field of View
(3) pH vaginal discharge > 4.5;
(4) “whiff test” positive
 TREATMENT

NON PHARMACOLOGY PHARMACOLOGY

• Maintain hygiene or cleanliness of the
genital organs,
• Avoid intercourse sexual intercourse while
undergoing therapy,
• The patient's sexual partner does not need
to be given therapy if you do not
experience clinical symptoms.
• Reduce levels of anxiety and depression
 COMPLICATION AND PROGNOSIS
Trichomoniasis also has complications with several very serious diseases such as an increased risk
of transmission of Human Immunodeficiency Virus (HIV), an increased risk of cervical cancer,
and the release of Herpes Simplex Virus-2 (HSV-2) in the female genital tract area which can
result in an increase in the transmission of other STIs.
 EDUCATION
• Maintain hygiene or cleanliness of the genital organs,
• Avoid intercourse sexual intercourse while undergoing therapy,
• The patient's sexual partner does not need to be given therapy if you do not
experience clinical symptoms.
• Reduce levels of anxiety and depression
 increased growth of Trichomonas
vaginalis
the number of lactobacillus bacteria is
not balanced aspartyl proteinase production
destroy host cellls

decrease in H2O2 levels

inflammatory reaction (PMN)
infects vaginal epithelial cells,
Vaginal pH is alkaline destroying erythrocytes

increase in vaginal pH

VAGINAL
DISCHARGE
 increased growth of candida albicans

gardnella vaginalis aspartyl proteinase production

increases amino release destroy host cellls

unpleasant smelling liquid inflammatory reaction

increase in vaginal pH
VAGINAL
DISCHARGE
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