Definition:
The leukorrhea correspond to the flow of vaginal secretions whose abundance and appearance vary.
They appear at puberty and their presence is physiological, provided they meet the following characteristics:
– Odorless;
– Whitish or light;
– Not associated with burns, vulvovaginal itching or pelvic pain.
Mechanisms:
The leukorrhea is a common reason for consultation, be aware reassure explaining the mechanism of these:
– The vaginal mucosa peeling;
– Endocervical secretions of the glands under the influence of estrogen (cervical mucus);
– Vulvar secretions and periurethral glands;
– Vaginal transudation by vasodilation during sexual stimuli;
– Presence of a physiological flora (lactobacilli Döderlein and Veillon).
Normal vaginal flora is composed of:
– Gram-positive aerobic and anaerobic bacilli (Lactobacillus, Corynebacterium, Bifidobacterium, Clostridium, etc.);
– Gram-positive cocci (Staphylococcus aureus and epidermidis, Streptococcus D and bêtahémolytique, Peptococcusand Peptostreptococcus);
– Gram-negative bacilli (Escherichia coli, Klebsiella, Bacteroides);
– Gram-negative cocci (Veillona);
– Some Candida species may be present.
The vaginal pH through flora Döderlein which lactic acid product is maintained below 4.5, struggling against the development of pathogens except Candida that grows well in acidic conditions.
Pathological vaginal discharge can be a symptom:
– An imbalance of the vaginal ecosystem: the disappearance of the physiological flora (antibiotics), estrogen deficiency by atrophy or hormonal imbalance;
– A sexually transmitted infection: increase in sexually transmitted infections (STIs) incentives for increased vigilance.
In half the cases, it is not an infection but leukorrhea related to hormonal abnormalities, irritation or allergic reactions related to the use of unsuitable cosmetics.
DIAGNOSIS:
Examination:
The interrogation accurate STI risk factors (multiple partners, non-use of condoms, young age) and recent history of endo-uterine maneuvers (abortion, poses an intrauterine device, hysteroscopy, hysterography). These then leave presage pelvic inflammatory disease.
Review:
Clinical examination search:
– Signs of pelvic inflammatory disease:
– Endocervical mucus ladle
– Painful uterine mobilization and slack vaginal,
– Palpation of an adnexal mass, pain in the vaginal fornices, witnessed a pyosalpinx,
– Possible signs of peritoneal irritation: exquisite pain triggered by touching the vaginal cul-de-sac of Douglas, digestive disorders, abdomen and defense;
Warning: fever and biological infectious syndrome are rarely observed and their absence does not eliminate the presence of a severe infectious process.
– Vulvovaginal lesions: inflammation (herpes, candidiasis), ulcers (sores), single ulcer (syphilis, chancroid), vulvar erythema white flaky limit, crumbled, symmetrical (candidiasis);
– The appearance of vaginal discharge: curd aspect fungal infections; fluid and grayish in Gardnerella vaginitis, frothy, greenish when Trichomonas;
– Inflammatory appearance of the cervix (cervicitis); lymphadenopathy, common in primary herpes infection, bilateral, painful but not bulky. Primary syphilis is associated with inguinal lymphadenopathy associated with multiple bulkier lymphadenopathy;
– Anal lesions should be sought: chronic pruritus and erythema for a candidiasis digestive starting point;
– In case of suspicion of STI, a review buccopharyngé looking for ulcers and other lymph nodes should be performed.
Clinical and laboratory characteristics of the main infections are summarized in Table I, and we must keep in mind some causes summarized in Box 1.
Box 1. Some remarks
In pregnant women, the presence of abundant vaginal discharge is physiological. Nevertheless caution should be exercised so as not to misunderstand chorioamnionitis or a crack in the amniotic sac. The presence of contractions or pelvic pain requires an obstetrical examination and realization of vaginal specimens for bacteriological referred.
The ectropions (everted endocervical mucosa) can secrete physiologically lot of mucus. Outside the cervicovaginal smear screening for cervical dysplasia, there is no therapeutic specifi if they are not superinfected; we can then propose a chronic treatment with antiseptics ovules Amphocycline® (2 app / wk).
The brutal hydrorrhées are abundant emission of aqueous liquid to distinguish leucorrhoea. Intrauterine devices may be the cause, but we must also look for upstream complications (hydrosalpinx, exceptional cancer of the fallopian tube).
Atrophic vaginocervicite of postmenopausal women may be at the origin of yellowish vaginal discharge associated with atrophic mucosa bleeds easily. Treatment aims to restore trophicity neck (ovules containing estrogen) after checking that it is not a pyometra.
Indeed, in postmenopausal women before purulent vaginal discharge, one must evoke the diagnosis of pyometra requiring antibiotic treatment but also an exploration of the cavity by ultrasound and possibly hysteroscopy and biopsy (endometrial neoplasia associated).
The endocervicites are treated by systemic antibiotics.
On suspicion of STIs, it must be done by performing screening serology hepatitis B and C, syphilis serology, HIV.
The vaginal discharge in connection with a low infection can when the clinical aspect is typical for a first episode happen for bacteriological examination. In special situations: pregnancy, recurrences suspicion of STIs, IUD port, bacteriological samples must be requested. The search for Trichomonas is specified and the search for gonorrhea and chlamydia require suitable transport media.
The samples relate to the vaginal fornices and endocervix.
TREATMENT:
Vaginal mycosis:
Treatment includes:
– Toilet with alkaline soaps during the episode (Gyn Hydralin®, soap) or bath seat with sodium bicarbonate (3 tablespoons to a bowl of water);
– Local treatments based on derivatives of ova in single azole treatment through sustained release pessaries: econazole (Gynopévaryl LPR), sertaconazole (Monazole®), omoconazole (Fongarex®); is renewable 3-7 days later.
Azole derivatives of the emulsions can be applied on the vulva twice a day for 5 to 10 days (Pevaryl® emulsion). The partner can apply this emulsion on the rod when pruritus.
In case of recurrence, look for a home and treat digestive systemically. The treatment includes a local antifungal treatment for 3 weeks, then:
– Prescription of prolonged Colposeptine® ova;
– An antifungal orally for 15 to 20 days: Nystatin (Mycostatin®) or amphotericin B (Fungizone®) to treat digestive tract;
– After failure of these simple measures, treatment with ketoconazole (Nizoral®) 200 mg / day can be offered for 10 days, but is hepatotoxic. Fluconazole (Triflucan®) may be offered for 3 days or cures at a dose of 150 mg once a month (off-label, cons-indicated during pregnancy);
– Partner treatment may be recommended if symptoms (pruritus ani is a good sign).
The patient should be warned of the resurgence of symptoms within hours after application of the ovum (release candidin) and giving hygiene tips: pants and underwear tight little cotton, avoid wearing a thong and do Boil the laundry. Sitz baths with bicarbonate of prevention may be proposed (to return to the pool for example).
During pregnancy, some eggs may be used (for Monazole® AMM).
Trichomoniasis:
Treatment includes:
– Toilet soap with an acidifying (Lactacyd®);
– Minute treatment with imidazole, renewed at the following rules associated with local treatment:
– Po: Fasigyne® 2 g once daily (tinidazole) Flagyl® 2 g once daily (metronidazole) or Secnol® 1 bag (secnidazole);these treatments can be renewed two weeks later,
– Ova Flagyl®, 1 / day for 6 to 10 days.
It must be treated by a partner minute treatment renewed once and warn patients of the antabuse effect with the alcohol.
During pregnancy, only a local treatment ova Flagyl® may be prescribed.
These treatments also affect bacterial vaginitis and vaginosis, but not all of the marketing authorization in the last indications.
Gardnerella vaginalis and bacterial vaginosis:
Bacterial vaginosis can enjoy a minute systemic therapy based imidazole (Secnol®, off-label), or a 7-day treatment with metronidazole 1 g / day, which can be renewed the following rules.
Partner treatment is carried out only in case of recurrence.
Mycoplasma and Ureaplasma urealyticum:
These germs are usually found and are related to sexual activity. They are pathogenic when the concentration of nuclei is greater than or equal to 104 CCU / mL. They can then cause moderate signs of vaginitis.
Partner treatment is desirable.
During pregnancy, these germs may favor of premature birth and chorioamnionitis.
Chlamydia trachomatis infection:
In case of proven infection, screening of the partners is essential.
The treatment of endocervicites includes cyclins:
– Doxycycline (Vibramycin 100 mg: 2 cp / d in one take);
– Minocycline (Mynocine® 200 mg / day in 1 outlet) for 7 days.
A minute treatment exists, reserved exclusively for urethritis or cervicitis: Zithromax azithromycin 1 g single dose in one outlet.
Second line:
– Oflocet® 400 mg / day;
– Erythromycin 2 g / day for 7 days.
In pregnant women, the alternative is erythromycin.
In case of high infection, the treatment is prolonged: for 15 to 21 days. The untreated chlamydia infections result in medium term with an increased risk of ectopic pregnancy and infertility by tubal damage.
Herpes simplex virus (IST):
Treated with valaciclovir (Zelitrex® 500): 2 cp / day for 10 days during the primary infection.
During relapses, the treatment time is 5 days.
In case of recurrence (at least six annual episodes), prophylactic treatment is possible: 1 tablet / day Zélitrex® continuously reassess after 6 to 12 months.
Gonococcal infection (STI):
In first-line treatment minute:
– Ceftriaxone (Rocéphine®) 250 to 500 mg intramuscularly once (off-label);
– Cefixime (Oroken®): single dose of 2 tablets of 200 mg;
– Pefloxacine (Péflacine®) a single dose of 800 mg;
– Ofloxacin (Oflocet®) 400 mg;
– Ciprofloxacin (Ciflox®) 500 mg;
– Alternatively: spectinomycin 2 g by intramuscular injection.
You have to treat a possible infection chlamydia associated with 1g of azithromycin or doxycycline.
Disseminated form requires treatment with 1 g of ceftriaxone for 7 days.
In case of suspicion of pelvic infection:
Should be administered antibiotics suitable for STIs and anaerobes (+ Augmentin® Vibramycin®) and hold for 4 weeks. A strict rest and clinical monitoring for judging the effectiveness of treatment. The most common causes areChlamydiae (> 50% of cases) often superinfected by other bacteria (including anaerobic).
Laparoscopy is useful in case of pyosalpinx of pelvic inflammatory disease or tubo-ovarian abscess resistant to medical treatment, but should not be systematic.