Vaginal Discharge

Background

  • The vagina normally secretes some mucoserous fluid which is influenced by hormones
    • Normal vaginal discharge can vary with time of cycle, use of contraceptive (hormonal), pregnancy, puberty
  • A sudden, unexplained and abnormal (e.g. altered colour/smell, association with itch/pain) discharge is more likely to be infective
  • In the UK, most common causes are non-sexually transmitted e.g. candida or bacterial vaginosis
    • Worldwide, trichomoniasis is common
    • Gonorrhoea, chlamydia and HSV (herpes) can all cause vaginal discharge

History

  • PC and HPC
    • I.e. onset, duration, progression, timing, characteristic/appearance (bloody, white, yellow, frothy, runny, thick, smelly)
    • Associated features e.g. pain, itch, abdominal pain, dyspareunia, dysuria, frequency
      • Pain is often associated with Trichomonas but not with BV
  • Ask about PMHx and RHx
    • Including contraception
  • SHx
    • Including detailed sexual history (if appropriate) and, perhaps, hygiene
    • (Associated travel hx)

Examination

  • Inspection
    • Look at the external genitalia for any signs of inflammation
  • Speculum examination
    • Colour (off-white is suggestive of either candida or BV; yellow-green- trichomonas vaginalis)
    • Appearance (curdy (candida))
    • Amount
    • Smell
  • Where there is any suggestion of upper genital tract (fallopian tubes, uterus, ovaries) infection/disease, abdominal examination and bimanual examination should also be done

Investigation

  • Vaginal pH
    • (High) pH>4.5 suggestive of BV
    • pH<4.5 can be suggestive of candidiasis
  • For investigation of chlamydia/gonorrhoea (NAAT)- endocervical swab

Differential

  • Candidiasis
    • Vulval and vaginal inflammation; curdy, white discharge adherent to walls of vagina; low pH
    • Clotrimazole pessary (500mg) or cream +/- Fluconazole 150mg orally (e.g. Canesten Duo
  • Trichomoniasis
    • Frothy yellow/green discharge and vulval/vaginal inflammation; dysuria; abdominal pain and superficial dyspareunia
    • Metronidazole (400mg BD; 5-7 days)
  • Bacterial Vaginosis
    • Thin, white, homogenous discharge; often malodourous (fishy); no inflammation/pain; high vaginal pH
    • Metronidazole (as above)
  • Chlamydia/Gonorrhoea
    • Usually clear/purulent discharge (can be copious)
  • Other non infective causes include foreign body (consider e.g. with pessary use; often foul smelling, disanguinous discharge); malignancy; fistulae;
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