Surabhi Saharan¹, Jaya Choudhary^2*, Aakarsh Sinha³

¹Senior Resident, Department of Obstetrics and Gynaecology, PDU Medical College, Churu-331001, Rajasthan, INDIA.

²Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and University, Jaipur, Rajasthan, INDIA.

³Senior Resident, Department Of Obstetrics And Gynaecology, Madhubani Medical College Andhospital, Madhubani, Bihar, INDIA.

Email: spiffingsurbhi@gmail.com

Table 2: Etiological examination by laboratory tests

Out of 300 cases most commonly diagnosed syndromes were vaginal discharge syndrome (54%) followed by lower abdominal pain syndrome (17.33%). No cases of genital ulcers and genital warts were reported.

Table 3: Distribution of the cases according to Pap Smear

Table 4 showed distribution of cases according to etiological diagnosis, out of 300 cases 147 (49%) cases were normal, Bacterial vaginosis was diagnosed in 21% cases, candidiasis was observed in 20.3%, 6.67% cases had mixed infection and 3% were of trichomonas.

Table 4: Distribution of the cases according to Final (Etiological) Diagnosis

DISCUSSION

Reproductive tract infections are most common gynecology complaint among women in reproductive age group. Vaginal discharge is often reported to be the most frequent RTI among women.⁵ In our study, out of the 300 women, 296 (98.7%) presented with vaginal discharge. This is due to the fact that awareness related to RTIs and health seeking behavior is inadequate among them. Excessive vaginal discharge was reported, due to menstrual disorders and unhealthy cervix leading to cervical erosion and infections leading to abdominal pain. Abdominal pain can be explained by associated pelvic congestion. Also the presence of backache and pain abdomen indicates the presence of sub clinical involvement of surrounding tissues or irritation of para-cervical nerves by chronic infections. Hawkes et al.⁶ in their study 94% women reported with abnormal vaginal discharge, Patnaik et al.⁷ concluded that vaginal discharge syndrome is the most commonly diagnosed syndromic diagnosis. Shethwala et al.⁸ showed that the most common symptom reported was vaginal discharge 147 (98%), Bote et al.⁹ found in their study that major symptom reported was vaginal discharge. On per vaginal examination, in our study, out of 300 cases, 249 (83%) were normal, 10.3% cases presented with normal size uterus and tenderness in fornix and 6.7% cases presented with bulky uterus and tenderness in fornix. Fornicial tenderness was present in cases 17%. In women tenderness was most common with lower abdominal pain. This indicated that awareness of RTIs and health seeking behavior is inadequate in those women. Excessive vaginal discharge was because of erosion of cervix, pain in abdomen, back pain and menstrual disorders. Presence of back ache and pain in abdomen indicated the possibility of sub clinical involvement of surrounding tissues or irritation of para-cervical nerves by chronic infections. Pain in abdomen can be explained by associated pelvic congestion and tenderness. Ray et al.¹ in their study observed lower abdominal tenderness in 13.5% of women. Chauhan V et al.¹⁰ in this study, cervical motion tenderness and nabothian follicles were observed in cases of cervicitis, bacterial vaginosis and trichomoniasis.

Out of 300 cases, whiff test was positive in 83 (27.7%) cases. Whiff test confirmation of bacterial vaginosis if fishy smell present then whiff test positive. According to wet mount findings were normal in 147 (49%) cases, Hyphae and pseudohyphae seen in 25% cases, Clue cells seen in 23% cases, while flagellated protozoa were seen in 3% cases. Wet mount is confirmation of bacterial vaginosis, candidiasis and trichomonas. In bacterial vaginosis clue cells are seen in wet mount and Hyphae and pseudohyphae are seen in candidiasis and flagellated protozoa are seen in trichomoniasis. Out of 300 cases, most of the cases 210 (70%) were sterile on vaginal swab culture. candida species were present in 27% cases while Trichomoniasis were present in 3% cases. Swab culture is confirmatory diagnosis of candida and trichomonas. Vasantha et al.¹¹ in their study whiff test, wet mount and vaginal swab culture showed by laboratory diagnosis which was 52%.  In present study, out of 300 patients, gram staining was found normal in 211 (70.3%) cases, pus cells, gram positive bacteria were seen in 14.7% cases. Pus cells, gram negative bacteria were seen in 15% cases. Gram staining is confirmatory diagnosis of bacterial vaginosis and diagnosis for gram positive and gram negative bacteria. Bohara et al.¹² found in their study that thirteen percent had trichomoniasis and 7% had gonorrhoea identified in Gram stained smears and cultures. Aggarwal et al.² found that out of 234 Gram stained smears, 70 (29.9%,95% CI = 24.4-36.0%) showed presence of >5 pus cells/OIF. On ELISA test, HbsAg was positive in 9 (3%) cases, VDRL positive cases were in 1.7% and HIV positive were 0.67% cases. Aggarwal et al.² only two women were HIV positive; one showed VDRL reactivity, though the VDRL titre was low (1:4), she was also reactive by TPHA test. On pap smear finding, out of 300 cases, 186 (62%) cases were reported normal, 32.3% cases were inflammatory, 2% bacterial vaginosis, 2.33% candidiasis, 0.67% trichomoniasis and 0.67% were low grade squamous epithelial lesion (LSIL). Prabha et al.⁵ pap smear showed 32.9% inflammatory changes and 0.25% low grade squamous intraepithelial lesion. Garg et al.¹³ Pap smear showed 32.9% inflammatory changes and 0.25% low grade squamous intraepithelial lesion. Microbiologically, 33.14% were positive for at least one organism. On etiological diagnosis, out of 300 cases, 147 (49%) cases were normal, bacterial vaginosis was diagnosed in 21% cases, candidiasis was observed in 20.3%, 6.7% cases had mixed infection and 3% were of trichomonas. Endogenous infections are more prevalent (Bacterial vaginosis, candidiasis) followed by trichomoniasis. Most commonly bacterial vaginosis is diagnosed by laboratory test. Patnaik et al.⁷ The most commonly infections identified by laboratory diagnosis was bacterial vaginosis (14.3%). Ray et al.¹ found that laboratory diagnosis of patients most common etiology was candida albicans. In a study by Shethwala et al.⁸ out of 150 patients, 34 (22.6%) had bacterial vaginosis, 27 (18%) had candidiasis whereas, 24 (16%) were found to have HSV-II. 4 (2.7%) patients were having positive test for syphilis. In a study of Aggarwal et al.² most common cause was bacterial vaginosis (positive= 21.4%, 95% CI= 16.6- 27.1%; intermediate score= 17.5%, 95% CI= 13.2- 22.9%), followed by candidiasis (13.7%, 95% CI= 98- 18.7%) and trichomoniasis (0.4%, 95% CI=0-2.6%). No etiological diagnosis for vaginal discharge could be established in approximately half of the women. Only two women were HIV positive; one was reactive by VDRL and TPHA tests. Prabha et al.⁵ found prevalence of reproductive tract infections/sexually transmitted infections by laboratory diagnosis of 33.1%. Most common infection diagnosed by laboratory test was bacterial vaginosis (14.3%). In a study by Shah M et al.¹⁴ out of 183 (78.54%) pregnant females had vaginal discharge on clinical examination and Candida albicans was the most common clinical diagnosis among them. Of 183 cases diagnosed clinically as vaginal discharge syndrome, 38 (20.7%) were tested positive in laboratory investigations. Out of 50 clinically negative cases, 9 (18%) were detected positive for one of the STIs on laboratory testing.

CONCLUSION

The treatment may be initiated on the basis of signs and symptoms, however, it is essential that the treatment is modified as and when laboratory test results become available. The laboratory services need to be strengthened to ensure accurate and standardized availability of diagnostic services.

REFERENCES

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