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Probability diagnosis

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Normal or excessive physiological discharge

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Vaginitis:

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  • bacterial vaginosis (40–50%)

  • candidiasis (20–30%)

  • Trichomonas (10–20%)

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Serious disorders not to be missed

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Neoplasia:

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  • cancer (cervix, uterus, vagina)

  • fistulas

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STIs/PID (i.e. cervicitis):

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  • gonorrhoea

  • Chlamydia

  • herpes simplex—types 1 and 2

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Sexual abuse, esp. children

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Tampon toxic shock syndrome (staphylococcal infection)

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Streptococcal vaginosis (in pregnancy)

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Pitfalls (often missed)

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Chemical vaginitis (e.g. perfumes)

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Retained foreign objects (e.g. tampons, IUCD)

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Endometriosis (brownish discharge)

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Ectopic pregnancy (‘prune juice’ discharge)

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Poor toilet hygiene

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Pelvic fistula

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Genital herpes (possible)

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Cervical polyp

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Bartholinitis

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Atrophic vaginitis

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Threadworms

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Latex allergy (e.g. condoms)

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Masquerades checklist

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Diabetes

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Drugs

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UTI (association)

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Is the patient trying to tell me something?

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Needs careful consideration; possible sexual dysfunction.

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Key history

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The history should include:

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  • nature of discharge: colour, odour, quantity, relation to menstrual cycle, associated symptoms

  • exact nature and location of irritation

  • sexual history: arousal, previous STIs, number of partners and any presence of irritation or discharge in them

  • use of chemicals, such as soaps, deodorants, pessaries and douches

  • pregnancy possibility

  • drug therapy

  • associated medical conditions (e.g. diabetes).

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Key examination

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  • Inspection with good light includes viewing the vulva, introitus, urethra, vagina and cervix

  • Look for the discharge and specific problems such as polyps, warts, ectropion, prolapses and fistulas

  • Full pelvic examination in a postmenopausal woman

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Key investigations

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  • pH test with paper of range 4–6

  • Amine or ‘whiff’ test

  • Wet film microscopy of a drop of vaginal secretions

  • Full STI workup including high vaginal swab

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Diagnostic tips

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  • Vaginal discharge is an uncommon symptom before puberty.

  • It is common to overlook the problems caused by hygienic preparations including deodorant soaps and sprays and contraceptive agents especially spermicidal creams.

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