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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