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Vaginal discharge – a guideline for
nurses
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Aims
To diagnose and treat vaginal discharges and to refer on where necessary
History of presenting complaint
- Duration
- Abdominal Pain
- Colour
- Fever
- Smell
- Previous episodes
- Itch
- Irregular bleeding
- Timing of discharge
- Dysuria
- Dyspareunia
History
- Age
- Sexual History; contraception; LMP; recent change of partner; partner
symptomatic
- Menstrual/obstetric history
- General Health
- Medication – including recent course of antibiotics.
- Allergies
Examination
- Not always necessary if sure it is thrush and not recurrent.
- May be too painful if severe thrush or herpes
- Essential if offensive discharge to exclude a retained tampon
Speculum examination
- Examine external genitalia (from pubis to anus). Look for lesions, ulcers,
inflammation, discharge, leukoplakia, infestations.
- Observe vaginal mucosa for lesions, inflammation and discomfort. Note colour,
viscosity and smell of discharge. Observe the cervix for inflammation, colour,
lesions, polyps, friability. Also discomfort on cervical movement or uterine
palpation.
Tests
- HVS; Endo-cervical swabs, using chlamydia and Ames swabs.
- Temperature
- ?Urinalysis
- ?Bloods HIV; Hepatitis screen; diabetes.
Normal Physiological Discharge
A non-offensive vaginal discharge may be a normal physiological discharge, many
women do not understand that it is normal to have a clear, slightly milky
discharge which is heavier at the time of ovulation and before a period.
Thrush
- Commonest. Thick, white, curds. Itchy. Vulva and vagina may be red, fissured and
sore.
- Risk Factors – pregnancy; diabetes; antibiotics; the pill; immunodeficiences.
- Tests – HVS for mycology (?bloods for glucose).
- Treatment – Clotrimazole 10% vaginal cream; pessaries; Fluconazole 150mg. Or
consult BNF for alternative anti-fungal treatments. Live yoghurt, sodium
bicarbonate. Education.
Trichomonas Vaginalis
- Vaginitis, thin, frothy, fishy smelling discharge. STI.
- Tests – triple swabs
- Treatment – Metronidazole 400mg TDS for 5 days. No alcohol. Treat partner.
Bacterial Vaginosis
- No inflammation. Fishy smelling discharge, not likely to be itchy. Symptoms
worse around menstruation and after intercourse. Warn midwives if positive.
- Tests – HVS pH >5.5
- Treatment – Metronidazole 400mg TDS for 5 days.
Gonorrhoea
- May have discharge. Dysuria. Cervicitis.
- Test – Endo-cervical Ames swab
- Refer GP/GUM clinic. Contact tracing. Ciprofloxacin. Education.
Chlamydia
- Does not usually cause vaginal discharge but may co-exist with other infections.
Strawberry cervix. If febrile, abdo pain, mentstrual disturbance or dysuria – be
highly suspicious of PID and consult GP. Will need combined therapy for 2 weeks
for PID (Doxycline and Metronidazole)
- Tests – triple swabs including endo-cervical chlamydia swab. Temperature.
- Treatment for uncomplicated chlamydia. Abstinence for a month. Contact tracing.
?refer GUM. Doxycline 100mg BD for a week or Azithromycin 1Gram stat. (If
pregnant Erythromycin). Education.
Atrophic Vaginitis
- Because of a lack of eostrogen, post menopausal women are more at risk of
vaginal infections. Thinning of the mucosa may lead to a brownish or blood
stained discharge. This may be prevented by treatment with vagifem pessaries –
every night for 2 weeks, then once or twice weekly. However, post menopausal
bleeding should be referred on, to exclude more serious pathology.
- Herpes; Wart Virus and Syphilis may all cause vaginal discharges.
Refer to GP – Same day
- Abdominal pain. Uterine tenderness. Fever. Genital blisters. Irregular bleeding.
- Refer to GP – Routinely if recurrent symptoms, GP or GUM for STI
Caution
- Genital herpes causes blisters and pain, rather than itch.
- PID causes abdo pain, uterine tenderness, fever, irregular bleeding, dysuria.
- Ectopic pregnancy causes PV bleed with abdominal pain EMERGENCY
- An ulcer, could be syphilis or herpes (excruciatingly painful).
Jane
Smithson: