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Vaginal discharge in the elderly is most commonly due to atrophic vaginitis. Other causes include foreign bodies, bacterial vaginosis and neoplasia. It is important to exclude malignancy of the uterus, cervix and vagina in the older patient.
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Vulvovaginal candidiasis does not occur in healthy, non-diabetic women who have not been taking antibiotics and lack oestrogen. However, it can occur in women taking menopause hormone therapy (MHT) and topical oestrogen. In this case, stop oestrogen treatment and treat for chronic vulvovaginal candidiasis until symptoms resolve. It may then be appropriate to recommence oestrogen therapy at a lower dose or continue the usual dose, but with intermittent treatment for candida.5
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In the absence of oestrogen stimulation, the vaginal and vulval tissues begin to shrink and become thin and dry. This renders the vagina more susceptible to bacterial attack because of the loss of vaginal acidity. Rarely, a severe attack can occur with a very haemorrhagic vagina and heavy discharge:
++
yellowish, non-offensive discharge
tenderness and dyspareunia
spotting or bleeding with coitus
the vagina may be reddened with superficial haemorrhagic areas
++
oestrogen cream or pessary (e.g. Ovestin, Vagifem) daily at bedtime for 2–3 weeks, then once or twice weekly
or
zinc and castor oil soothing cream
Note: perform a careful speculum examination.
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Vulvovaginal candidiasis
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Candida species are commensal organisms of the gastrointestinal and genital tract. Most cases of candidal vulvovaginitis are infrequent episodes resulting from sporadic increases in vaginal candida. It occurs when the vagina is exposed to oestrogen and is especially common in women aged 20–30 years and during pregnancy. It is not sexually transmissible, although sexual intercourse may be a trigger. Recurrent candidal vulvovaginitis is defined as four or more acute episodes per year.
++
Some 10–20% of women may be colonised with candida without signs or symptoms. Treatment is not indicated for these women.
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Intense vaginal and vulval pruritus
Vulval soreness
Vulval fissures
Vulvovaginal erythema (brick red)
Vaginal excoriation and oedema
White, curd-like discharge (see FIG. 106.3)
Superficial dyspareunia
Dysuria
++
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Factors predisposing to vaginal candidiasis6
++
++
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Before starting treatment, take a swab to confirm the diagnosis and determine the species of Candida. For the first attack of candidiasis, it is appropriate to select one of the range of vaginal azole therapies (clotrimazole, miconazole) for 1–7 days, depending on strength. There appears to be no significant difference between azoles. Nystatin is best reserved for recurrent cases or if there is local reaction to the azoles.
++
Creams can be applied to the vulva if there are vulval symptoms. Combining azole therapy with a topical corticosteroid such as 1% hydrocortisone may also be useful.
++
Gentian violet (0.5% aqueous solution) is useful for rapid relief, if available.
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Recommended initial regimen5
++
clotrimazole 1%, 2% or 10% vaginal cream, 1 applicatorful intravaginally, at bedtime for 6 nights if 1%, 3 nights if 2% or once only if 10%
or
miconazole 2% vaginal cream, 1 applicatorful intravaginally, at bedtime for 7 nights
or
clotrimazole 100 mg or 500 mg pessary intravaginally, at bedtime for 6 nights if 100 mg, once only if 500 mg
++
An alternative regimen, especially for recurrent infections:
++
++
If the patient does not tolerate vaginal therapy or prefers oral therapy, use fluconazole 150 mg (o) as a single dose
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Chronic vulvovaginal candidiasis8
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Patients with chronic vulvovaginal candidiasis are a less well-recognised and -managed group. The pathogenesis is unknown but may relate to an exaggerated immunological response to candida. Viewing the condition as a hypersensitivity reaction to the presence of candida, rather than infection, helps understanding and guides treatment. It may start at any age from menarche onwards and ceases at menopause provided MHT is not used.
++
The most common complaint is chronic itch with dyspareunia and pain. Vaginal discharge is common but may be absent and the typical cottage cheese exudate is not seen. Symptoms are often worse in the premenstrual week and improve during menses. Initial response to azole treatment is common but there is gradual resistance to topical therapy. Almost 95% of cases are caused by C. albicans.
++
When taking the swab, a low vaginal swab usually has a higher yield than a high vaginal swab. False negatives are common.
++
++
The time to achieve remission varies from 2 weeks to 6 months. Review treatment after 3 months. A mild topical steroid is also appropriate to use in addition.
++
Note: There is no evidence to support routine screening or treatment of asymptomatic partners.1 If a male partner is symptomatic (usually balanitis in an uncircumcised male), treat with clotrimazole 1% + hydrocortisone 1% topically, 12 hourly until 2 weeks after symptoms resolve.
++
A significant number of cases of vulvovaginal candidiasis are due to non-albicans species of Candida. Candida glabrata is the commonest non-albicans species, which exhibits reduced susceptibility to azoles. In resistant infections, use boric acid 600 mg (in a gelatin capsule) intravaginally at bedtime for 14 days. Do not use in pregnancy.
+++
General advice to patients with vaginal candidiasis5,9
++
Bathe the genital area with water and dry gently but thoroughly after showering or bathing.
Wear loose-fitting, cotton underwear.
Avoid wearing pantyhose, tight jeans or tight underwear.
Do not use vaginal douches, powders or deodorants or take bubble baths.
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Trichomonas vaginalis10
++
This flagellated protozoan, which is thought to originate in the bowel, infects the vagina, Skene’s ducts and lower urinary tract in women and the lower genitourinary tract in men. It is easily transmitted through sexual intercourse. In Australia, trichomonas is more common in older women and women from regional and remote areas, especially Aboriginal and Torres Strait Islander. If untreated, the infection is cleared more easily in men. NAAT test is available on vaginal swab and first-pass urine.
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Profuse, thin discharge (grey to yellow–green in colour) (see FIG. 106.4)
Small bubbles may be seen in 20–30%
Vulval itch
Malodorous discharge
Dyspareunia
Diffuse erythema of cervix and vaginal walls
Characteristic punctate appearance on cervix
++
++
++
++
Bacterial vaginosis is a clinical entity of mixed aetiology characterised by the replacement of the normal vaginal microflora (chiefly Lactobacillus) with a mixed flora (referred to as polymicrobial clinical syndrome) consisting of Gardnerella vaginalis, other anaerobes such as Atopobium vaginae, Mobiluncus species and Mycoplasma hominis. This accounts for the alkalinity of the vaginal pH.
++
A white or grey, homogenous discharge (see FIG. 106.5)
Malodorous
No obvious vulvitis or vaginitis
Liberates an amine-like, fishy odour on admixture of 10% KOH (the amine whiff test)
Clue cells on wet preparation
± Dyspareunia and dysuria
± Pruritus (uncommon)
++
++
Note. About 50% of patients are asymptomatic.
++
++
++
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Clindamycin 300 mg (o) bd for 7 days or 2% clindamycin cream, 1 applicatorful at bedtime for 7 nights, can be used for resistant infections or during pregnancy. Treating male partners has not been recommended; however, consider screening and treating female sexual partners.2
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Group B Streptococcus vaginosis11
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Group B Streptococcus (S. agalactiae) is a commensal in up to 30% of healthy humans. It is a problem if detected in pregnant women because of the risk of serious infection in the neonate that is delivered vaginally. Other than in pregnancy, it is generally an incidental finding and should be ignored.
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Rarely, Group B Steptococcus produces a symptomatic vulvovaginitis with an irritating discharge. However, other causes of vulvovaginitis are more common and should be considered. Suitable treatment for symptomatic patients includes clindamycin 2% vaginal cream, 1 applicatorful intravaginally at bedtime for 14 nights, and phenoxymethylpenicillin 500 mg orally, bd for 10 days.
+++
Retained vaginal tampon
++
A retained tampon, which may be impacted and cannot be removed by the patient, is usually associated with an extremely offensive vaginal discharge. Its removal can cause considerable embarrassment to both patient and doctor.
++
Using good vision the tampon is seized with a pair of sponge-holding forceps and quickly immersed under water without releasing the forceps. A bowl of water (an old plastic ice-cream container is suitable) is kept as close to the introitus as possible. This results in minimal malodour. The tampon and water are immediately flushed down the toilet if the toilet system can accommodate tampons. An alternative method is to grasp the tampon with a gloved hand and quickly peel the glove over the tampon for disposal.
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Tampon toxic shock syndrome: staphylococcal infection
++
This rare, dramatic condition is caused by the production of staphylococcal exotoxin associated with tampon use for menstrual protection. The syndrome usually begins within 5 days of the onset of the period.
++
The clinical features include sudden onset fever, vomiting and diarrhoea, muscle aches and pains, skin erythema, hypotension progressing to confusion, stupor and sometimes death.
++
Active treatment depends on the severity of the illness. Cultures should be taken from the vagina, cervix, perineum and nasopharynx. The patient should be referred to a major centre if ‘shock’ develops. Otherwise the vagina must be emptied, ensuring there is not a forgotten tampon, cleaned with a povidone iodine solution tds for 2 days, and flucloxacillin or vancomycin antibiotics administered.
++
Good general hygiene with care in handling and inserting the tampons.
Change the tampon 3–4 times a day.
Consider using an external pad at night during sleep.