Poor personal hygiene, wiping gfrom back to front not front to back. Wiping not dabbing.

The major cause.

Hi Bagaria,

When you talk of persistent non-infective, non-physiological malodorous vaginal discharge, the first thing that came to mind is Bacterial vaginosis. Bacterial vaginosis (BV) is a complex alteration in the vaginal flora illustrated by a decrease in concentration of the normally main hydrogen-peroxide producing lactobacilli and an increase in concentration of other organisms, especially anaerobic gram negative rods such as G. vaginalis; which is believed to be the key player in the pathogenesis of BV. BV produce non-infective, non-physiological malodorous vaginal discharge.

Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age, accounting for 40 to 50 percent of cases. And in nearly 30 percent of patients with initial responses to therapy, recurrence of symptoms may occur within three months and more than 50 percent experience a recurrence within 12 months. But the only interventions proven to reduce development or recurrence of BV are chronic suppressive therapy and circumcision of male partners.

Refer to this site for a recent update: http://www.uptodate.com/contents/bacterial-vaginosis

But since your patient has cronh's disease, chronic suppressive therapy may have some serious side effects. Therefore, i suggest you use metronidazole gel 0.75 percent or an oral nitroimidazole for 7 to 10 days followed by twice weekly dosing of gel for four to six months. use of condom and good perineal hygiene is also helpful.

I assume that you have excluded Trichomonas vaginalis and a tiny fistula – this is worth a very careful search. In which case the most common cause of offensive vaginal discharge is bacterial vaginosis (BV). However, BV is not a cause of persistent “vaginal” (I imagine you mean vulval) irritation.

Almost all authorities advise against use of soaps, bath additives, shampoos, etc, because they have an alkaline pH in which lactobacilli will perish. You could measure your patients’ vaginal pH with narrow range pH paper and, if above 4.5 - 5.0, this will favour a diagnosis of BV. Microscopy of a vaginal smear will give a more accurate measure. What is less often taken into consideration is the effect of excess vulval and/or vaginal hygiene. Douching or washing the vagina in a bath exposes the flora to water which, with a pH around neutral (7), has as deleterious an effect on the lactobacilli as soaps, etc.

Oral Metronidazole 400mg twice daily for 5-7 days may help and this can be repeated around the time of menstruation (the menses have an alkaline pH). Ejaculate also has an alkaline pH and the use of a condom for a period of some months may help.

Finally, the irritation is likely (assuming again there is no tiny fistula) to be due to candida species. If you wish to eliminate this, it is vital to use an antifungal agent, cream or ointment, on a daily basis on the vulva, perineum and perianal skin. The use of intravaginal pessaries is not enough and oral treatment has not been as successful in my hands. Good Luck!

Thank you for your comments. My patients don't have bacterial vaginosis or candida infection. They even  have had vaginal metronidazole course without any relief.

Hi

It sounds to me as malodorous loachia. this is a normal vaginal discharge however it is disturbing the patient.

I would consider very simple actions:

1. Do not use any synthetic sanitary aid. Only 100% cotton pads!!!! and cotton underwear.

2. Daily  internal vaginal wash with a simple 20CC syringe with a solution of  tap water mixed with a teaspoon of viniger. 

I understand it sounds like a witchcraft medicine , but believe me,  i am  a conventional physician!!! It seems to me that the alteration of acid-base relationship in the vaginal flora is influenced by synthetics of any kind!!!! this creates a vicious cycle  of discharge needing pads which crates more discharge and so on. 

The mechanism is probably allergic reaction and not infection.

regards

Ilan

hi 

I recommended decrease vaginal sex, avoid rectal sex, use condom and do vaginal wash with water and white vinegar ( 1 lit water & 20 cc white vinegar)

Madhu Bavaria,

Listen to what I said about hygiene. Your answer is great and trust me that this will work.

Now Mashid  Bokaiealso gives good advice about rectal sex. But let us not spoil people's enjoyment of each other. It is all right in these malodorous circumstances to continue with rectal sex, provided that one has VAGINAL INTERCOURSE FIRST, then rectal/anal intercourse. If however, and I have had such patients, who prefer anal intercourse first, then vaginal intercourse, one of the solutions in that case is for a condom to be worn during anal intercourse, then for the condom to be discarded prior to vaginal penetration.

Not many doctors around the world know about such techniques, I'll tell you now!

Hi Bagaria,

Thanks for the stimulating question.

I wish you can tell us more about these your patients. How is their life-style? On examination, how does the vulva and the vagina look like - I mean any features of inflammation, ulcerations etc?, and what is the nature of the vaginal discharge? i.e. quantity, colour, liquidity, presence or absence of froth e.t.c.  did you tested for the PH of the vaginal discharge? 

These inquiries will help us to have better deliberations.

But try the medication I advice you above and let us get the feedback. 

Regards,

After excluding any atypical infection and suggesting correct hygiene, I treat with lactobacilli capsules within vagina and orally. If constipation is reported and if it is not relieved by lactobacilli, I treat constipation with macrogol. Sometimes, lactobacilli creams are needed on the vulva.

I acknowledge that, sometimes, the symptom is difficult to treat and may lead to both vulvodynia or vaginal discomfort during sexual intercourse.

Persistent non infective and malodorous vaginal discharge: Indeed bad smell from coliiforms or lactbacilli therefore infective. Indeed there is dirt somewhere full of organisms that are emitting the smell. Hit them with an antibiotic preferably topical. You cant have malodorous with no bacteria even in cancer there is something rotting and that is why hygiene advised above is handy in addition

Hi Madhu,

Very interesting! I read all responses you've got (counting yours) and I wonder if it could help consider expend the question. If all those advices about hygiene, metronidazole and lactobacilli creams don't work and change nothing, I suggest exploring the body-spirit link. I often encounter women presenting inexplicable facts and symptoms which were courageously and successfully addressed and treated via psychology. The sexual organs (especially women's ones) aren't only reproductive ones, with pH and flora. They are also identity, and the heart of intimate relationships.

I wonder how intimacy, femininity and seduction take place with Cronh's disease if it's not openly addressed. My expérience is that persistent women's organs diseases are rarely neutral or objective. Maybe it worth to explore more widely :)

Please, let us know your next steps and outcome!

France

Lol, France Paradis?

This is not easy to address. Hygiene is the first thing to tackle if culture & pap smear are negative then reassurance with a clinical psychologist

Vaginal probiotics as mentioned above would be a good option.  The GI health probiotics do not carry the vaginal colonizing strains though.  There are two retail probiotics on the market that do contain them.  L. Rhamnosus GR-1  and L. Reuteri RC-14 are the important strains.  Hope this helps. 

Gentle Vulvar Care, for example:

https://www.ottawahospital.on.ca/wps/wcm/connect/6c5288804b25b25a9182d51faf30e8c1/vulvar-care-e.pdf?MOD=AJPERES

I  gree dr davis for use of probiotics locally along with calcium supplimentation and treatment of husband as well for STD.