Vaginal Discharge

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Vaginal discharge is a common and often distressing complaint. Though it is often non STI related, consider additional STI risk. Non-pathological discharge may be physiological or iatrogenic (eg hormonal contraception related) A degree of vaginal discharge that changes with the menstrual cycle can be normal, but a change in the nature or volume of the discharge or other genital or pelvic symptoms (such as dyspareunia, pelvic pain, itch, irregular bleeding and vaginal malodour) suggests a pathological cause.

Oestrogen status will alter the possible causes of non STI discharge.- candida should only occur in reproductive years (unless HRT is used). Consider the risk factors below.

Assess STI risk 
Do microscopy and pH – discharge appearance is often atypical or of negligible amount
Always consider Pelvic Inflammatory Disease
Always exclude a possible pregnancy 

COMMON CAUSES OF VAGINAL DISCHARGE

Infective

Bacterial vaginosis
Candidal vulvo-vaginal infection
Streptococcal or haemophilus bacterial infections – especially premenarche and postmenopausal, or if late pregnancy. 

Infective and Sexually transmitted 

Chlamydia trachomatis
Neisseria gonorrhoea
Mycoplasma genitalium
Trichomonas vaginalis
Herpes simplex virus 

Non Infective

Retained foreign body in the vagina
Cervical polyps or ectropion
Atrophic vaginitis
Inflammatory skin conditions affecting the vaginal mucosa eg desquamative inflammatory vaginitis (DIV)
Malignancy of the genital tract
Vaginal fistulae

The commonest cause of vaginal discharge in a woman of reproductive age is bacterial vaginosis (BV) which affects 12% of Australian women. It is often recurrent and treatment can trigger candida symptoms.

MANAGEMENT OF A WOMAN PRESENTING WITH VAGINAL DISCHARGE

History

  • Details of vaginal discharge itself: a detailed history including: nature of discharge, colour, smell, relationship to cycle, blood staining. 
  • Associated symptoms: such as vulval itch or irritation, scratching, rash, postcoital bleeding or any irregular bleeding outside normal menstrual loss, introital or pelvic pain or dyspareunia, urinary symptoms
  • Menstrual history including contraception: LMP, intermenstrual bleeding ( IMB), post coital bleeding (PCB), post menopausal bleeding (PMB) method of contraception eg COCP or IUD, or recent emergency contraception.
  • Risk assessment for STIs: recent change of partner, unprotected sex, contact with an STI, overseas contact.
IMPORTANT POINTS IN THE HISTORY OF A WOMAN WITH VAGINAL DISCHARGE
  • PCB, pain with intercourse, possibly blood stained discharge may indicate cervicitis (chlamydia, gonorrhoea, mycoplasma genitalium or herpes)
  • Vulval symptoms such as superficial dyspareunia, vulval itch, pain or irritation suggest vulvo-vaginitis (candida)
  • No associated symptoms and the only complaint being excessive discharge with malodour suggests BV. 
  • The presence of BV may increase the likelihood of STI/PID so this needs to be considered if the history is suggestive. 

Examination

  • Palpate the abdomen and inguinal lymph nodes.
  • Vulval exam for , dermatitis, fissures, ulcers or erosions
  • Speculum examination for visualisation of the cervix and vagina and excluding a foreign body, pH testing
  • Pelvic examination unless no risk of clinical PID or pregnancy.

Investigations of a woman presenting with a vaginal discharge

  • Vulval swab if signs of vulvitis: looking for candida (and possibly HSV) – Gram stain and culture
  • Vaginal Gram stain without wet prep if pH <4.5 (detects candida and BV) 
  • Vaginal Gram stain plus wet prep if pH >4.5 (BV and trich), plus trichomonas testing
  • Cervica or high vaginal swab or first void urine for chlamydia.
  • Include M genitalium testing if cervicitis or PID
  • Cervical swab for gonorrhoea 
  • Cervical pap smear if indicated
  • Consider anal swabs for chlamydia and gonorrhoea. 
  • HSV PCR if any fissures or ulcers.

Other causes of vaginal discharge such as streptococcal infection uncommonly need to be considered.

TREATMENT

For detailed treatments of individual conditions please see MSHC treatment guidelines on the following:
BV, candidiasis, PID, gonorrhoea, chlamydia, mycoplasma genitalium, herpes and trichomonas.
A summary is below in the table.

Diagnosis

Inspection of vulva

Inspection of vagina & cervix

Treatment summary

Bacterial vaginosis:

 

 

Minimal inflammatory changes in vagina and vulva, excessive discharge may be seen on inspection

White homogenous vaginal discharge, raised vaginal pH 
> 4.5, fishy smell from vagina, no inflammatory changes, but occasionally coexists with symptomatic candida

Metronidazole 400mg orally twice a day 7 days.
Clindamycin 2% cream PV for 7 days. 

Candidal vulvo- vaginitis

Inflammatory vulvo-vaginitis, thick curd like discharge sometimes visible externally

Thick white discharge, vulval and vaginal inflammation fissuring of vulval skin, pH < 4.5
Discharge not always typical.

Fluconazole 150mg orally stat or antifungal vaginal cream.for 6-7 nights.
1% hydrocortisone/clotrimazole to vulva

Trichomonas vaginalis

Vulval contact irritation if excessive

Yellowish discharge

Vaginitis and sometimes ecto-cervicitis (strawberry cervix), ph
> 4.5

Metronidazole 2g stat. Partners need testing and treatment

Atrophic vaginitis

(post menopausal)

Atrophic vulvo vaginal changes ie pallor,patchy redness ie hypo-oestrogenisation

Vaginitis, superficial dyspareunia, contact vaginal wall bleeding,  loss of vaginal rugae, occasionally a mustardy coloured discharge
pH >4.5

Exclude other causes (esp lichen sclerosis) Treat with topical oestrogen and refer gynaecologist if severe or irregular bleeding

Retained tampon or other material

Retained product in vagina, normal vulva

Offensive discharge, product seen and felt in vagina

Remove foreign body

Herpes Simplex Virus (HSV)

vulval /perianal ulcers or fissures

Cervicitis or cervical ulcers with blood stained or purulent discharge possible vaginal ulcers.

See MSHC treatment guidelines

Chlamydia Gonorrhoea
Mycoplasma genitalium

Normal but may have visible discharge.

Possible muco-purulent cervicitis, may be normal, may have PID on exam ie. pelvic tenderness,  discharge may be seen coming from cervix, Cervix may bleed with cotton tip touch.

If cervicitis only treat as uncomplicated chlamydia infection azithromycin 1g or doxycycline 100mg bd 7 days but consider gonorrhoea, MG and HSV. PID needs 2 weeks of treatment.


Disclaimer
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.

Last Updated October 2014