SEXUALLY TRANSMITTED INFECTIONS: Discharges

Dr. Nihar Dash, MD, D(ABMM)

Overview
Gonococcal

& non-gonococcal urethritis Vaginal microbiota Vaginal discharge

Trichomoniasis Vulvo-vaginal candidiaisis Bacterial vaginosis

Investigating

a patient with vaginal

discharge

Gonococcal & non-gonococcal urethritis

Case 1: Urethral dischage

Mr

X, 24year old, presented with 2day history of yellowish urethral discharge associated with dysuria. History of unprotected sexual contact with multiple partners during a recent holiday abroad. Diagnosis?

Differential

STIs of Concern: Drips (discharges)

Gonococcal urethritis
N. gonorrhea

Nongonococcal urethritis
C. trachomatis : serotypes D-K Mycoplasmas:

Mycoplasma spp ; Ureaplasma spp

Trichomoniasis
T.vaginalis Caused by a protozoa; usually associated with vaginitis in women

Copious foul smelling discharge

Gonococcal infection

Neisseria gonorrhoeae

Virulence factors

Pili and outer membrane proteins facilitate adherence to epithelial cells of the genitourinary tract, rectum, pharynx & conjunctiva and it contirbutes to antigenic diversity of gonoccoci

 Clinical

Presentations of Gonococcal infection

Men Women Newborn Any extra-genital manifestations?

Gonorrhea - Clinical Manifestations

Urethritis - male

Incubation: 1-14 d (usually 2-5 d) Dysuria and urethral discharge (5% asymptomatic)

Urogenital infection - female

Endocervical canal primary site 70-90% also colonize urethra Majority asymptomatic Symptomatic women may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain

Other clinical manifestations

Ascending infection in many women

Salpingitis, PID, infertility

Rectal (anogenital) infections

Prevalent in male homosexuals Constipation, painful defaecation, purulent rectal discharge

Pharyngitis

Contracted by oral-genital contact Purulent pharyngeal exudate

Ophthalmia neonatorum

Eye infection in the newborn Infection acquired during passage through the birth canal

Complications - Local
Epididymorchitis

Urethral

strictures Pelvic inflammatory disease (PID)

Tubal scarring & occlusion Infertility Ectopic pregnancy

Chorioamnionitis

during pregnancy

Systemic complications of gonorrhea

Disseminated gonococcal infection- gonococcal arthritis most common acute septic arthritis in young adults Commoner in females 60% of cases manifest as bacteremic infection (arthritisdermatitis syndrome)
Arthritis-dermatitis syndrome includes the classic triad of dermatitis, tenosynovitis, and migratory polyarthritis

40% of cases manifest as localized septic arthritis

Perihepatitis (Fitz-Hugh-Curtis syndrome)

Usually in women Can also result from genital chlamydia infection

Endocarditis
Meningitis (rare)

Non-gonococcal urethritis (NGU)

Chlamydia trachomatis (serovar D-K) Mycoplasmas:

Ureaplasma spp: Ureaplasma urealyticum Mycoplasma spp: Mycoplasma genitalium & Mycoplasma hominis

Clinical presentation of NGU:

Patients with NGU present with a longer incubation period than with GCU Subacute onset dysuria & discharge Discharge is usually mucoid or mucopurulent

Genital chlamydia infection

Elementary body Epithelial cell

Chlamydia trachomatis

72 hours 12 hours

Serovar D-K Obligate intraelluar Cell wall outer lipopolysaccharide membrane lacks peptidoglycan but instead contains cysteine-rich proteins

48 hours

24 hours

Inclusion

Causes - cervicitis, urethritis, proctitis, pelvic inflammatory disease

Clinical manifestations

Men

Important cause of non-gonococcal urethritis Mucoid urethral discharge 50% of men are asymptomatic

Women

Infection affects the cervix causing cervicitis progressing to PID & infertility Mucoid vaginal discharge 90% of women are asymptomatic

Newborn infected at delivery

Conjunctivitis, pneumonia

Reactive arthritis (Reiters syndrome)

aseptic inflammatory polyarthritis that usually follows nongonococcal urethritis or infectious dysentery May present as a triad of polyarthritis, conjuctivitis & NGU Associated with HLA-B27 genotype

Chlamydia cervicitis in women

NGU: Mycoplasmas

Mycoplasma species: unique among prokaryotes in that they lack a cell wall

lack of a Gram stain reaction Non-susceptibility to beta-lactams

Genital mycoplasmal organisms: reside in the mucosa of urogenital tract

Ureaplasma urealyticum ; Mycoplasma genitalium & Mycoplasma hominis frequently detected in the lower urogenital tracts of healthy adults, they can also produce localized urogenital diseases

Frequently associated with:

M. genitalium: NGU M. hominis: PID, postabortal and postpartum fevers U. urealyticum: NGU, prostatitis

Investigations: Specimens

Gonococcal urethritis:

Men: Swab of urethral discharge Women: Endocervical swab Rectal & Pharyngeal swabs: depending on patient & clinical presentation First void urine (only used for nucleic acid amplification tests)

NGU:

Men: Urethral swab Endocervical swab First void urine for Chlamydia trachomatis
only used for nucleic acid amplification tests

Mr X should be investigated for both GU & NGU

Specimen Collection:

Collection of Urethral swab for Chlamydia investigation Collection of endocervical swab

Laboratory identification

N. gonorrhea

Gram stain: Culture (Thayer-Martin Agar) Nucleic acid amplification tests

C. trachomatis

Direct antigen detection Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-2 Cell culture: Not done routinely; Important in medico-legal cases DNA amplification assays
Polymerase chain reaction (PCR) Strand displacement amplification (SDA)

Mycoplasma

Culture on special mycoplasma media PCR

Neisseria gonorrhoeae

Gram negative diplococci in PMN

Neisseria colonies on Thayer-Martin agar plate

Chlamydia culture in McCoy cells

Iodine-stained inclusion in McCoy cells

Chlamydia Direct Fluorescent Antibody (DFA)

Fluorescent-antibodystained inclusion in McCoy cells

Nucleic acid (DNA) amplification assays

DNA amplification assays

Polymerase chain reaction (PCR) Strand displacement amplification (SDA)

Highly sensitive & specific

Can be used for first void urine & swabs

Now used for Chlamydia screening in developed countries Assays for simultaneous detection of Chlamydia & N. gonorrhoeae are available

Treatment of uncomplicated gonococcal infections of the Cervix, Urethra, and Rectum

Recommended regimen (drug of choice)

Ceftriaxone 125 mg IM in a single dose OR Cefixime 400 mg orally in a single dose

Alternative Regimens

Spectinomycin 2 g in a single intramuscular (IM) dose particulary effective for anogenital infections; expensive OR Single-dose cephalosporin regimens
ceftizoxime 500 mg IM; or cefoxitin 2 g IM, administered with probenecid 1 g orally; or cefotaxime 500 mg IM

ALWAYS INCLUDE TREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT (Azithromycin 1g stat)

Ciprofloxacin is no longer recommended for treatment of gonococcal infection

Antimicrobial susceptibility of N. gonorrhoea isolated at SMC, Bahrain

Antimicrobial agent Ciprofloxacin Ceftriaxone

2003 (141)
% resistant 41.8 3.5

2004 (130)
% resistant 42.3 2.3

Treatment : NGU

Same treatment for both Chlamydia & Mycoplasma Drug of choice: Macrolides

Penicillins and all cephalosporins have no role in the management of chlamydial infection
Recommended drugs for treatment of uncomplicated genital Chlamydia infection
azithromycin 1g stat or doxycycline 100 mg twice daily for 7 days Alternatives; Ofloxacin 300 mg orally twice a day for 7 days OR Levofloxacin 500 mg orally once daily for 7 days In pregnant women: Erythromycin 500mg four times a day for 7 days

Azithromycin is usually used because the single stat dose ensures compliance

Vaginal discharge

Case 2: Vaginal Discharge

32

year old woman presented with history of vaginal discharge of three days duration.

Discharge is copious, foul smelling and frothy Associated pruritus No genital ulcers or warts

Differential

diagnosis?

Normal vaginal fluid

pH

3.8-4.5
Clear, transparent

Colour

Consistency Odourless

VAGINAL MICROBIOTA
Lactobacillus

spp (Doderlein's Bacillus)

Predominant (95%) Beneficial Maintains low vaginal low pH (pH =3.8- 4.5) Inhibits growth of other bacteria

Bacteroides Gardnerella

vaginalis Candida albicans

Usually present in low numbers

Vaginal Discharge

Types of discharge

Purulent discharge: N.gonorrhoeae Mucoid discharge: Chlamydia; Mycoplasma Frothy greenish malodorous : T. vaginalis Thin greyish, fishy smell with alkaline pH: Bacterial vaginosis Whitish cheesy, itchy: Candida

Other causes of vaginal discharge

Atrophic vaginitis (post menopausal) Foreign body (children) Allergic vaginitis (spermicides, douching products)

Trichomoniasis

Trichomas vaginalis

Protozoa Humans are the only natural host Almost always transmitted sexually Occurs with other STIs Equally distributed in all age groups

Associated with poor pregnancy outcomes Increase risk of HIV Treatment: Metronidazole 2 g orally in a single dose OR

Tinidazole 2 g orally in a single dose

Trichomoniasis: Yellowish, greenish, foamy, foul smelling discharge

Vulvovaginal candidiasis

Fungal infection

Caused by Candida spp (Candida albicans)

incidence

Use of broad spectrum antibacterial antibiotics Diabetes mellitus Pregnancy

Presentation

Whitish cheesy vaginal discharge Vaginal puritus

White, curdy, cheesy, itchy

Candidiasis

Classification of vulvovaginal candidiasis (VVC) Uncomplicated VVC

Sporadic or infrequent VVC Mild-to-moderate VVC

Complicated VVC
Recurrent VVC Severe VVC

Likely to be Candida albicans

Nonimmunocompromised women

Nonalbicans candidiasis
Women with uncontrolled diabetes, debilitation, or immunosuppression, or those who are pregnant

Treatment : uncomplicated VVC

Vaginal

& oral antifungal

Vaginal pessaries or cream

3-day or 7 day course (depending on dose given) e.g. Miconazole 100 mg vaginal pessary for 7 days OR 200 mg vaginal pessaryfor 3 days

Oral - Fluconazole 150 mg oral tablet, one tablet in single dose

Bacterial Vaginosis (BV)

Ecosystem Imbalance

Reduction or absence of normal vaginal lactobacilli Increase or overgrowth of other vaginal anaerobes

Bacterial vaginosis

Risk Factors:

Douching, Multiple/new sexual partners, Intrauterine devices (IUD), Low socio-economic class

Clinical presentation:

Thin, gray-white, homogeneous vaginal discharge Discharge has a fishy odor

Due to metabolic by-products of anaerobic bacteria More noticeable after menses and intercourse due to alkalinity of blood and semen

Vulval irritation : May or may not be present

Up to 60% of women may be asymptomatic

Treatment of BV

Clindamycin or metronidazole : Given orally or per vagina

Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole gel, 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for 7 days

High rate of recurrence New approaches Probiotics

Emerging evidence for the usefulness of probiotics in the treatment of BV Probiotics are beneficial bacteria given to replace harmful ones Probiotic preparations with specific strains of Lactobacilli can be given orally or per vagina

Investigating a patient with vaginal discharge

Investigation of vaginal discharges: Specimen collection

High

vaginal swab: BV, Trichomoniasis, Candida

swab: gonococcal &

Endocervical

chlamydia
First

void urine: Nucleic acid amplification tests for Chlamydia & N. gonorrhoeae

Microbiological procedures
Microscopy

Wet preparation (wet mount): T. vaginalis & Candida spp

Microbiological procedures
Microscopy
Wet preparation : T. vaginalis & Candida Gram stain: N. gonorrhoeae, BV, Candida

Gram stain of vaginal smear

Normal

Bacterial vaginosis

Normal Lactobacilli Vaginal epithelial cell

Clue cell

Candida: Budding yeast, pseudohyphae

Microbiological procedures

Microscopy
Wet preparation : T. vaginalis & Candida Gram stain: N. gonorrhoeae, BV, Candida

Culture
Special agar media: N. gonorrhoeae, Candida; T. vaginalis Cell culture: Chlamydia

Diagnosis: Trichomonas

Neisseria colonies on Thayer-Martin agar plate

Candida colonies (culture on Sabouraud agar)

Microbiological procedures
Special techniques
Direct antigen detection: Chlamydia DNA probes for hybridization: Chlamydia, Trichomonas PCR: Chlamydia, Gonorrhoeae, Trichomonas

Differentiating common types of vaginal dischage

Diagnostic Criteria Vaginal pH Discharge

Normal 3.8 - 4.2 White,thin, clear

Bacterial vaginosis > 4.5 Thin, white, (milky) gray

Vaginitis Trichomonas 4.5 Yellow, green, foamy

Candida Vulvovaginitis < 4.5 (usually) White, curdy cottage cheese

Fishy Amine odor

Odour Absent
Positive whiff" test : odour increases when 10% KOH is added

Malodorous

Absent/yeast like

Microscopy

Lactobacilli Epithelial cells

Clue cells adherent cocci, no WBC's

Trichomonads WBC's >10/hpf

Budding yeast, Pseudohyphae