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Key history

The history should include:

• nature of discharge: colour, odour, quantity, relation to menstrual cycle, associated symptoms

• exact nature and location of irritation

• sexual history: arousal, previous STIs, number of partners and any presence of irritation or discharge in them

• use of chemicals, such as soaps, deodorants, pessaries and douches

• pregnancy possibility

• drug therapy

• associated medical conditions (e.g. diabetes)

Key examination

• Inspection with good light includes viewing the vulva, introitus, urethra, vagina and cervix

• Look for the discharge and specific problems such as polyps, warts, ectropion, prolapses and fistulas

• Full pelvic examination in a postmenopausal woman

Key investigations

• pH test with paper of range 4–6

• Amine or ‘whiff’ test

• Wet film microscopy of a drop of vaginal secretions

• Full STI workup including vaginal swab

Vaginal thrush (candidal vaginitis)

• Bathe genital area bd or tds with sodium bicarbonate (esp. before using treatment).

• Dry area thoroughly.

• Wear loose-fitting cotton underwear.

• Avoid wearing tight clothing or using tampons.

• Avoid vaginal douches, powders or deodorants.

Treatment

Can use an azole (clotrimazole, isoconazole, butoconazole, miconazole, ketoconazole or fluconazole), amphotericin, nystatin.

Examples:

• first line: clotrimazole 500 mg vaginal tab statim, or 100 mg for 6 nights and/or clotrimazole 2% cream applied to vagina and vulva (for symptomatic relief) or (esp. if recurrent)

• nystatin pessaries, once daily for 7 d and/or nystatin vaginal cream, 4 g once daily for 7 d or (if recalcitrant)

• fluconazole 150 mg (o) as a single dose or ketoconazole 200 mg (o) bd for 5 d

Male sexual partner not usu. treated (on current evidence). If the male is symptomatic, treat with clotrimazole 1% + hydrocortisone 1% topically, bd, until 2 wks after symptoms resolve.

Bacterial vaginosis

Due to overgrowth of Gardnerella vaginalis and other anaerobes such as Mobiluncus species.

Treatment

• Metronidazole 400 mg (o) bd for 5 d, 0.75% vaginal gel at bedtime for 5 d or

• Clindamycin 300 mg (o) bd for 7 d or clindamycin 2% cream nocte for 7 nights (for resistant infections and pregnancy)

• Restore pH with douches (e.g. topical Acigel or vinegar, 3–4 tbsp/L water)

• Safe sex should be practised with both male and female partners

Trichomonas vaginalis

Treatment

• Oral metronidazole 2 g as a single dose (preferable) or 400 mg bd for 7 d (if relapse) or tinidazole 2 g as a single dose.

• Use clotrimazole 2% vaginal cream daily for 3 nights during pregnancy.

• Attention to hygiene.

• The sexual partner must be treated simultaneously.

• The male partner should wear a condom during intercourse.

• For resistant infections a 3–7 d course of either metronidazole or tinidazole may be nec.

Atrophic vaginitis

Treatment

• Oral hormone replacement therapy

• Local oestrogen cream or tab (e.g. Vagifem). The tab is preferred as it is less messy

The area typically affected by varicose eczema and ulceration is the ‘gaiter’ area of the leg. The secret of treating ulcers due to chronic venous insufficiency is the proper treatment of the physical factors, esp. graduated compression at 20–40 mmHg. Removal of fluid from a swollen leg is also mandatory.

Treatment method

1. Clean the ulcer with N saline. If slough, apply Intra Site Gel.

2. Apply paraffin gauze, then pack the defect with sponge rubber or other suitable dressing (e.g. Melolin).

3. Apply a compression bandage below the knee (e.g. graduated compression stockings, Eloflex bandage). Alternatively, an occlusive paste bandage (e.g. Flexi-dress or Gelocast) can be applied for 7 d from the base of the toe to just below the knee, plus compression bandage. Consider Tubigrip stockinette cover.

4. Prescribe diuretics if oedema is present.

5. Encourage early ambulation and exercise.

6. Insist on as much elevation of the leg as is possible, esp. at rest.

Note: Dressings should be changed when they become loose or fall off, or when discharge seeps through. Patients may get ulcers wet and have baths.

Wound dressing

There are five main types of modern wound dressings: films, hydrogels, hydrocolloids, alginates and foams—all expensive. Films, hydrogels and hydrocolloids increase the wound moisture whereas alginates and foams absorb exudate. The more traditional dressings such as tulle grass, non-adherent pad dressings and saline soaks can be useful. Crepe bandages can be used to hold non-adherent dressings in place.

General rules:

• Allow 2–3 cm of dressing greater than the wound.

• Place ⅓ above and ⅔ below the wound.

• Remove when ‘strike-through’ occurs.

• Remove with care in older patients.

• Remove under the shower if necessary.

• When in doubt, DO NOT HARM: use foam and gel combinations.

Apart from migraine, virtually all cases of sudden loss of vision require urgent treatment.

Important causes

Amblyopia

In children, a lazy eye with reduced vision. Refer strabismus early.

Retinoblastoma

In children: white pupil and ‘cat's eye’ reflex.

Cataracts

• Reduced visual acuity (sometimes improved with pinhole)

• Diminished red reflex on ophthalmoscopy

• A change in the appearance of the lens

Advise extraction when the patient cannot cope.

Glaucoma

Acute—rapid onset over a few days

Chronic—gradual loss of outer fields of vision

Tonometry: 22 mmHg is upper limit of normal

• Medication (for life) usually selected from:

  • timolol or betaxolol (beware of asthma) drops bd

  • latanoprost drops, once daily

  • pilocarpine drops qid

  • dipivefrin drops bd

  • acetazolamide (oral diuretics)

• Surgery or laser therapy for failed medication

Retinitis pigmentosa

• Begins as night blindness in children

• Ophthalmoscopic examination—irregular patches of dark pigment

Acute and subacute painless loss of vision: diagnostic strategy model

Probability diagnosis

• Amaurosis fugax

• Migraine

• Retinal detachment

• Acute glaucoma

• ‘Wet’ macular degeneration

Serious disorders not to be missed

• Cardiovascular:

  • central retinal artery occlusion

  • central retinal vein occlusion

  • hypertension (complications)

  • CVA

• Neoplasia:

  • intracranial tumour

  • intraocular tumour:

    • primary melanoma

    • retinoblastoma

    • metastases

• Vitreous haemorrhage

• AIDS

• Temporal (giant cell) arteritis

• Acute glaucoma

• Benign intracranial hypertension

Pitfalls (often missed)

• Acute glaucoma

• Papilloedema

• Optic neuritis

• Intraocular foreign body

Amaurosis fugax

• Usually due to embolus from carotid artery

• Requires investigation, inc. carotid duplex Doppler US

Retinal detachment

• Sudden onset of floaters or flashes or black spots

• Vision in one eye becoming worse

• Immediate referral for sealing of retinal tears

Vitreous haemorrhage

• Sudden onset of floaters or ‘blobs’ in vision; US aids diagnosis

• Urgent referral to exclude retinal detachment

• Surgical vitrectomy for persistent haemorrhage

Central retinal artery occlusion

• Sudden loss of vision like a ‘curtain descending’

• Vision not improved with 1 mm pinhole

• Classic ‘red cherry spot’ at macula

Management

If seen early, use this procedure within 30 mins:

• Massage globe digitally through closed eyelids (use rhythmic direct digital pressure)—may dislodge embolus.

• Rebreathe carbon dioxide (paper bag) or inhale special carbon dioxide mixture (carbogen).

• Intravenous acetazolamide (Diamox) 500 mg.

Refer urgently.

Central retinal vein thrombosis

Ophthalmoscopy shows swollen disc and multiple retinal haemorrhages.

No immediate treatment is effective but refer urgently.

Macular degeneration

There are two types: exudative (acute) and pigmentary (slow onset).

Acute visual distortion then sudden fading of central vision.

Usually white exudates, haemorrhage in retina.

Referral for possible injection of antivascular endothelial growth factor agents into the vitreous humour.

Temporal arteritis

• Sudden loss of central vision in one eye (central scotoma)

• Can rapidly become bilateral

• Associated temporal headache

Management

• Other eye must be tested

• Immediate corticosteroids (60 mg prednisolone daily for at least 1 wk—be careful of avascular necrosis of neck of femur)

• Biopsy temporal artery

Posterior vitreous detachment

• Sudden onset of floaters—possible associated retinal detachment

• Visual acuity usually normal

• Flashing lights indicate traction on the retina

Refer urgently.

Optic (retrobulbar) neuritis

• Usually a woman 20–40 yrs with multiple sclerosis

• Loss of vision in one eye over a few days

• Retro-ocular discomfort with eye movements

• Variable visual acuity

• Usually a central field loss (central scotoma)

• Optic disc changes

Refer immediately. Steroids hasten recovery.

Difficult to treat—consider camouflage make-up (e.g. self-tanning preparations). Treatment includes PUVA and oral psoralens (e.g. methoxsalen, trioxysalen).

A trial of prolonged topical corticosteroids is claimed to be effective (e.g. hydrocortisone 1% for 6 mths followed by methylprednisolone aceponate 0.1% for 6 mths).

Vomiting in infancy

Important warning signs in neonates:

• excessive drooling of frothy secretions from mouth

• bile-stained vomitus—always abnormal

• delayed passage of meconium (>24 h)

• inguinal hernias

First question: Is the vomiting bile stained?

• Green vomiting = urgent surgical referral ?intestinal malrotation

• Non-bile stained vomitus? pyloric stenosis, gastro-oesophageal reflux, feeding problems, etc. Both pyloric stenosis and GOR cause projectile vomiting.

Oesophageal atresia

• Vomiting occurs with the first feeding

• Excessive drooling of frothy secretions

• Pass 10 g French catheter through mouth to aid diagnosis

Congenital hypertrophic pyloric stenosis

• Usually sudden onset 3rd–6th wk

• Projectile vomitus

• M:F ratio = 5:1

• Gastric peristalsis during test feeding

• Metabolic alkalosis with Na↓ Cl↓

Symptomatic relief of vomiting

The first-line management is to ensure that any fluid and electrolyte imbalance is corrected and that any underlying cause is identified and treated. Various anti-emetics can give symptomatic relief.

Note: Avoid the use of the dopamine antagonist drugs (e.g. metoclopramide and prochlorperazine) in children because of risk of extrapyramidal side effects.

Drug-induced nausea and vomiting

• Metoclopramide 10 mg (o) or IM 8 hourly prn

For chemotherapy and radiotherapy:

• metoclopramide 10 mg (o) or IM 1 to 2 hours prior to therapy then 8 hourly (if mild) or

• ondansetron 4 mg (o or SL) bd + dexamethasone 4 mg (ο)/d

For severe cases:

• ondansetron 8 mg (o) or IV prior to therapy then two doses 6 hourly plus

• dexamethasone 8 mg IV 30 minutes prior to therapy, then 2 doses 6 hourly

Clinical manifestations of vulvar disorders include itching, pain or discomfort, irritation, white mucosal patches, lichenification, erosions and intertrigo. The dermatoses, notably dermatitis, psoriasis, lichen planus and lichen sclerosus, are the main cause of vulvar problems. Pruritus vulvae is presented on 412.

Lichen sclerosus

This chronic inflammatory dermatosis of unknown aetiology presents as well-defined, white, finely wrinkled plaques that almost exclusively affect the anogenital skin but spare the vagina. The differential diagnosis is atrophic vaginitis.

Features

• Genital pruritus (main symptom) + soreness + white wrinkled plaques

• Bimodal peak: prepubertal girls, perimenopause

• Purpuric and ulcerated areas

• Lifetime risk SCC 2–6%

Management

• Confirm diagnosis by biopsy. Best to consult with dermatologist.

• Use potent topical steroids for 6 mths, then hydrocortisone 1% long term.

Chronic vulvovaginal candidiasis

This is different from acute candidiasis and may represent a localised hypersensitivity to C. albicans. Aim for symptom remission with continuous antifungal treatment up to 6 mths. Relieve itching with hydrocortisone 1%.

Streptococcal vulvovaginitis

Usually presents as an acute, beefy red, sore vulva or vagina or a low-grade vulvitis. Take swabs from the vulva or vagina for diagnosis. Treat with oral phenoxymethylpenicillin for 10 d or other antibiotic according to sensitivity. Topical mupirocin may help prevent recurrences.

Vulvodynia

This describes the symptom of pain (burning, rawness or stinging) and discomfort where no obvious cause can be found. Conditions include vestibular hypersensitivity (vulvar vestibular syndrome) and dysaesthetic vulvodynia (neuropathic pain in middle-aged to elderly women).

Provoked vestibulodynia (vulvar vestibular syndrome)

Features

• Severe pain with vestibular touch, inc. vaginal entry, e.g. intercourse, tampons

• Young female usually in 20s and 30s

• Nulliparous: family history

• Superficial entry dyspareunia

• Sexual dysfunction

Diagnosis

Inappropriate tenderness to light touch with a cotton bud.

Management

Patient education, counselling and support with bland emollients or 2% lignocaine gel prior to intercourse. May require intralesional therapy or anti-neuropathic pain agents or vestibulectomy (as last resort).

Dysaesthetic vulvodynia

The typical patient with this neuropathic pain problem is a middle-aged to elderly woman who presents with a constant burning pain of the labia. Examination is usually normal. Causes include pudendal neuralgia, post-herpes simplex infection, referred spinal pain or idiopathic. Treatment options include antidepressants and gabapentin.