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Table V1Vaginal discharge: diagnostic strategy model (modified)
Key history

The history should include:

  • nature of discharge: colour, odour, quantity, relation to menstrual cycle, associated symptoms (e.g. dyspareunia)

  • irritation or itch and location

  • sexual history: STI risk factors, previous STIs

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

  • pregnancy possibility

  • drug therapy

  • associated medical conditions (e.g. diabetes)

Key examination

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

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

  • Consider bimanual pelvic examination

Key investigations

  • High vaginal swab for microscopy and culture

  • pH test with paper of range 4–7

  • Amine or ‘whiff’ test

  • Wet film microscopy of a drop of vaginal secretions (if microscope available)

  • Vaginal swab for STIs: chlamydia, gonorrhoea, mycoplasma (consider trichomonas, HSV)

Table V2Characteristics of discharge

Vaginal thrush (candidal vulvovaginitis)

  • Limit washing to once/day with water or a pH adjusted wash for sensitive skin

  • Dry area thoroughly

  • Wear loose-fitting cotton underwear

  • Avoid wearing tight clothing

  • Avoid vaginal douches, powders or deodorants


Can use an azole (clotrimazole, isoconazole, butoconazole, miconazole, ketoconazole or fluconazole) for 1–7 days, depending on strength.


  • first line: clotrimazole 1%, 2% or 10% vaginal cream, 1 applicator-full intravaginally, nocte for 6 d if 1%, 3 d if 2% or once only if 10%

  • if recalcitrant: nystatin vaginal cream, 1 applicator-full, nocte for 14 d

  • fluconazole 150 mg (o) as a single dose if topical therapy not tolerated or oral therapy preferred

For patients with chronic vulvovaginal candidiasis, use fluconazole 50 mg (o) or itraconazole 100 mg (o) daily until remission achieved and ...

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