Incidence of various causes of vaginal discharge among sexually active females in age group 20-40 years

Introduction

Vaginal discharge is a common clinical problem with many etiologies. In the past vague terminology such as "non-specific vaginitis" or "non-specific lower genital tract infections" often was used to describe conditions that produce vaginal discharge. Recently, careful definition of clinical syndromes and increased knowledge about the specific agents that cause genital infection in women have made more precise diagnosis possible.[1]

The vagina, ectocervix and endocervix are all suspectible to various pathogens, depending on the type of epithelium present and other factors in the microenvironment. The squamous epithelium of the vagina and ectocervix is susceptible to infection with candida species and Trichomonas vaginalis and the columnar epithelium of the endocervix is susceptible to infection with Neisseria gonorrhoeae and Chlamydia trachomatis. Herpes simplex virus may infect both types of epithelium.[2]

Vaginal discharge is a common symptom of genital infection in women. Identifying its source can be challenging, because a large number of pathogens cause vaginal and cervical infection, and several infections may co-exist. Patient history and physical examination findings may suggest a diagnosis. Useful tests for etiological diagnosis include pH analysis of vaginal fluid, the "whiff test", wet mount examination, culture and Gram′s stain.[1]

Vaginitis resulting from bacterial, fungal or protozoal infections can be associated with altered vaginal discharge, odour, pruritus, vulvovaginal irritation, dysurea or dyspareunia depending on the type of infection. Bacterial vaginosis which is primarily characterized by a malodorous discharge is common in women with multiple sex partners and is caused by the overgrowth of several facultative and anaerobic bacterial species. Vulvovaginal candidiasis is characterized by pruritis and cotton cheese like discharge. Vaginal trichomoniasis, is associated with a copious yellow or green, sometimes frothy discharge. Differential diagnosis of these infections requires a thorough history, vulvo-vaginal examination, simple laboratory tests, including microscopy of the vaginal discharge.[3]

Material and Methods

The present study was carried out to investigate incidence of various causes of vaginal discharge among sexually active females. One hundred sexually active females in the age group of 20-40 years, with complaint of vaginal discharge attending Obstetrics and Gynaecology clinic and STD clinic of Government Medical College and Hospital, Faridkot, were selected for this study at random. A detailed clinical history and a thorough examination of all the cases was done. After making the clinical diagnosis, appropriate tests for diagnosing candidiasis, trichomoniasis, gonorrhoea and bacterial vaginosis were done.

A sterilized Cusco′s speculum was inserted into the vagina to visualize the vagina and cervix. Any pathology of vagina and cervix like vaginitis, discharge, cervicitis, cervical erosions were looked for. The amount, colour, character and smell of the vaginal discharge in the vagina were noted. pH of the discharge was noted with a narrow range pH paper.

The discharge was then collected from the upper part of the posterior fornix and lateral vaginal walls. Wet smear and KOH preparation of vaginal secretions were made and examined immediately under microscope.

The swabs of vaginal discharge were processed as under

1) One swab was used to inoculate two slopes of Sabouraud′s dextrose agar medium, one incubated at 22 degree centigrade and second at 37 degree centigrade for 1-2 days. The cultures were confirmed by studying colony morphology, lactophenol cotton blue preparation, Gram smear and formation of germ tube.

2) Second swab was used for inoculating Mac Conkey′s and Blood agar media for any non-specific pyogenic organisms.

3) Third swab was used for making smears for Gram staining.

The swab and test tubes in use were oven sterilized at 160 degree centigrade for half an hour.

A study of vaginal swabs was carried out as under.

For candido

(a) KOH preparation : A drop of 10% KOH was added to the vaginal secretions taken on a clean glass slide and mounted with a cover slip. Candida was identified as highly refractile, round or oval budding yeast cells.

(b) Gram stained vaginal smears were examined which showed Gram positive pseudohyphae with budding yeast cells.

(c) Cultures on Sabouraud′s dextrose agar medium showed growth of creamy, greyish moist colonies. Lactophenol cotton blue preparation of the colony showed budding cells and pseudohyphae.

For the differentiation of C. albicans, germ tube test formation was studied by emulsifying a portion of the colony, and incubating in one millilitre of serum and incubating the tube at 37 degree centigrade.

For Trichomonas vaginalis

Specimens for the wet smear examination were taken from the posterior fornix with a sterilized cotton swab which was mixed with a drop of normal saline taken on a clean glass slide. A cover slip was mounted on the glass slide and the wet film was examined immediately under microscope. Similarly, wet smear of vaginal secretions was looked for flagellate organisms under microscope.

For Neisseria gonorrhoeae

Gram stained smear of the discharge from the cervix and urethra, if any, was examined under microscope for intracellular Gram negative diplococci.

For bacterial vaginosis

(a) Wet film

The discharge from posterior fornix was taken with a sterilized cotton swab and mixed with a drop of normal saline taken on clean glass slide. A cover slip was mounted on the glass slide. The wet film was examined for the presence of clue cells which are vaginal epithelial cells with granular surface and blurred margins because of attached bacteria.

(b) Amine test/whiff test

A drop of 10% KOH was put on vaginal secretions taken on a glass slide and presence of ammonical odourwas noticed.

(c) Gram stained smears

These smears were examined for presence of altered vaginal flora in form of Gram negative cocco-bacilli studding vaginal epithelial cells instead of normally predominant Gram positive lactobacilli. The vaginal epithelial cells in cases of bacterial vaginosis were having a granular surface and blurred margins because of the attachted bacteria and these cells are called as clue cells.

The cases which were showing positive culture on Mac-Conkey′s medium and blood agar - medium were diagnosed as cases of non-specific urogenital infections.

The cases with complaint of . vaginal discharge and other associated symptoms with pH > 4.0 - but with all the other tests negative - were grouped under other causes of . vaginal discharge.

Observations and results

The present study showed 45% incidence of bacterial vaginosis, 31% vulvovaginal candidiasis, 2% trichomoniasis, 3% gonorrhoea, 5% non-specific urogenital causes, and 14% with other causes [Table - 1].

The cases which were showing positive culture on Mac Conkey′s medium and blood agar medium were diagnosed as females of age group cases of non-specific urogenital infections. In the present study, their incidence was found to be 5%.

The cases with com-plaint of vaginal discharge and other associated symptoms with pH>4.0 and Gram smears showing polymer-phonuclear leucocytes but with no other finding were grouped un-der other causes of vaginal discharge. These accounted for 14% of the cases in the present study.

Patients had pruritis (49%); odour (69%); bur-ning micturition (50%); frequency of micturition (20%); dysuria (17%); dyspareunia (31%). Maximum number of patients with bacterial vaginosis had a complaint of foul-smelling discharge (84.44%) while in cases of vulvo-vaginal candidiasis, pruritis (83.87%) was the most common symptom. All patients (100%) with trichomoniasis complained of pruritis, odour, burning micturition, dysuria, dyspareunia along with vaginal discharge. Pruritis was absent in patients of gonorrhoea. Urinary complaints were more as compared to other symptoms in cases grouped under non-specific urogenital infections and with other causes [Table - 2].

Discussion

The present study showed a maximum incidence of bacterial vaginosis (45%) followed byvaginal candidiasis (31 %). This is in agreement with finding of Fox et al. The reported incidence of various causes of vaginal discharge in different studies is shown in [Table - 3].

The incidence of bacterial vaginosis has compared favourably to that of : Ries,[5] 30-35%; Mahadani et al,[6] 44.30%; Fonck et al,[9] 50%; Kamara et al,[10] 44.10%.

The incidence of vulvovaginal candidiasis in our study has compared favourably to that of Levett,[4] 44.6%; Ries,[5] 20-25%; Kamara et al,[10] 30.7%.

The incidence of gonorrhoea in our study has compared favourably to that of: Alary et al,[7] 5.1% and Fonck K et al[9] (2000), 7%.

However, a low incidence of trichomo-niasis (2%) which might be because of previous treatment taken by the patients has been found in the present study. Natarajan, et al[12] observed a changing clinical profile of vaginal trichomoniasis by diminishing trend of acute symptoms and in-creasing trend of asymptomatic status. It was ob-served that increasingly wide spread use of nitramidazine group of drugs (metronidazole, tinidazole) for gynaecological and non-gynaecological indications both on definite and sus-pected clinical grounds should be contributing to this changing clinical profile of trichomonal infec-tion. Malla N et al[11] reported thatthe incidence of trichomoniasis in normal population is approxi-mately 10 percent, though it varies between 0-65 percent in different geographical locations.

Patients with candidal vulvovaginitis often present with itching, burning, white discharge, vulvar or vaginal erythema, painful intercourse and stinging on urination. Bacterial vaginosis is characterized by a musty or fishy vaginal odour and a thin, white vaginal discharge. Patients with trichomoniasis usually complain of profuse, yellow green discharge and vaginal or vulvar irritation with complaints of vaginal odour, itching painful intercourse and painful unrination.[5]