Vaginal Discharge

Vaginal discharge may be bloodstained or otherwise.Here we are only concerned with a withe cream,yellow or greenish discharge which is often loosely and wrongly called "leucorrhea".
The complaint of discharge depends very much on the ideas,powers of observation and fastidiousness of individual women.The vulva and vagina are normally moistened by secretion and woman who are overanxious,introspective,or suffering from fears of venereal disease and cancer tend to exaggerate this into something pathological.On the other hand it is not uncommon to find women denying the existence ot an obviously pathological discharge found during examination.
A woman sometimes complains of discharge when she really means vulval odour.
Vulval odour is a normal secondary sex character arising partly from the secretion of Bartholin's glands(two glands located below and to the left and right of the opening of the vagina) but mainly as a result of the acion of bacteria on the secretion of apocrine glands.
providing a reasonable standard of cleanliness is maintained,vulval odour is never apparent to bystanders and those women who complain of it have a disorder of the mind rather than the body.
The idea usually arises from a misinterpretation of some innocent remark of an acquintance and thereafter becomes an obsesion difficult to eradicate.
Despite the fact that nothing more than regular washing is necessary for hygienic purposes.Exist today advertisement to diferent deodorants or spray to clean women genitals but this have an opposite effect if they destroy natural odour and makeover they are harmful as they are unecessary.
The slight discharge normally seen at the vulva and in the vagina is a mixture of the following,all of wich vary in amount and character with ovarian function.
The amount of vaginal discharge ordinarily present in the adult is such that the itoitus feels confortably moist but there is not enough to leave more than an occasional stain on underclothing.
It is normally increased to the extent of becoming noticeable in the following circumstances at the time of ovulation when there is the ovulation cascade from the cervix.During few days premenstrually when there is increased secretion from all parts of genital tract,during pregnancy there is an increase in vaginal and cervical discharge,and during sexual excitement when there is outpouring of Bartholin's secretion on to the vulva.

Genital Infections-Genital Herpes

The changing sexual habits in the last few decades have been associated with an increased incidence of genital herpes.
Genital herpes is important not only because of its increasing incidence but also because of the physical and psychological trauma it can induce,the risk of serious complications including a possible link with cervical cancer and risk of maternal transfer to neonates.
Disseminated herpes in the newborn is certainly one of the most severe of all manifestations of herpes infections.Prematurity and spontaneous abortion have also been associated whit active maternal genital herpes.
Herpes simplex genitalis is most often caused by infection whit herpes simplex virus type 2,which has usually been sexually transmitted by an infected partner,but may possibly be trasmitted by orogenital contact.
Herpes simplex virus type 1 infection accounts for an increasing proportion of cases.Genital diseases caused by either of these viral types are clinically indistinguishable.As with other herpes infections,the virus replicates in the epithelium,giving rise to painful symptoms and signs.This typically follows a course which commences with redness and inflammation,leading to formation of vesicles which progress to multiple,small and shallow ulcers found on the labia and around the introitus and resolve with crusting and healing.This cycle may take up to 3 weeks in a primary infection.
After the primary infection the virus remains quiescent in the sacral ganglia and can re-emerge to cause recurrence at a later time.
The symptoms of recurrent genital herpes tend to milder and of shorter uration and are ofetn precede by prodromal phase consisting of cutaneous itching or burning and redness in the affected region.
The frequency of recurrences can vary from days to years.

Diagnosis and management:
When genital herpes is suspected it is important to confirm the diagnosis with laboratory culture.The natural history of the disease should be explained and advice given on genital hygiene.It is obviously important to trace sexual partners and would be wise to inform the obstetrician if the patient is pregnant.
Preparation including saline,gentian violet,ether and boric acid have been used for the topical treament of genital herpes.
Antiviral agents such as idoxuriene have also been tried but the results from controlled therapeutic trials have so far shown little clinical benefit from topical application of such drugs.
Many antiviral agents are toxic if ingested.
A standard cours of treatment is for 5 days,five times daily,but in the initial disease or severe recurrence the treatment may be extended up to 10 days.
Acryclovir cream is well tolerted and affective for out-patient management of genital herpes.The cream seems suitable patient initiated treatment which is important in a condition where recurrences are most effectively treated if the therapy is initiated at the first indication of recurrence.
If the secondary infection is present it should be treated.patient should be advised to have regular  cervical smears and to avoid intercourse when lesions are present.

Genital Infections-Phyogenic Infections

We will talk about infections that affect individual organs.

VULVITIS:
Vulvitis is an infection of abrasions and wounds.
Local injuries or abrasions resulting from sanitary towels and tight underclothing(often impregnated whit irritant detergents left from washing) are common source of vulval dermatitis.
Excoriation of the skin can also be caused by vaginal discharge and by ammonia liberated by ureaspliting organisms when the vulva is exposed to constant leakage of urine.All this lesions can become secondarily infected to cause local pain and tenderness.
The treatment consists of rest,warm baths and removal of the cause.

1.INTERTRIGO:
Intertrigo-lack of cleanliness leads to a collection of irriting sebum and other secretions in the skin folds and secondary infection follows.The only treatment required is care over hygiene.
Inattention to the skin in the area of clitoris can result in the collection of a concretion of smegma resembling a small stone under the prepuce.This have to be removed.
2.FURUNCULOSIS:
Infection of vulval hair follicles leads to boils and carbuncles which are sometimes recurrent.Glycosuria(the excretion of glucose in urine) must be excluded in such cases.Otherwise,reccurent boils means the pathogenic staphylococci are being harboured in a carrier site (for exemple the nose or axilla) of the patient or of a close associate.This have to be found and eliminated.
For the vulval skin the remedies are scrupulous attention to cleanliness regular application of chlorhexidine cream or swabbing whit a solution of hexachlorophene.
During a phase of active furunculosis a full course of treatment whit penicillin or of other antibiotic appropriate to te infecting organism,should be given systemically,not locally.
3.INFECTION OF SEBACEOUS AND APOCRINE GLANDS:
Single abscesses,often representing secondary infection of retention cyst of an apocrine or sebaceous glands,have the clinical characteristics of a boil and are treated in the same way.
4.INFANTILE AND SENILE VULVITIS:
When the vulval epithelium is thin and inactive as in childhood and old age any of the organisms to  which it is normally,resistant can set up a simple vulvitis.This sometimes leads to labial adhesions.

Rectal and anal pain-Hemorrhoids

Hemorrhoids known as pilles too,are part of the anal canal and they are pathological when become sawollen or inflamed.
In case of women who have a baby the hemorrhoids are more common,specially those whit a family history of hemorrhoids and varicose veins suffer most.In this case the hemorrhoids develop as part of the pelvic congestion of pregnancy and are probably encouraged by atony of the vesel walls.
The hemorrhoids are painful when they prolapse and become thrombosed as a result of their strangulation by the anal ring-this is particularly likely to occur in women cases during the second half of pregnancy or during and immediatly after labour.
Once the hemorrhoids are thrombosed they remain extruded and become swollen,tense oedematous and tender and after they may ulcerate.The thrombus begins to organize in a few days and swelling then subsides and the pain disappears.But the hemorrhoid remains as small and more fibrous structure.

Prevention:
It is impossible to avoid hemorrhoids but it is often possible to prevent their becoming strangulated and painful.This is done by:
-keeping the bowels regularly and the stool easy to pass without straining.
-gentle replacement of prolapsed hemorrhoids immediately after defecation.
-resting flat in bed for 15-30 minutes after defecation to give the anal sphincter time to recover tone.
-avoiding standing whit the pelvic floor muscles relaxed.

Treatment.
Treatment of strangulated hemorrhoids:
the best treatment for an attack of pilles is rest.Two or three days lying flat in bed will cure more quickly than any other procedure.Lying is essential,sitting up makes the situation worse.The prone position with the hemorrhoids at the hihest level of the body often brings quick relief.
Anaesthetic ointments and anal suppositories satisfy tha patient that something is being done but are of little intrinsic value.
Ice packs and cold compresses are more helpful.hot bath should be avaoided becouse although temporarily soothing,they increase the congestion.
Removal of the thrombus by incision under local anaesthesia is sometimes advised but the results are poor.

Treatment between attacks:
-injecting the internal hemorrhoids with slertosing fluids is indicated when their symptoms is bleeding but this is not reliable in preventing their prolapse.
-other methods of treating internal hemorrhoids without anaesthesia are the application of rubber bands or cryotherapy.
-although the hemorrhoidectomy is a common operation it should only be used when all other methods have failed.
Use a healthy diet based on full grain cereals and fresh fruits and vegetables and fluids!

Rectal and anal pain-Fissue in ano

A fissure in usually posteriorly as a tiny crack in the anal margin.It occurs in an acute form also as a chronic indolent ulcer,but tends to eal more easily in women than in men.Often it is associated whit haemorrhoids.
A fissure is generally caused by the passage of bulky hard stools and commonly develops during the days or weeks after delivery.

Symptoms:
The main complaint is pain during defecation,fallowed by a deep-seated throbbing ache for 2 or 3 hours afterwards.
The aching is caused by rectal spasm and is extremely trying to the sufferer.The fissure often sheds a few drops of blood during defecation but this stops immediately afterwards.

Signs:
The crack or ulcer is visible on careful inspection.The attempt at digital rectal examination causes severe pain and spasm of the sphincters.

Treatment:
Most fissures can be healed by conservative treatment.This consist of:
-keeping the bowels regular and the stool soft by habit,diet and liquid paraffin,and by avoiding straining at stool.
-supporting the anal ring manually during defecation to prevent the crack reopening.
-careful anal hygiene(washing with cotton wool swabs or preferably sitting n warm bath after defecation).
-applying a local anaesthetic ointment before defecation and when this is acting passing an anal dilator which is left in place for a few minutes.This overcome the spasm which is the cause of the pain and the basis for the fissure failing to heal.

If these measures fail more active treatment consists of the fallowing:
-injection of the base of the fissure and of the anal sphincter whit local anaesthetic solution followed by digital dilatation of the anal ring.
-dilatation of the anus under general anesthesia  is probably the most effective of all treatments.
-incision of the internal sphincter.
-excision of the fissure.

Dysmenorrhea-painful menstruation

Dysmenorrhea means painful menstruation but the term is often used to cover two essentially different symptoms.These are:
-A pain wich is utherine origin and directly due to menstruation.This is known as true dysmenorrhea.
-A pain which arises in a organ or tissue other than the uterus and which is merely associated with menstruation.
A pain which is equally severe before,throughout and after menstruation is lakely to have its origin in the psyche,no pelvic lesion can cause such.
Menstrual disconfort is typically midle or bilateral in the lower abdomen or back,but can be unilateral.
One sided dysmenorrhea experianced in the lower abdomen has only four possible bases:one horn of a malformed uterus,endometriosis which a unilateral distribution,a small fibroid at the uterotubal junction-the site of origin of uterine contractions,or spasm or distension in the colon.
Not less then 50% of wemen are said to experiance some disconfort in relation to manstruation,and 5-10% of girls in their late teens and early twenties are incapacitated for several hours each month.
Circumstances wich lead to nervous tension may make dysmenorrhea worse even if they do not cause it.This include unhappiness at home or at work,unsatisfied sex life,fear or loss of employment,or anxiety over examinations.

In true dysmenorrhea the pain sensation arise in the uterus and is related to muscle contractions.It is experianced a few hours before and after the onset of menstruation and rarely lasts in a severe form for longer than 12 hours.
During a severe attack the patient looks drawn and pale and may sweat,nausea and vomiting are common,there may be diarrhea and rectal and blodder tenesmus.All this features suggest an upset in the autonomic nervous system.

Prevention:
Unfavourable environmental factors,malnutrition,general ill health and any errors in the patient's mode of life should be corrected.
Regular physical activity of some kind is to be encouraged both between and during mensatruation.
While the pain is at its highest the girl may have to lie down relief from warmth applied to the lower abdomen.

Treatment:
The drugs most commonly employed to relieve pain and induce sleep were aspirin,paracetamol and codeine in various combinations.Proprietary antispasmodics can be effective if given 2 days before the expected date of the period has started Buscopan 20mg four times daily may be tried

Hormone therapy:
Anovulatory cycle are always painless so suppression of ovulation gives certain relief from true dysmenorrhea.This is best achieved by means of one of the progesteron-oestrogen oral contraceptive preparations