Vaginal
dischargeHistory 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
Trichomonas vaginalis
- Vaginitis, thin, frothy, fishy smelling discharge. STI.
- Tests – triple swabs
- Treatment
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
Gonorrhoea
- May have discharge. Dysuria. Cervicitis.
- Test – Endo-cervical Ames swab
- Refer GP/GUM clinic. Contact tracing. Ciprofloxacin. Education.
- Treatment
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
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.
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).
Management of bacterial infections
- Bacterial vaginosis
- Metronidazole 2 g as a single oral dose, metronidazole 400-500 mg twice daily for five to seven days, intravaginal clindamycin cream (2%) once daily for seven days, or intravaginal metronidazole gel (0.75%) once daily for five days4
- The infection often recurs and acidic vaginal jelly (such as Relact from Kora Healthcare) may reduce relapse rates27
- Partner notification not needed
- Vulvovaginal candidiasis
- Vaginal imidazole preparations (such as clotrimazole, econazole, miconazole—various preparations are available including single dose ones), or fluconazole 150 mg orally
- The role of alternative treatments like tea tree oil and yoghurt containing Lactobacillus acidophilus have not been evaluated
- Oral versus vaginal treatment depends on preference
- Treatment for candidiasis is available over the counter in the UK
- Partner notification not needed
- Chlamydia trachomatis
- Doxycycline 100 mg twice daily for seven days (contraindicated in pregnancy), azithromycin 1 g orally in a single dose (WHO recommends azithromycin in pregnancy but the British National Formulary advises against its use unless no alternatives are available)
- A test of cure is not indicated
- Partner notification required
- Gonorrhoea
- Cefixime 400 mg as a single oral dose or ceftriaxone 250 mg intramuscularly as a single dose
- Referral to a genitourinary medical unit is encouraged because of the existence of resistant strains of the organism
- A test of cure is not routinely indicated if an appropriately sensitive antibiotic has been given, symptoms have resolved, and there is no risk of reinfection
- Partner notification required
- Trichomonas vaginalis
- Metronidazole 2 g orally in a single dose or metronidazole 400-500 mg twice daily for five to seven days
- Partner notification required