Vaginal discharge
- Vaginal discharge is a common complaint
- Vaginal discharge consists of cervical mucous, vaginal transudate, vaginal epithelial cells and vaginal flora
- The most common cause of vaginal discharge in people of reproductive age is normal physiological discharge
- Consider other causes with history, examination and investigations
Vulvovaginal candidiasis
Sexually transmitted infections
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Trichomonas vaginalis
- Herpes simplex virus (HSV) (cervical infection)
Non-infectious causes
- Hormonal contraception, physiological, cervical ectropion and cervical polyps
- Foreign body (e.g. retained tampon)
- Atrophic vaginitis in lactating and postmenopausal women or women on hormonal contraception e.g. hormone releasing intrauterine device (IUD), Mirena, Depo-Provera or more rarely combined oral contraception
- Desquamative inflammatory vaginitis (DIV) or aerobic vaginitis
Rare
- Bacterial vaginitis e.g. streptococcal or staphylococcal
- Cervical malignancy
Symptoms
- Volume of discharge
- Change in characteristics e.g. yellow, green or white, curd-like, frothy
- Odour – fishy smelling, malodorous
- Associated vulval symptoms – itching, tenderness, rash
- Other relevant symptoms – abnormal vaginal bleeding, dyspareunia, pelvic pain may indicate pelvic inflammatory disease (PID)
- Change from usual vaginal discharge
- Examination recommended, including inspection of external genitalia, speculum examination of cervix and vagina, and bimanual palpation (if indicated)
- Specifically, examine for:
- Characteristics of discharge (colour, consistency, distribution, volume and odour)
- Cervicitis
- Vaginitis
- Vulvitis
- Ulceration
- Signs of PID
- foreign body (e.g. tampon or condom)
Investigations
- As per sexual health check guideline
- Syndromic management of vaginal discharge described below
- Refer to appropriate guideline if results known.
|
Examination findings |
Treatment |
|
Vulvovaginitis Thick white curd-like discharge Itching and tenderness |
· Presumptive vulvovaginal candidiasis · Clotrimazole 2% vaginal cream 3-day course · OR clotrimazole 1% vaginal cream 6 nights (preferred regimen for pregnancy as less likely to respond to shorter course) · OR fluconazole 150 mg orally, as a single dose (not in pregnancy) |
|
Fishy smelling white or grey adherent discharge NO vulvovaginitis |
· Presumptive bacterial vaginosis · Metronidazole 400 mg orally, twice daily for 7 days (preferred regimen for pregnancy) · OR metronidazole 2 g orally, as a single dose if adherence an issue (less effective) |
|
Offensive purulent frothy discharge +/- vulvovaginitis |
· Presumptive trichomoniasis · Metronidazole 400 mg orally, twice daily for 7 days (preferred regimen for pregnancy) · OR metronidazole 2 g orally, as a single dose |
Special situations
|
Situation |
Recommendation |
|
Foreign body/retained tampon |
Remove foreign body Metronidazole 400 mg orally, twice daily for 7 days May cause a discharge similar to bacterial vaginosis, and there may often be cervicitis if present for some time |
|
Peri or postmenopausal women |
Consider vaginal oestrogen cream for symptomatic women with negative tests Note: Bacterial vaginosis may be reported in this setting due to the altered microbiome of menopause, and topical oestrogen may be used as treatment |
- Treat initially empirically as above, and then based on results when they become available
- More than one pathology may be present e.g. bacterial vaginosis and vulvovaginal candidiasis
- If sexually transmitted infection (STI) suspected, advise no unprotected sexual intercourse until results available
- Vaginal creams can damage latex condoms
- Contact tracing is only required for STIs – see appropriate guideline
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Test of cure
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Retesting
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Referral to or discussion with a sexual health specialist is recommended for:
- Persistent or recurrent vaginal discharge
- Lack of response to appropriate treatment
- Complicated clinical situations for further management