Key learning points:
– Diagnosis and management of common gynaecological infections
– Implications of gynaecological infections
– Opportunities for health promotion
Infections of the vagina and genital tract in women are common, affecting one third of women during their lifetime. Symptoms are usually a combination of abnormal discharge, pain, pruritus (itching) and erythema (redness). (1) The commonest causes of abnormal discharge can be subdivided into sexually or non-sexually transmitted infections.
Non-sexually transmitted infections
The healthy vagina is host to a flora of native bacteria, predominantly lactobacilli that maintain vaginal pH < 4.5. Overgrowth of other anaerobic bacteria can cause pH to rise and result in an imbalance of vaginal bacteria. Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge in women. (2) It classically causes painless discharge with an offensive ‘fishy’ odour although 50% of women can be asymptomatic (see Table 1).
Diagnosis is with gram stained vaginal smear analysis or Amsel’s criteria, encompassing vaginal pH, microscopy and clinical features. (2) Metronidazole is the treatment of choice for symptomatic women, either as a 2g single dose or a longer course. BV has been linked to sexual activity but is not a sexually transmitted infection (STI). There is therefore no need for partner notification or treatment. However, lifestyle counselling on avoiding vaginal douching, smoking cessation and protected sexual intercourse should all be addressed at consultations and a full STI screen should always be offered as another pathogen may co-exist. (2) Patients should be informed that the infection may reoccur but should respond to repeat antibiotic treatment.
Candida infection is caused by vaginal overgrowth of candida albicans in up to 92% of cases, the remainder due to other members of the candida yeast family. (3) It is a common infection among women of reproductive age due to the relationship between candidiasis and high vaginal oestrogen levels. It is also more common in women who are immunosuppressed, have diabetes and have recently completed a course of antibiotics. (1) Between 10-20% of women of reproductive age may be colonised with candida therefore treatment is only required if the patient is symptomatic, commonly with vaginal and vulval pain, pruritus and discharge (see Table 1). (3)
Diagnosis is often clinical, but a swab from the anterior fornix should be taken in suspected resistant infection. Supportive treatment involves education on genital hygiene, soap substitutes, avoidance of tight fitting clothing and local skin irritants. Uncomplicated infections are treated with antifungals, either orally or as vaginal pessaries, and a longer course is offered during pregnancy. (3) A test of cure is unnecessary unless symptoms persist and there is no need to test or treat sexual partners.
Sexually transmitted infections (STIs)
Chlamydia is the most common STI in the UK and is asymptomatic in 70% of women. (1) Less common symptoms include post coital or intermenstrual bleeding, abdominal pain, dysuria (pain on urination) and occasionally offensive purulent vaginal discharge. Risk factors include: age under 25 years, largely unprotected sexual intercourse, new sexual partners and more than one partner in the last year. (4) Chlamydia trachomatis is detected and diagnosed by nucleic acid amplification testing (NAAT). Self-swabs can be taken from the lower vagina, which have a sensitivity of 90-95% and are more acceptable to the patient than invasive testing.(5) An endocervical swab is only taken if a speculum examination is required during the consultation.
Treatment is with antibiotics – doxycycline or azithromycin are first line recommendations. As for all STIs, a full STI screen should be offered and the importance of contact tracing and partner treatment emphasised to avoid re-infection. It is essential that patients are educated on abstaining from sexual intercourse until treatment is completed and that this opportunity is used to promote future barrier contraception use. (4)
Due to the largely asymptomatic nature of the infection, a steady increase in the number of yearly cases, and the future implications of untreated disease, the Department of Health introduced the National Chlamydia Screening Programme in 2003 to all sexually active people under the age of 25. Testing is offered annually, on every change of partner and should be discussed in any opportunistic primary care setting, such as routine medical and contraceptive appointments. (6)
Gonorrhoea is a sexually transmitted bacterial infection. In women 50% of endocervical infections are asymptomatic, 50% present with altered vaginal discharge and 25% present with mild lower abdominal pain. (7) Diagnosis depends on a thorough sexual history and swabs for NAAT testing and/or culture. Treatment is with a single ceftriaxone 500mg intramuscular dose and 1g of oral azithromycin in uncomplicated infection, although guidelines vary across regions depending on local patterns of resistance. All patients with suspected gonorrhea should additionally be screened for chlamydia. Azithromycin is administered regardless of the test results for chlamydia as evidence suggests dual therapy limits cephalosporin resistance. (7)
Partner notification is a vital part of treatment in all STIs. A test of cure follow up appointment should be made to check compliance, ensure eradication and assess treatment resistance, and to identify areas of sexual health promotion. This should be done within 72 hours if still symptomatic. (7)
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is a term encompassing ascending infection from the endocervix to the higher reproductive tract. (8) It is not strictly an STI however a quarter of cases are secondary to chlamydia and gonorrhea infection, therefore it can be regarded as a complication of primary STI infection.
Up to 40% of women who do not receive treatment for chlamydia infection will develop PID. (8) Symptoms include lower abdominal pain, deep dyspareunia (pain on sexual intercourse), abnormal discharge and abnormal menstrual bleeding. The patient is usually febrile, with cervical excitation and bilateral adenexal tenderness on examination. Chlamydia and gonorrhea swabs should be taken alongside a pregnancy test and routine bloods for inflammatory markers.
Treatment is with triple antibiotic therapy: ceftriaxone 500mg IM single dose, with oral doxycycline and metronidazole for two weeks (local guidelines may vary). Intravenous antibiotics may be indicated in severe pyrexia and evidence of local abscess or peritonitis.
PID increases the risk of ectopic pregnancy, tubal factor infertility and future chronic pelvic pain. (8) Women treated for PID need to be counselled appropriately on the condition and the future implications. PID increases the risk of ectopic pregnancy due to scarring of the fallopian tubes, and women should be educated accordingly to encourage them to seek early scans in future pregnancies. Tubal factor infertility is also a complication of PID. Fertility can usually be preserved with prompt treatment but the risk of infertility increases exponentially with each repeated pelvic infection, hence the importance of partner notification and health promotion as previously discussed. (8)
Trichomonas vaginalis (TV) is a flagellated protozoon causing urethral, vaginal and paraurethral gland infection in women. It can be asymptomatic in 10-50% of women, or cause pain and a classical yellow frothy discharge (see Table 1). (9) Endocervical or vaginal swabs are recommended for NAAT, microscopy and culture for diagnosis. Treatment is with oral metronidazole and a follow up with partner a notification and a full STI screen.
Herpes simplex virus (HSV) 1 is the most common cause of ano-genital infection. (10) The incubation period for the virus ranges from two days to two weeks and the patient may be asymptomatic or present with symptoms of painful ulceration, dysuria (pain on urination) and discharge. The virus lies dormant in the sensory ganglia, sporadically reactivating and shedding causing outbreaks of ulceration and transmission to others. On average, HSV1 infection causes outbreaks four times per year, while HSV2 outbreaks occur four times as frequently. (10) Diagnosis is by virus detection from swabs at lesion sites.
Supportive treatment involves saline bathing, topical lidocaine and analgesia. Episodic antiviral treatment taken during outbreaks reduces the severity and duration by up to two days. Patients having more than six outbreaks per year or significant psychological distress may benefit from suppressive therapy with daily antivirals. (10)
Herpes simplex is a lifelong condition, and transmission can occur not only during outbreaks but also from asymptomatic viral shedding. Condoms can reduce transmission by up to 50% if used consistently, and suppressive therapy can reduce the risk of transmission between discordant couples. (10) In women of childbearing age specialist input will be required with future pregnancies, as rarely the virus can be transmitted from mother to child during pregnancy and delivery. (11) Patients need sensitive counselling from healthcare professionals, tailored to their individual lifestyle and relationship status. The condition still caries significant stigma and concerns over disclosure and infection of partners are understandably high. Support groups such as the Herpes Viruses Association and written information leaflets are good sources of support for patients following an initial diagnosis.
Ano-genital warts are most commonly caused by subtypes six and 11 of the human papillomavirus (HPV) and are transmitted by sexual contact, with the exception of direct mother to child transmission during childbirth. (12) Warts are benign epithelial skin tumours and often cause no symptoms but can cause psychological distress. Diagnosis is clinical, with a full visual examination of the perianal region, speculum examination and proctoscopy if indicated. Any lesions that are irregular, pigmented or suspicious for neoplasia should be biopsied before further treatment is initiated. (12)
Treatment depends on the morphology of the lesions and all have significant failure rates. Topical regimes include podophyllotoxin or imiquimod creams, and ablation can be achieved with cryotherapy, electrosurgery and laser therapy. (12)
A full STI screen is recommended as well as screening current sexual partners who may have asymptomatic infection. Condom use can reduce transmission in 50% of cases, but the infection cannot be eradicated and patients need support and counselling to accept the chronic nature of the condition. In pregnancy the aim is to reduce the number of vaginal lesions to prevent rare laryngeal and ano-genital transmission to the neonate. Rarely a caesarean section is required if warts cause significant vaginal obstruction. (12)
From September 2012, the Department of Health amended the vaccine used in the HPV immunisation programme for cervical cancer. Initially only covering the oncogenic HPV variants 16 and 18, the new vaccine now covers strains six and 11 as well. This public health initiative will hopefully see a reduction in genital warts infection as well as a reduction in cervical cancer in the future. (13)
Genital infections are common in women, and often are asymptomatic or have non-specific features. Treatment is usually straightforward but especially the chronic STIs can have significant psycho-social effects. Concerns over future relationships, fertility, pregnancy and detrimental effects on self worth and mental health are not unusual secondary to a diagnosis of an STI. (14)
Primary care plays an important role in the treatment of the above infections and appropriate referral of complex cases to genito-urinary specialists for treatment and psychological support. Due to the number of asymptomatic conditions, screening and prevention are invaluable in community care. All healthcare professionals can play a role in opportunistic sexual health promotion, such as: recommending regular sexual health checks, discussing the benefits of barrier contraception, providing leaflets on gynaecological infections, advocating the chlamydia screening and HPV vaccination programmes and being aware of local sexual health clinic services to re-direct patients for further support.
British Association of Sexual Health and HIV
www.bashh.org (a useful source for patient information leaflets)
Herpes Virus Association
www.herpes.org.uk (support and information for new and chronic diagnoses)
1. Faculty of Sexual and Reproductive Health. Management of Vaginal Discharge in Non-Genitourinary Medicine Settings 2012. www.fsrh.org/pdfs/CEUGuidanceVaginalDischarge.pdf (accessed 26
2. British Association of Sexual Health and HIV. UK National Guideline for the Management of Bacterial Vaginosis 2012. www.bashh.org/documents/4413.pdf (accessed 26 March 2015).
3. British Association of Sexual Health and HIV. United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis 2007. www.bashh.org/documents/1798.pdf (accessed 26 March 2015).
4. British Association of Sexual Health and HIV. UK National Guideline
for the Management of Genital Tract Infection with Chlamydia trachomatis 2006. www.bashh.org/documents/65.pdf (accessed 26 March 2015).
5. British Association of Sexual Health and HIV. Chlamydia trachomatis UK Testing Guidelines 2010. www.bashh.org/documents/3352.pdf (accessed 26 March 2015).
6. Health Protection Agency. National Chlamydia Screening Programme Standards 2012. www.chlamydiascreening.nhs.uk/ps/resources/core-requirements/NCSP%20Stan... (accessed 28 March 2015) .
7. British Association of Sexual Health and HIV. UK national guideline for the management of gonorrhoea in adults 2011. www.bashh.org/documents/3920.pdf (accessed 26 March 2015).
8. British Association of Sexual Health and HIV. UK National Guideline for the Management of Pelvic Inflammatory Disease 2011. www.bashh.org/documents/3572.pdf (assessed 26 March 2015).
9. British Association of Sexual Health and HIV. UK National Guideline on the Management of Trichomonas vaginalis 2014. www.bashh.org/documents/UK%20national%20guideline%20on%20the%20managemen... (assessed 26 March 2015).
10. British Association of Sexual Health and HIV. UK National Guideline for the Management of Anogenital Herpes 2014. www.bashh.org/documents/HSV%20Final%20guidelines%20with%20ref%20sorted.pdf (assessed 26 March 2015).
11. Royal College of Obstetrics and Gynaecology. Management of Genital Herpes in Pregnancy. www.rcog.org.uk/en/guidelines-research-services/guidelines/genital-herpes/ (accessed 28 March 2015).
12. British Association of Sexual Health and HIV. United Kingdom National Guideline on the Management of Ano- genital Warts 2007. www.bashh.org/documents/86/86.pdf (accessed 26 March 2015).
13. Cancer Research UK. HPV vaccines. www.cancerresearchuk.org/about-cancer/cancers-in-general/cancer-question... (accessed 28 March 2015).
14. Danielle C. Newton and Marita P. McCabe. Sexually Transmitted Infections Impact on Individuals and Their Relationships. Journal of Health Psychology. 2008; 13(7) 864–869.
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