Vaginal discharge &

Pruritus vulvae
Dr. Mohammed EL-Shafei
Prof. of Ob. & Gyn.
Faculty of medicine
Mansoura university
Egypt
 Vaginal discharge &
Pruritus vulvae

Vaginal discharge (leukorrhea)

The term leucorrhea means white discharge
and should be used to describe the white
non-infected discharge due to excess of
the normal secretion or transudation but it
is frequently used to describe all genital
discharge except bleeding.
 I) Normal vaginal discharge
Normally the vagina & the introitus are kept moist with
occasional one or two drops that stain the underwear.
 Source:
Vulva: Bartholin, sebaceous, sweat and Skene’s glands.
Vagina: transudate (acidic)
Cervix: cervical mucus (alkaline)
 Composition:
1- Water and electrolytes
2- Microorganisms
3- Epithelial cells (vagina – cervix)
4- Organic compounds (fatty acids – proteins – carbohydrates)
 Criteria of normal vaginal discharge:
– Semifluid, clear & about 0.5 ml/day
– Vulva, vagina, cervix appear normal.
– PH < 4.5 (acidic). The acidity varies during life-time and is
influenced by the presence of glycogen (is caused by
estrogen)and Doderlin bacilli
– Has little or no smell
– Micro-organism & their metabolic products
 II) Excessive vaginal discharge
Some women may be very troubled by a discharge
which is not profuse while others may have a much
heavier discharge and consider this to be quite normal
A) Physiological: may be sufficiently heavy to produce
irritation
1- Physiological changes during menstrual cycle (
during ovulation)
2- Administration of sex hormones
3- Sexual arousal  vaginal fluid rich in glycoprotein
 B- Pathological infection
Cause Clinical picture & diagnosis
Bacterial Replacement of  Homogeneous grayish or yellowish discharge
Vaginosis normal lactobacillus  Clue cells on microscopy
with mixed flora e.g.  Vaginal PH > 4.5
gardnerella vaginilis,  Positive whiff test (i.e. fishy odor of discharge before
or after addition of 10% KOH)
mycoplasma hominis
 Diagnosis: requires at least 3 of above clinical
features
Vulvo-vaginal Candida albicans  Thick, white discharge with pruritus. Vulvar burning,
Candidiasis vaginal soreness, dyspareunia, dysuria.
 Diagnosis: clinical symptoms + identification of
budding yeast on a wet mount or KOH prep or Gram
stain of vaginal discharge
Trichomoniasis Trichomonas  Profuse, malodorous, often frothy, yellow-green
vaginalis discharge and vulvar irritation. May have: urinary
symptoms, dyspareunia,
Diagnosis: saline wet mount will show motile
trichomonad in positive culture
Gonorrhea Neisseria gonorrhea Commonly asymptomatic
Chlamydia Chlamydia Commonly asymptomatic
trachomatis
Acute Gonorrhea  Purulent, yellow, abundant discharge
cervicitis chlamydia  Pelvic pain
and B.V  Urinary symptoms
 Diagnosis: wet smear ( WBC's) > 10/HPF
II] Other pathological conditions:

tumours as cancer cervix and endometrial

carcinoma usually cause bleeding but may
 discharge which may be foul smelling
as a result of sloughing of necrotic tissue
C) Psychological: 20% of women who
complain of discharge are found to have
normal secretion on examination, with no
abnormal findings
 Pruritus vulvae
Definition: It is a vulval burning sensation with
attempts to gain relief by itching. It is usually a
symptom of another disease process but it can
be a primary diagnosis if there is no pathological
finding.
Types:
I) Pruritus associated with vaginal discharge
( more common):
Causes: trichomoniasis, moniliasis
Characters: itching is situated within the
introitus as well as on the vulva and is out of
proportion to the amount of discharge
II) Pruritus without vaginal discharge
(less common)
Causes:
1- Generalized disease: as uremia, jaundice,
drug induced.
2-Skin diseases not specific to the vulva:
- Psoriasis
-Seborrheic dermatitis
- Scabies
- Neoplastic
- Carcinoma in situ & paget’s disease
- Squamous cell carcinoma
 II) Pruritus without vaginal discharge
(cont.)
3- Parasitic : pediculosis (parasitic) will cause pruritus pubis
4- Diseases of the anus & rectum:
- Enterobius: skin irritation by the worm is the most common
cause in children
5- Urinary conditions: glycosuria in diabetes
6- Allergy & drug sensitivity.
7- Deficiency states:
- Decrease vitamin A, vitamin B2, vitamin B12, and folic acid
- Alimentary tract lesions interfering with biosynthesis or absorption such
as: chronic diarrhea, malabsorption, postgastrectomy. Achlorhydra
(treated by dilute HCl 1ml. & water, t.d.s)
8- Psychological features.
9-Chronic vulval dystrophies.
10-Chronic vascular changes: all lesions that cause itching have a
vascular change e.g. insect bites & varicose veins
 Diagnosis of pruritis vulvae
A) History:
- Itching; its onset, site & duration
- General itching (allergic condition)
- Presence or absence of vaginal discharge
- Family history of diabetes
B) Examination: for vulvitis or discharge
C) Investigations:
- Urine for sugar or bile pigments
- Blood for Hb%, glucose & bilirubin
- Vaginal discharge culture & sensitivity
- Biopsy: if there are suspicious skin changes or if symptoms persist and do
not respond to simple advice or a short trial of hydrocortisone cream
- Fractional test meal for achlorhydra
The diagnosis of primary idiopathic pruritis vulvae is made by exclusion.
The patient is complaining from itch rather than burning or other pain
Treatment of pruritis vulvae
1- Treatment of the cause: if identified
2- General measures: sedatives & antihistaminic
3- Local treatment:
- Avoid scratching, wear cotton underwear, clean the affected area on a
regular basis
- Avoidance of identified irritants, such as nylon underwear, tight fitting
clothes, soaps, perfumes and over-zealous cleansing.
- Estrogen cream in p.m women
- Hydrocortisone lotion
- Antihistaminic lotion or cream
- Antifungal cream
- Ultraviolet rays
4- Surgical measures: rarely resorted for severe pruritus not relieved by
medical methods
- Infiltration of the nerves by S.C. local anesthetic, hydrocortisone or 95%
alcohol
- Cut the nerves by a circular incision around the vulva
- Simple vulvectomy in resistant cases.