In all cases of abnormal vaginal discharge consider the possibility of the sexually transmitted infections, gonorrhoea and non-specific urethritis. Dr Stella Heley, Victorian Cytology Service, 2001
Vaginal discharge is one of the commonest complaints seen by family physicians yet it is one of the most difficult to solve, especially if it is recurrent or persistent. It is present if the woman’s underclothes are consistently stained or a pad is required. It is important to make a proper diagnosis, to differentiate between abnormal (physiological) and pathological discharge and to be aware of the considerable variation in secretion of vaginal fluid.
This variation extends to different age groups, from prepubertal girls where dermatoses and Streptococcus sp. infections occur to the elderly with postmenopausal dermatoses and atrophic vaginitis.
The differential diagnoses should include consideration of normal discharge, vaginitis, either infective or chemical, STIs, and urinary tract infection.
Key facts and checkpoints
A survey of a large family planning clinic found that 17% of women complained of vaginal discharge.1
Vaginal discharge may present at any age but is very common in the reproductive years.
Vaginal discharge is a common presentation of those STIs responsible for PID.
The first step in diagnosis is to determine if the discharge is cervical or vaginal in origin.
One of the simplest methods of making a proper diagnosis is a wet film examination.
A summary of the diagnostic strategy model is presented in Table 106.1.
Vaginal discharge: diagnostic strategy model
|Favorite Table|Download (.pdf) Table 106.1
Vaginal discharge: diagnostic strategy model
|Q. ||Probability diagnosis |
|A. ||Normal physiological discharge |
| ||Vaginitis:3 |
• bacterial vaginosis 40–50%
• candidiasis 20–30%
• Trichomonas 10–20%
|Q. ||Serious disorders not to be missed |
|A. ||Neoplasia: |
| ||STIs/PID (i.e. cervicitis): |
• herpes simplex—types 1 and 2
| ||Sexual abuse, esp. children |
| ||Tampon toxic shock syndrome (staphylococcal infection) |
| ||Streptococcal vaginosis (in pregnancy) |
|Q. ||Pitfalls (often missed) |
|A. ||Chemical vaginitis (e.g. perfumes) |
| ||Retained foreign objects (e.g. tampons, IUCD) |
| ||Endometriosis (brownish discharge) |
| ||Ectopic pregnancy (‘prune juice’ discharge) |
| ||Poor toilet hygiene |
| ||Latex allergy |
| ||Genital herpes (possible) |
| ||Atrophic vaginitis |
| ||Threadworms |
|Q. ||Seven masquerades checklist |
|A. ||Diabetes |
| ||Drugs |
| ||UTI (association) |
|Q. ||Is the patient trying to tell me something? |
|A. ||Needs careful consideration; possible sexual dysfunction. |
The two most common causes of vaginal discharge are physiological discharge and infective vaginitis.
Normal physiological discharge is usually milky-white or clear mucoid and originates from a combination of the following sources:
cervical mucus (secretions from cervical glands)
vaginal secretion (transudate through vaginal mucosa)
vaginal squamous epithelial cells (desquamation)
cervical columnar epithelial cells
resident commensal ...
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