This document discusses the causes, diagnosis, and treatment of persistent or recurrent vaginal discharge. It outlines various infectious and non-infectious causes including bacterial vaginosis, candidal vaginitis, and trichomonal vaginitis. The document provides details on symptoms, signs, and tests for diagnosis. It recommends treatments for each condition such as oral and topical antifungal and antibiotic regimens. Factors that can predispose women to recurrent infections are also identified, including multiple sexual partners, STIs, and lack of barrier contraception.

1. Persistent or recurrent
vaginal discharge
Aboubakr Elnashar
Benha University Hospital, Egypt
Aboubakr Elnashar

2. Causes of persistence or recurrence
I. Wrong diagnosis of the cause
II. Wrong or inadequate treatment
Type
Dose
Duration
III. Persistence of predisposing factors
Aboubakr Elnashar

3. I. Diagnosis
Causes of vaginal discharge
Non-infective
Physiological: pregnancy, ovulation, s stimulation
Cervical ectopy
Foreign bodies, such as retained tampon
Vulval dermatitis
Non-sexually transmitted infection
Bacterial vaginosis (BV)
Candidal vaginitis (CV)
Sexually transmitted infection
Trichomonal vaginitis (TV)
Chlamydia trachomatis (CT)
Neisseria gonorrhoeae (NG)
Aboubakr Elnashar

4. 1. Symptoms
TVCVBV
Offensivenon offensiveDischarge:
Offensive
fishy smelling
Vulval itching /
irritation
Vulval itching
soreness
DysuriaSuperficial
dyspareunia
Rarely low
abdominal
discomfortAboubakr Elnashar

5. 2. Signs
TVCVBV
Vulval erythemaVulval erythema
Vaginitisfissuring,oedemaAbsence of
vaginitis
70%: frothy
30%: yellow
Curdy (non
offensive)
Discharge:
Thin white
homogenous
coating walls of
vagina and
vestibule
2% “strawberry”
cervix
Satellite skin
lesions
Aboubakr Elnashar

6. TVCVBV
>4.5<4.5>4.5pH
NoneNonePresentWhiff
test
Leukocytes;
motile
trichomonads
seen in 80%
Leukocytes,
epithelial
cells; yeast,
mycelia or
pseudomycelia
seen in 80%
Clue cells;
rare leukocytes;
lactobacilli
outnumbered by
profuse mixed flora,
including Gram
positivecocci and
coccobacilli
Microsc
opy
3. Tests
Aboubakr Elnashar

7. Aboubakr Elnashar

8. II. Treatment
Bacterial vaginosis CDC, 2010
Recommended regimen
Metronidazole (Flagyl)
500 mg orally twice daily for seven days
Alternative regimen
Tinidazole (Fasigyn)
2 g orally for two days or 1 g for five days
Clindamycin
300 mg orally twice daily for seven days
Pregnancy*
Metronidazole
500 mg orally twice daily for seven days
Aboubakr Elnashar

9. Recurrent BV: European (IUSTI/WHO)Guideline, 2011
Most patients will have recurrences within 3 to 12
months, whatever treatment has been used.
Suppressive regimens
Metronidazole vaginal gel (Metrogel)
weekly for 16 weeks
Aboubakr Elnashar

10. Vulvovaginal candidiasis, uncomplicated CDC,
2010
Miconazole 4% cream
5 g intravaginally once daily for three days
Miconazole vaginal suppository
100-mg vaginal suppository once daily for seven days
200-mg vaginal suppository once daily for three days
1,200-mg vaginal suppository in a single dose
Nystatin vaginal tablet
100,000-unit vaginal tablet once daily for 14 days
Tioconazole 6.5% ointment
5 g intravaginally in a single dose
Terconazole 0.4% cream
5 g intravaginally once daily for seven days
Terconazole 0.8% cream
5 g intravaginally once daily for three days
Terconazole vaginal suppository
80-mg vaginal suppository once daily for three days
Fluconazole (Diflucan)
150 mg orally in a single dose
Aboubakr Elnashar

11. Vulvovaginal candidiasis CDC, 2010
Recurrent:
4 or more episodes/Y. Non albicans: 30% of cases.
Culture: confirm diagnosis & to identify non-albicans.
Initial regimen
Any topical agent 7-14 days or
Fluconazole
100, 150, or 200 mg orally once daily every 3rd day
for 3 doses
Maintenance regimen
Fluconazole
100, 150, or 200 mg orally once weekly for 6 months
Aboubakr Elnashar

12. Non-albicans VVC
1.First line therapy:
Nystatin (Nysert, Mycostatin, Nystan) pessaries once
or twice nightly for 14 d.
2.2nd line:
600 mg boric acid in gelatin capsule vaginally once
daily for 14 d.
3.The final resort:
Amphotericin B (Fungizone) 50 mg supp for 14 d
4. If non-albicans continues to recur,
Maintenance regimen: Nystatin vaginally /w
Aboubakr Elnashar

13. Trichomoniasis: CDC, 2010
Recommended regimen
Metronidazole
2 g orally in a single dose
Tinidazole
2 g orally in a single dose
Alternative regimen
Metronidazole
500 mg orally twice daily for seven days
Pregnancy*
Metronidazole
2 g orally in a single dose
Aboubakr Elnashar

14. Persistent / recurrent TV: European (IUSTI/WHO)Guideline, 2011
{re-infection
±drug resistance}
Check
compliance and exclude vomiting of metronidazole.
re-infection from new or untreated partners
1. Repeat course of standard treatment.
Aboubakr Elnashar

15. 2. If this fails:
HVS or empirical treatment with erythromycin or
amoxycillin
{reduce B-haemolytic streptococci before retreating
with metronidazole as some organisms present in
the vagina may interact and reduce effectiveness of
metronidazole}.
3. Metronidazole
2 to 4 g daily for 7-14 days for metronidazole-
resistant strains.
Aboubakr Elnashar

16. III. Avoiding predisposing factors
TVCVB V
•multiple s
partners,
•other ST
infections
•lack of
barrier
contraceptive
•smoking
•antibiotics
•diet high in refined
sugars
•uncontrolled DM
•Douching
•local irritants,
perfumed products
•tight-fitting
synthetic clothing
•vaginal douching
•smoking,
•IUCD
•new/multiple s partners
•unprotected SI
•higher doses of
spermicide nonoxynol-9
•shower gels, antiseptic
agents and shampoo in
the bath
Aboubakr Elnashar

17. Thank you
elnashar53@hotmail.com
Aboubakr Elnashar