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VAGINAL DISCHARGE

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Table V1 Vaginal discharge: diagnostic strategy model (modified)
  • Probability diagnosis

  • Normal physiological discharge

  • Vaginitis

    • bacterial vaginosis

    • candidiasis

  • Serious disorders not to be missed

  • Neoplasia

    • carcinoma

    • fistulas

  • STIs/PID

    • N. gonorrhoea

    • Chlamydia trachomatis

    • Mycoplasma genitalium

    • Herpes simplex types 1 and 2

  • Sexual abuse, esp. children

  • Tampon toxic shock syndrome

  • Ectopic pregnancy (‘prune juice’ discharge)

  • Pitfalls (often missed)

  • Contact dermatitis (e.g. perfumes)

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

  • Endometriosis (brownish discharge)

  • Erosive lichen planus

  • Desquamative inflammatory vaginitis

  • Latex allergy

  • Atrophic vaginitis

  • Masquerades

  • Diabetes

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 if there is pelvic pain or deep dyspareunia

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)

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

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Table V2 Characteristics of discharge

Infective organism

Colour

Consistency

Odour

Candida albicans

White

Thick (cottage cheese)

Trichomonas

Yellow/green

Bubbly, profuse (mucopurulent)

Malodorous, fishy

Bacterial vaginosis

White or grey

Watery, profuse, bubbly

Malodorous, fishy

Physiological

Milky white or clear (oxidises to yellow or brown)

Thin or mucoid, varies with cycle

Atrophic vaginitis

Yellow (may be bloody)

Thin—slight to moderate

STIs/PID

Yellow/green (from cervix)

Thick—mucopurulent

Usually malodorous

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

Treatment Can use an azole (clotrimazole, isoconazole, butoconazole, miconazole, ketoconazole or fluconazole) for 1–7 days, depending on strength. Alternatively, use fluconazole 150 mg (o) as a single dose.

For recurrent infections, use a longer course of vaginal azole cream or fluconazole 150 mg (o) for 3 doses, 3 days apart, followed by maintenance with fluconazole 100 mg (o) wkly for 6 mths.

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

Bacterial vaginosis

Due to overgrowth of Gardnerella vaginalis and other anaerobes such as Mobiluncus species.

Treatment...

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