Vulvar Discharge

Chapter 212


Vulvar Discharge



Vaginal discharge, more accurately described as vulvar discharge, is a common presentation of intact or spayed bitches. Too often it is diagnosed erroneously as vaginitis, when in fact it is a symptom of an underlying problem of the urogenital system. The discharge actually may originate from the perivulvar region, vulva, vestibule, cervix, uterus, urethra, or urinary bladder with or without involvement of the vagina. Vulvar discharge in queens is uncommon and usually has a uterine cause (e.g., pyometra). Inappropriate use of antibiotics (overuse or insufficient duration) and failure to address the inciting cause are the most common reasons for treatment failure.



Clinical Signs


Presenting complaints include vulvar discharge, vulvar licking, vulvar swelling and hyperemia, clitoral hypertrophy, “scooting,” pollakiuria, or recurrent urinary tract infections. Vulvar discharge may be mucoid, mucopurulent, purulent, or hemorrhagic. Purulent discharge may be suppurative (indicating irritation or infection) or lymphocytic (indicating allergic or immune mediated). Vaginal cytology rarely determines the etiology of the inflammation but confirms the presence of neutrophils. Degenerate neutrophils with swollen nuclei and intracellular bacteria indicate a septic component, whereas neutrophils with hypersegmented nuclei suggest a noninfectious, reactive component. A speculum or vaginoscopic exam is necessary to determine if the purulent discharge is confined to the vestibule or extends from the vagina. In spayed or nonestrous bitches, vaginal examination may require heavy sedation or anesthesia.



Etiology



Uterine Causes


In intact bitches, normal vulvar discharge originates from the uterus. It may be estral bleeding, cervical mucus during late gestation, fetal fluids at parturition, or lochia for up to 4 weeks after parturition. All other vulvar discharges in intact female dogs and all vulvar discharges in spayed females are abnormal. Pathologic uterine causes of vulvar discharges in intact and spayed bitches are summarized in Table 212-1. Involvement of the uterus must be ruled out when working up the complaint of vulvar discharge. Further insight into uterine diseases is beyond the scope of this chapter.




Lower Reproductive Tract Causes


The causes of vulvar discharges (not originating from the uterus) are similar in intact or spayed dogs and can be categorized broadly as causing vaginitis (inflammation of the vaginal vault from the vaginovestibular junction to the cervix), vestibulitis (inflammation of the vestibule from the vulvar mucosal margin to the vaginovestibular junction), and perivulvar dermatitis (inflammation of the skin around the vulva). These three entities may occur independently or one may incite either or both of the other two conditions. Also, a bacterial component may or may not be present. Proper treatment relies on elucidating and resolving the inciting condition.



Vaginitis


Vaginitis is inflammation, and commonly infection, of the mucosa cranial to the vaginovestibular junction (Figure 212-1) and is most often the symptom of an underlying problem. It often presents as purulent or mucopurulent vulvar discharge, and it must be differentiated from vestibulitis, pyometra, and other diseases that present as vulvar discharge. Direct visualization of the vaginal canal by speculum or vaginoscope helps to elucidate whether the discharge is originating from the vestibule, vagina, or cranial to the cervix. Cytologic examination and culture of a guarded swab passed cranial to the vestibule may implicate vaginal involvement. Finally, a vaginal biopsy definitively indicates the presence or absence of inflammation in the vagina. Vaginitis often is categorized into juvenile (puppy) vaginitis or adult-onset vaginitis.




Juvenile (Puppy) Vaginitis.

Juvenile vaginitis commonly is seen in bitches between 6 weeks and 1 year of age. It develops as the bitch establishes a symbiotic relationship with her endogenous bacteria and naïve vagina. Puppy vaginitis may persist for months without detrimental effects on the puppy. In fact, juvenile vaginitis usually poses greater distress to the owner than to the puppy. Cytologic evaluation of the discharge usually demonstrates mature, hypersegmented, nondegenerate neutrophils; culture often results in no significant growth (that is, either no growth or low-level, mixed populations of normal vaginal flora [Table 212-2]).



Owners often request antibiotic treatment; however, conservative treatment usually is advised. Antibiotic therapy may predispose to opportunistic bacterial overgrowth in the absence of normal bacterial flora and development of antibiotic resistant strains of bacteria. If puppy vaginitis persists for more than 2 months or becomes excessive, irritating, or problematic, antibiotic therapy may be initiated based on culture and sensitivity results. However, discharge commonly returns when antibiotics are discontinued.


Conflicting opinions exist whether to spay affected bitches before the first estrus. The rationale for waiting until after the first estrus is that the influence of estradiol on the vaginal mucosa increases vascular circulation and local immune function, thereby clearing up the vaginitis. No clear evidence supports or disparages this theory.


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Jul 18, 2016 | Posted by in PHARMACOLOGY, TOXICOLOGY & THERAPEUTICS | Comments Off on Vulvar Discharge
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