Leukorrhea

LEUKORRHEA (fluor albus), pathological discharge from the female genital organs. The study of leukorrhea is closely connected with the question of the normal secretion of the various parts of the female genital tract. One distinguishes the secretion of the tubes, the uterine cavity, the cervical canal, the vagina, and the vestibule. The normal mucosa of the tube and uterine cavity appears moist, thanks to a thin layer of watery, transparent, colorless fluid, which has an alkaline reaction and is free of bacteria. The amount of discharge from a healthy tube and the secretion of the uterus is so insignificant that it is sufficient only for moistening the mucosa. The cavity of the cervical canal is filled with thick, viscous mucus, produced by the glands of the cervical mucosa and partly mixed with the discharge from the uterine cavity. The serous-mucous content of the cervical canal has an alkaline reaction and normally contains neither cellular elements nor bacteria. Usually, the content of the cervical canal enters the vagina only in a very insignificant amount, mixing with its contents. The so-called 'vaginal secretion' is subject to significant fluctuations in quantity and quality even in healthy women, depending on age and various physiological states, for example, menstruation, pregnancy, sexual arousal, etc. In healthy women, the amount of vaginal content is small (from 0.3 g to 1.0–1.5 g). The content of the vagina of constitutionally healthy virgins who do not suffer from any gynecological diseases can be considered normal. Macroscopically, the vaginal content appears milky-white, sometimes crumbly or viscous. In normal vaginal discharge, there is usually no mucus, although the latter may sometimes (before menstruation) mix with it, flowing down from the cervical canal. The vaginal content consists primarily of desquamated cells of the vaginal epithelium, leukocytes (in insignificant quantity), cellular detritus, and a huge number of microorganisms; the liquid part of the vaginal content is formed by transudation from vessels, which are found in abundance in the subepithelial layer of the vaginal walls. Normal vaginal content rarely has a neutral reaction; in the majority of cases, it is acidic. The degree of acidity can be measured with simple litmus paper, by titration, or by determining the concentration of hydrogen ions (pH). The acidity of the vaginal content can change under the influence of various physiological states and age. The highest acidity titer is found in healthy pregnant women. According to Gräfenberg, the degree of acidity of the vaginal environment may depend on the ovarian-menstrual cycle, with the maximum occurring in the period shortly before the onset of menstruation. The degree of acidity in multiparous women is weaker than in primiparous women. There are some disagreements regarding the question of the relationship between the reaction of the vaginal environment and age. According to Krönig et al., the vaginal secretion of a newborn already reacts acidically; according to Heurlin and Lahm, the vaginal content from the age of six weeks to 10 years has an alkaline or neutral reaction, and only with the onset of puberty does the reaction become acidic. As the climacteric age approaches, the reaction of the vaginal secretion gradually changes from acidic to neutral or even weakly alkaline, especially in the upper third of the vagina (Stroganov). There are different opinions regarding the source of the acidity of the vaginal secretion. Most authors (Zweifel) are inclined to attribute it to lactic acid, formed from glycogen, which is found in large quantities in the superficial layers of the stratified squamous epithelium of the vaginal walls. However, there is no strict parallelism between the quantitative content of glycogen in the vaginal mucosa and the percentage content of lactic acid in the vaginal secretion. The possibility of the presence in the vaginal secretion of other acids (carbonic, phosphoric, and sarcolactic) is not excluded, formed either due to the vital activity of bacteria from glycogen or from products of enzymatic breakdown of proteins. Döderlein considers the vaginal bacillus discovered by him to be the dominant factor in the process of lactic acid formation. This opinion is not shared by other authors, who point out, for example, that the vaginal secretion of newborn girls has an acidic reaction in the absence of bacterial flora. Besides the vaginal bacillus, other bacteria (streptococci, pneumococci, and Bacterium coli) may play a role in the formation of the acidity of the vaginal content. The vaginal flora appears extremely rich and diverse. From a practical standpoint, the division of vaginal flora into 4 degrees of purity, proposed by Heurlin and Schröder, is important. In perfectly normal vaginal secretion, the vaginal bacillus predominates to such an extent that it is sometimes difficult to prove the presence of other bacteria. The reaction of the content is acidic. In such cases, one speaks of the first degree of purity of the vaginal content. With a certain decrease in the number of vaginal bacilli in a smear and the simultaneous appearance of coccobacilli, vaginal cocci, Comma variabile, staphylococci, and anaerobes, in the presence of a definitely acidic reaction, the second degree of purity is obtained. If the conditions for the vital activity of the normal vaginal flora deteriorate due to various diseases of the genital apparatus, which lower the acidity of the vaginal environment or damage the integrity of the vaginal epithelium, then the vaginal bacilli disappear entirely, and pseudodiphtheria bacilli, Tetragenus, and anaerobic streptococci remain in the field of view—the third degree of purity. In many inflammatory diseases of the genital apparatus, vaginal bacilli are not visible at all in smears: instead, pyogenic bacteria and a huge number of anaerobes dominate—the fourth degree of purity. At this degree of purity, the reaction of the vaginal secretion often turns out to be neutral or even weakly alkaline, whereby the quantity of epithelial cells and leukocytes increases to a significant degree, corresponding to which the vaginal discharge becomes more abundant, acquiring a yellowish color of varying intensity. The degree of purity can depend (besides pathological factors) on incidental moments, such as, for example, sexual intercourse, gynecological examination, etc. Thanks to the ability of the healthy vagina for self-cleansing and under the influence, perhaps, of the manifestation of local immunity, pathogenic microorganisms that have entered the vagina usually perish or, at least, can exist here without causing harm. Various diseases of the genital apparatus are characterized, among other things, by certain changes in the normal vaginal flora. The discharge of the vaginal vestibule in a healthy woman consists of the discharge from the vagina, tissue transudate, and the discharge from the vestibular and paraurethral glands. Urine and the secretion of the Bartholin's glands may also mix here. The reaction of the vestibular discharge is usually acidic, but weaker than in the vagina. Its morphological and bacterioscopic pictures differ little from the picture of the vaginal secretion. However, here, with the help of bacteriological examination (using appropriate media), one can prove the presence of colonies of facultatively pathogenic microbes, especially Bacterium coli. Information about the glycogen content in the vestibular epithelium is very scarce. Usually, normal discharge does not flow out beyond the genital slit, and healthy women do not feel it. If, however, the secretion intensifies to such an extent that the discharge gets onto the external genital organs, attracting the woman's attention or causing her some suffering (an unpleasant feeling of constant moisture, itching, burning), then in such cases one must already speak of leukorrhea. Leukorrhea can be abundant or non-abundant; by color—white, transparent, or milky-colored, leaving something like starch stains on underwear (fluor albus), sometimes yellow or green from an admixture of pus (fluor flavus). By consistency, leukorrhea is divided into liquid and thick (depending on the predominance of mucus or transudate). If blood is mixed into the leukorrhea, one speaks of serosanguineous discharge. Leukorrhea can be odorless or very foul-smelling. One also distinguishes non-corrosive and corrosive leukorrhea; the latter property may, however, depend not so much on the character of the discharge as on the insufficient cleanliness of the patient. By the place of their origin, leukorrhea is divided into tubal, uterine (of the uterine body), cervical, vaginal, and vestibular. Leukorrhea serves as the most frequent complaint of gynecological patients, always being merely a symptom of some underlying disease. Leukorrhea can be of extragenital etiology or depend on a disease of one or another part of the genital apparatus. Ultimately, even with the extragenital etiology of leukorrhea, it is still a matter of functional or even anatomical changes in the genital apparatus. Extragenital causes include constipation, chlorosis, scrofula (especially in young girls), tuberculosis, and other general diseases that weaken the organism. Various intoxications (occupational hazards) should also be included here. Leukorrhea having an extragenital etiology is usually of a cloudy-white color and has no odor.

Leukorrhea (fluor albus) is encountered relatively frequently in neuropathic or constitutionally weakened subjects. According to the opinion of Menge, this involves a disturbance of the general metabolism in the organism, along with a disturbance of the synergistic function of the endocrine apparatus. Leukorrhea can also have a purely psychogenic etiology: Menge admits the possibility of central influences on the vegetative secretory nerves and the vasomotor apparatus. Numerous observations show that in cases of leukorrhea of constitutional origin, there occurs increased permeability of the mucous membranes of the genital tract (especially the vagina). The vaginal flora in such cases is characterized for the most part by the presence of the 2nd-3rd degree of purity of the vaginal secretion. While many authors (Loser, Jaschke) attach great importance to glycogen and the flora of the vaginal contents in the etiology of constitutional leukorrhea, others (Menge) place morphological changes in the mucous membranes of the genital apparatus in the first place. Changes in the vaginal flora in these cases are a secondary phenomenon. In general, the question of the etiology of leukorrhea that does not depend on a disease of one or another part of the genitals (so-called "essential leukorrhea") still has very much that is unclear and belongs to the number of the most urgent problems in gynecology. Leukorrhea of extragenital etiology rarely has as its source any single part of the genital tract; more often it is composed of the secretion of the uterus, the cervix of the uterus, and the vagina. In the majority of cases, however, leukorrhea is a symptom of a disease of the genital apparatus or some separate part of it. Tubal leukorrhea is encountered in practice extremely rarely: it may be a question of either so-called hydrops tubae profluens, expressed in the intermittent discharge of dropsical fluid from the tubal sac into the uterus, resp. the vagina and the vestibule, or of pus tubae profluens. Hydrops tubae profluens and pus tubae profluens occur in those cases where the blockage of the uterine opening of the tube depends not on the obliteration of its lumen, but only on the swelling of the mucosa. Uterine leukorrhea (from the cavity of the body of the uterus) can be of extragenital etiology (see above) or depend on a disease of the uterus itself. Hypersecretion of the uterine mucosa most often occurs in gonorrheal or septic endometritis. Tuberculous endometritis can also serve as a cause of leukorrhea, the etiology of which often remains unrecognized. Often, intrauterine contraceptive pessaries and intrauterine contraceptive injections serve as the cause of leukorrhea. An extremely rare cause of leukorrhea is the penetration of Oxyuris vermicularis into the uterine cavity. Benign neoplasms of the uterus (submucous fibromyomas, polyps) and, especially, malignant tumors (cancer, sarcoma) are usually accompanied by hypersecretion, whereby the discharge during the decay of the tumor is especially abundant, acquiring a purulent character and an extremely foul odor. It is necessary to mention so-called pyometra, i.e., the accumulation of pus in the uterine cavity due to complete or partial atresia of the cervical canal. The question of whether uncomplicated retroversio-flexio uteri mobilis can be a cause of hypersecretion of the uterine mucosa has not yet been finally clarified. It is all the more difficult to resolve this question because precisely in cases of retroversio-flexio uteri mobilis, extragenital factors of a constitutional nature can occur. Hypersecretion of the uterine mucosa can be temporary, resp. periodic, and depend on physiological processes: this includes fluor prae- et postmenstrualis. It is also necessary to mention that senile atrophy (due to a desquamative process) can be accompanied by hypersecretion. Depending on the cause, uterine leukorrhea can have a different color: from transparent-glassy to intensely purulent. Serosanguineous leukorrhea ("meat washings") indicates the presence of a malignant neoplasm. Cervical leukorrhea, just like uterine leukorrhea, can have an extragenital etiology (see above) or serve as a symptom of a local disease. The most frequent causes of them are: 1) inflammatory diseases (endocervicitis gonorrhoica acuta et chronica, endocervicitis catarrhalis, erosiones), 2) benign and malignant tumors of the cervix, and 3) old tears of the cervix, with eversion of the mucosa of the cervical canal. Vaginal leukorrhea stands at the center of the question of leukorrhea in general. Its source, besides the vagina, is the higher-lying parts of the genital tract. Pathological discharge from the body of the uterus and the cervix, flowing down into the vagina, can significantly change the character of the contents of the vaginal canal: the reaction of the medium and the character of the vaginal flora change. The composition of the vaginal contents changed in this way can secondarily act upon the vaginal wall, which becomes more permeable to tissue lymph. Similar to leukorrhea of uterine origin, vaginal leukorrhea proper can have an extragenital and local etiology. Vaginal leukorrhea of extragenital origin (see above) usually has a milky-white watery appearance, sometimes with a yellowish tint. Fluor albus is frequently found in virgins, being a persistent affliction that is difficult to treat with therapeutic measures. Besides the extragenital factors listed above, general infectious diseases (e.g., measles, scarlet fever, influenza) can also be a cause of vaginal leukorrhea. The mechanism of this leukorrhea is explained by the disturbance of the vital activity of the vaginal wall by toxins circulating in the diseased organism. Local causes of vaginal leukorrhea include: 1) ulcerative processes in the wall of the vagina, sometimes causing suppuration of the paravaginal tissue; 2) gonorrheal inflammation of the vaginal mucosa (colpitis gonorrhoica), which is observed almost exclusively in newborns and in small girls and only as an exception in pregnant women, women in childbirth, and in the climacteric period; 3) the presence in the vagina of animal parasites (Oxyuris vermicularis, Trichomonas vag.); 4) malignant neoplasms; 5) mechanical and chemical insults, for example, masturbation, abusus in Venere, rings, sponges, forgotten ligatures, irrationally applied douching, the entry of tobacco dust into the vagina in those working in tobacco production, etc. Vaginal leukorrhea of local origin usually has a greater or lesser admixture of pus and the 3rd or 4th degree of purity of the vaginal flora. Vestibular leukorrhea can also have an extragenital etiology or depend on a disease of the mucosa of the vaginal entrance. Local causes include: 1) maceration or the toxic influence of leukorrhea flowing down from the upper parts of the genital tract; 2) unhygienic maintenance of the external genital organs and the anal region, mechanical trauma, such as, for example, masturbation, coitus ante portas, etc.; 3) inflammatory diseases leading to ulcerative processes, gonorrheal urethritis, soor, etc., and 4) neoplasms. Vestibular leukorrhea usually has a watery-purulent character, whereby its consistency also depends on the admixture of secretion from the sebaceous glands. With insufficient cleanliness, vestibular leukorrhea usually acquires a very foul odor; in diabetes, it can have a fruity odor, and in cystitis, the odor of ammonia. Diagnosis. Besides examination of the leukorrhea itself (appearance, quantity, odor, flora, reaction), a comprehensive examination of the genital apparatus and the entire patient is necessary; it is necessary to take into account extragenital factors and, if possible, to determine precisely which part of the genital tract is the main source of hypersecretion. The presence of an admixture of mucus in vaginal leukorrhea always speaks for the involvement of the cervix of the uterus in the hypersecretion. In doubtful cases, the so-called Schultze tampon can be used, or, on the advice of Menge, swabbing the vaginal mucosa with 2% Arg. nitricum, which temporarily shuts off the secretion of the vagina. Sometimes a single inspection of the vaginal part with specula is sufficient to determine whether there is hypersecretion of the cervix. Prophylaxis of leukorrhea for the most part coincides with the prophylaxis of inflammatory diseases of the genital tract (gonorrhea, postpartum diseases, etc.). In this regard, the dissemination among the masses of correct knowledge about infectious diseases, the raising of the general cultural level, dispensary care, etc., are of great importance (for more details on the prophylaxis of leukorrhea of inflammatory origin, see the corresponding words). Prophylaxis of so-called essential (constitutional) leukorrhea, in view of the lack of clarity of its etiology, is extremely difficult and reduces to measures of a general character, such as, for example, physical culture, improvement of sanitary-living conditions, etc. Prophylaxis of leukorrhea that is the result of occupational hazards is closely connected with various measures for labor protection in hazardous industries, such as, for example, proper ventilation, rational work clothing, etc. Therapy of leukorrhea must always be based on accurate diagnosis and be strictly causal. Leukorrhea depending on a local disease of the genital organs is most easily amenable to treatment. Besides treatment of the underlying disease (tumor, infection, etc.), in the therapy of leukorrhea, one has to resort to douching, which is very common in everyday gynecological practice, which is usually only a symptomatic remedy, but often brings great benefit.

Depending on the desired effect, douches are prescribed: antiseptic (Kalium hypermanganicum, Hydrargyrum bichloratum corrosivum, Tinctura jodi, etc.), astringent (Acidum tannicum, Acetum pyrolignosum crudum, Alumen ustum + Zincum sulfuricum, Argentum nitricum, etc.), deodorizing, analgesic (Tinctura opii, Chloral-hydratum, etc.), alkaline (dissolving mucus—Natrium bicarbonicum, etc.), and indifferent (Natrium chloratum). When prescribing douches, it must be kept in mind that a douche bag usually holds one liter of liquid and that most agents for douching are prescribed in a 0.25–0.5% solution. The method of treating fluor albus proposed by Läser, which consists of introducing lactic acid bacilli suspended in milk sugar (Bacillosan) into the vagina, deserves attention. Läser's idea consists of restoring the normal vaginal flora by means of self-cleansing. In this regard, douches with Acidum lacticum (1–2 teaspoons per douche bag of water) can also be of great benefit. In recent years, the method proposed by Nassauer of spraying powders that dry out secretions (Bolus alba, Lenicet, etc.) into the vagina has been used relatively widely. The powders are introduced per se or with an admixture of disinfectants using a special apparatus proposed by Nassauer. The latter can be successfully replaced by an ordinary cylindrical speculum, through which one or another powder is introduced into the vagina. With a cotton swab, the powder is distributed evenly throughout the entire vaginal canal. In cases where leukorrhea is one of the symptoms of a general disease or constitutional weakness of the organism, treatment of the underlying disease and a general strengthening regimen (rest, hydrotherapy, stay at a health resort, etc.) are necessary. Unwisely applied local therapy for so-called essential leukorrhea can only cause harm.