Adolescent Health Committee FOGSI
ADOLESCENCE Vaginal Discharge in Adolescents What to do? Dr. Madhuri Chandra Professor Obstetrics & Gynaecology Gandhi Medical College, Bhopal Adolescence is the period of life during which the carefree child becomes a responsible adult. It roughly ranges from 13 to 19 years of age i.e. the teen ages. Adolescent girls are brought to the gynaec OPD for menstrual problems, urinary complains, pain in abdomen and frequently for discharge per vaginum. Vaginal discharge is highly subjective, depending on patients concept of hygiene, powers of observation, some girls are fastidious and complain with minimal discharge while others may be ignore mucopurulent smelly discharge. In evaluating a complain of vaginal discharge, it is important to note the amount, color, consistency, odor, presence of pruritus and relationship to the menstrual cycle. The discharge that appears at vulva is a composite of vulval secretions from Bartholin's gland, sweat, sebaceous & apocrine glands, vaginal transudate consisting of epithelial squames, electrolytes, proteins, lactic acid, Doderlien bacilli, cervical mucus secretion and endometrial fluid. A certain amount of vaginal secretion, enough to cause a moist feeling is normal. This clear white discharge may be increased in ovulatory and premenstrual phase of menstrual cycle but this physiological increase “leucorrhea” is never associated with odor or itching. In young girls it may present premenarchal where it signifies the onset of folliculogenesis and steriodogenesis by ovary. In fact a certain amount of discharge can occur in the female newborn in the first few days due to effect of maternal/placental hormones. Leucorrhea is also seen in pregnancy, sexual excitement and cervical ectropion. It is associated with anemia, chronic ill health, anxiety and use of external hormones like OCPs. Pathological causes of vaginal discharge could be : Trauma – foreign bodies, wounds, abrasion, chemical burns etc, any young child presenting with sudden onset of bloodstained or purulent discharge should have foreign body, trauma or growth excluded. Infections – Vulvovaginitis due to Trichomonas vaginalis, Bacterial vaginosis, Candida albicans. Cervicitis due to N. gonorrheae, Chlamydia or Endometritis which may be postabortal, postpartum, or due to tuberculosis. In India, any teenager specially a virgin with discharge, chronic pelvic pain and /or amenorrhea should be investigated for tuberculosis. Tumors which may be benign and malignant. Cervical polyps may present with white, creamy, non offensive discharge but soon get ulcerated and infected with purulent offensive, blood stained discharge. Malignant growths though rare in adolescence may cause profuse bloody discharge. Fistulas cause urinary or faucal discharge, and may be due to development defects, trauma or obstetric injury. Infections are the commonest cause of vaginal discharge, while vaginal infections like candidiasis, trichomoniasis, bacterial vaginosis give rise to discharge with itching, cervical infection with Chlamydia or N.gonorrhea may present with blood stained, mucopurulent discharge, postcoital bleeding and lower abdominal pain. Candidiasis or yeast infection occurs in 75% women, once in their life. It is caused by gram positive fungus Candida albicans. Predisposing factors which disturb the vaginal flora or pH like use of broad spectrum antibiotics, immunosuppressants, corticosteroids, pregnancy, OCPs, endocrinal disorders diabetes, hypothyroidism may be present. Male partner with balanitis is usually an asymptomatic reservoir. There is
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severe itching with thick white cheesy plaques and underlying erythema and dyspareunia. Itching leads to excoriations and secondary infection. The fungal hyphae can be seen under microscope by taking a drop of vaginal secretion and one drop of 10% KOH on a slide. Treatment is avoiding risk factors, oral antifungals like Fluconazole, Itraconazole and local treatment with Nystatin, Clotrimazole, and Miconazole. Persistent candidial infection may signify HIV AIDS. Trichomoniasis is most common cause of vaginal discharge with pruritus. Infection by Trichomonas vaginalis is sexually transmitted but can occur due to contaminated towels, bed linen, personal clothing, bath tubs, and pools and improperly sterilized surgical instruments. Onset of symptoms is post menstrual, 50% present with profuse thin creamy, frothy malodorous vaginal discharge with burning, itching, dysuria, dyspareunia & lower abdominal pain. There is vulval and vaginal erythema, granular vaginitis, strawberry cervix, urethritis and Bartholinitis. 50% may be asymptomatic; a wet film preparation with one drop of vaginal discharge and one drop of saline showing actively motile flagellates of Trichomonas vaginalis or cytological smear is diagnostic. Coexistent gonorrhea must be ruled out. Treatment is with systemic Metronidazole, Tinidazole, Secnidazole, Ornidazole or local Clotrimazole pessary. Contact tracing and treatment is mandatory. Bacterial vaginosis though not an STI, is more common in sexually active women. It produces a disturbance in normal vaginal flora which results in loss of hydrogen peroxide producing lactobacilli and an overgrowth of predominantly anaerobic bacteria like Gardenella, Bacteroids, and Ureaplasma. Girls with Bacterial vaginosis are at increased risk of PID, abnormal cervical cytology, pregnancy complications like PROM, preterm labor, chorioamnionitis, and endometritis. There is profuse milky white to grey sticky discharge with fishy odor. The vaginal pH is raised >4.5 and microscopy of vaginal secretions show clue cells (epithelial squames covered by rod shaped bacilli) and absence of pus cells. Addition of KOH to vaginal secretions produces a fishy amine smell the “whiff test”. Treatment is by systemic and local Metronidazole and Clindamycin. Mucopurulent cervicitis caused by sexually transmitted infection with N. gonorrheae, Chlamydia trachomatis, infected cervical erosion gives rise to discharge which is frankly purulent or thick tenacious and turbid. The cervix is inflamed, erythematous pouting, nabothian cysts may be present, intermenstrual bleed may occur along with systemic signs like fever, malaise, lower abdominal pain, backache, dysuria, dysmenorrhea, dyspareunia and adnexal tenderness. Vaginal cytology may reveal causative organism and increased pus cells, serological tests are required. Prompt and complete treatment of patient and contact is required, to avoid chronic PID and reproductive repercussion. Vaginal discharge in teenagers have varied reasons, it may be an excess of physiological discharge or pathological. A good history and examination (depends on age, symptoms, sexual history) is required, with prompt treatment in order to prevent adverse reproductive sequelae. Sound nutritional advice, anemia prevention, counseling about menstrual, sexual hygiene along with promotion of abstinence, safe sex, and barrier contraception is essential for growing years.