Vaginal Discharge

Vaginal discharge is a common presenting symptom and may be either physiological or pathological. Although many cases of vaginal discharge are not caused by sexually transmitted diseases (STD) and do require treatment, sexually transmitted infections may present with vaginal discharge.

A normal physiological discharge is a white or clear, non-offensive discharge that varies with the menstrual cycle.¹

• Non-infective:
  • Physiological
  • Cervical polyps and ectopy
  • Foreign bodies, e.g. retained tampon
  • Vulval dermatitis
  • Erosive lichen planus
  • Genital tract malignancy (cancer of cervix, cancer of uterus, ovarian cancer)
  • Fistulae
• Non-sexually transmitted infection:
  • Bacterial vaginosis; not a sexually transmitted infection, it is most commonly seen in sexually active women who have a concurrent sexually transmitted disease
  • Candida infections; caused by an an overgrowth of Candida albicans
• Sexually transmitted infection:
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
  • Trichomonas vaginalis; particularly common in young women attending the genito-urinary medicine clinic and is frequently found in association with N.gonorrhoeae infection

Physiological discharge

• Newborn infants may have a small amount of vaginal discharge, sometimes mixed in with a little blood, due to high levels of circulating maternal oestrogen.² This should disappear by two weeks of age.
• During the reproductive years, the fluctuating levels of oestrogen and progesterone throughout the menstrual cycle affect the quality and quantity of cervical mucus which is perceived by women as a change in their vaginal discharge. Initially when oestrogen is low, the mucus is thick and sticky. As oestrogen levels rise, the mucus gets progressively clearer, wetter and more stretchy. After ovulation, there is an increase in the thickness and stickiness of the mucus once more.
• At menopause the normal amount of vaginal discharge decreases as oestrogen levels fall.

• The most common cause of pathological vaginal discharge in women of child bearing age is bacterial vaginosis which occurs twice as frequently as vaginal candidiasis.³
• 50% of cases of Bacterial vaginosis are asymptomatic so the true prevalence is unknown.³
• The most common infective cause is vulvovaginal candidiasis which affects about 75% of women at some point during their reproductive life. 40-50% have two or more episodes and 10-20% may harbour Candida spp. asymptomatically at any one time.⁴

• A full clinical and sexual history should be sought with a particular note of the nature of the discharge (what has changed, odour, onset, duration, colour, consistency) and associated symptoms (may include itch, superficial dyspareunia or dysuria, abdominal pain, deep dyspareunia, abnormal bleeding, dysuria, pyrexia).
• Also consider concurrent medications (e.g. antibiotics, corticosteroids), previous treatments used (prescription and over-the-counter), and medical conditions (e.g. diabetes, immunocompromised state).
• Symptoms suggesting that discharge is abnormal include:
  • A discharge that is heavier than usual
  • A discharge that is thicker than usual
  • Pus-like discharge
  • White and clumpy discharge
  • Greyish, greenish, yellowish, or blood-tinged discharge
  • Foul-smelling (fishy or rotting meat) discharge
  • A discharge accompanied by bloodiness, itching, burning, a rash, or soreness

Infective (non sexually transmitted) vaginal discharge

• Bacterial vaginosis:
  • Caused by an overgrowth of anaerobic bacteria and occurs and remits spontaneously
  • May be asymptomatic (in up to 50% of women)
  • Causes a thin, profuse and fishy smelling discharge without itch or soreness
  • May cause dyspareunia
  • Associated with poor pregnancy outcomes, endometritis after miscarriage, and pelvic inflammatory disease
• Candidiasis:
  • Thick, white, non-offensive discharge which is associated with vulval itch and soreness, particularly in the patient with one or more risk factors (pregnancy, diabetes mellitus, recent antibiotic treatment or immunosuppression)
  • May cause mild dyspareunia and external dysuria
  • Examination may be normal or there may be erythema, oedema and fissuring
  • pH is less than 4.5

Infective (STD) vaginal discharge

C. trachomatis, N. gonorrhoeae, and T. vaginalis can present with vaginal discharge but may also be asymptomatic. They are associated with an increased risk of HIV transmission.¹

• Trichomonas vaginalis:
  • May cause an offensive yellow vaginal discharge, which is often profuse and frothy, associated with vulval itch and soreness, dysuria, abdominal pain and superficial dyspareunia
  • Many patients are asymptomatic
  • Is associated with preterm delivery
• Chlamydia trachomatis:
  • May cause a copious purulent vaginal discharge, but it is asymptomatic in 80% of women
  • 10-40% of untreated chlamydial infections result in pelvic inflammatory disease
  • Diagnosis is confirmed on swabbing
• Neisseria gonorrhoeae:
  • May present with a purulent vaginal discharge but is asymptomatic in up to 50% of women¹
  • Mild symptoms include slight discharge, dysuria, intermenstrual bleeding
  • Gonorrhoea may be complicated by pelvic inflammatory disease

Non infective causes of vaginal discharge

• Retained foreign bodies; result in a foul smelling serosanguinous discharge. Diagnosis is confirmed on examination.
• Cervical polyps and ectopy; tend to be asymptomatic but there may be increased discharge and intermenstrual bleeding. Diagnosis is made on speculum examination.
• Genital tract malignancy; presentation varies and in some cases, a persistent vaginal discharge not responding to conventional treatment may be the first clue. Diagnosis is made on examination and biopsy.
• Fistulae; history of trauma or surgery is suggestive. There may be a foul or feculent discharge in association with recurrent urinary tract infections.
• Allergic reactions; diagnosis is suspected on taking the history, e.g. use of irritant chemicals in douching, contact with latex and semen.

The quality and quantity of vaginal discharge often changes during pregnancy with most women producing more discharge during pregnancy.

• Bacterial vaginosis:
  • Is associated with late miscarriage, preterm labour, premature rupture of membranes, low birth weight and postpartum endometritis.
  • Routine screening during pregnancy is not yet recommended and current guidelines support screening only for women with a previous preterm birth (prior to 28 weeks gestation) or second-trimester miscarriage.
• Candidiasis: common in pregnancy (30-4%) and often asymptomatic.⁴ There is no evidence of any harm to the fetus.
• Trichomonas vaginalis: increasingly thought to be associated with pre-term delivery and low birth weight.

Vaginal discharge following miscarriage, abortion or delivery

• These patients should be fully investigated and empirically treated whilst awaiting results of swabs.
• Bacterial vaginosis is associated with endometritis and pelvic inflammatory disease following abortion but retained products of conception should be considered in all women, particularly in the presence of a heavy growth of coliforms.

• Patients who present with symptoms suggestive of bacterial vaginosis or vulvovaginal candidiasis can be treated without sampling.⁵
• Otherwise "Triple swabs" should be taken:
  • High vaginal swab to identify bacterial vaginosis, Candida infections, and Trichomonas vaginalis
  • Endocervical swab in transport medium (charcoal or non-charcoal) to diagnose gonorrhoea
  • Endocervical swab for a chlamydial DNA amplification test to diagnose Chlamydia trachomatis
• Vaginal pH testing (using narrow range pH paper) is a quick, cheap, and simple test that can help discriminate between bacterial vaginosis (pH 4.5 or above) and vulvovaginal candidiasis (pH <4.5).¹

• Take history with particular care to elicit clues suggestive of the presence of a STD. If there are suggestions that there might be a STD or for recurrent infections, refer to the genito-urinary medicine (GUM) clinic.
• The finding of an STD should prompt patient education and counselling, screening for other STDs and sexual contact tracing for testing and appropriate management.

Infective (non sexually transmitted) vaginal discharge⁵

Bacterial vaginosis

• Asymptomatic bacterial vaginosis in non-pregnant women does not require treatment.¹
• Routine: oral metronidazole 400-500 mg bd for 5-7 days or stat 2gm dose.
• Alternatively: topical metronidazole gel 0.75% (5 gm applicator) nightly for 5 days or oral clindamycin 300 mg bd for 7 days or topical clindamycin cream 2% (5 gm applicator) nightly for 7 days.
• Recurrent infection: oral metronidazole 300 mg bd for 3 days at the beginning and end of menstruation. Refer to GUM clinic.
• Avoid high dose single regimens in breast feeding mothers. Avoid alcohol during treatment with metronidazole and for 48 hours afterwards. Clindamycin cream can damage latex condoms. For patients on the oral contraceptive pill, advise to use additional measures when taking oral preparations.

Candidiasis⁴

• Asymptomatic vulvovaginal candidiasis does not need treatment.¹
• Vaginal imidazole preparations (e.g. clotrimazole, econazole, miconazole) or fluconazole 150 mg orally.¹
• The role of alternative treatments such as tea tree oil and yoghurt containing Lactobacillus acidophilus have not been evaluated.¹
• Whether oral or vaginal treatment is used depends on preference.¹
• Recurrent infection; initiate treatment as above, then oral fluconazole: 100 mg as a single dose weekly for 6 months or clotrimazole pessary: a single 500 mg pessary weekly for 6 months or for 6 months or oral itraconazole: 400 mg (two divided doses in 1 day) monthly for 6 months.
• For pregnant women, treat with topical imidazoles but longer treatment may be required. Avoid oral regimens due to potential teratogenicity.
• Latex condoms, cervical caps and diaphragms may be damaged by azole-containing local preparations.

Infective (STD) vaginal discharge

• These patients should be referred to the GUM clinic (unless your practice or local family planning clinic has the appropriate expertise and access to local treatment protocols).
• Chlamydia trachomatis; doxycycline 100 mg twice daily for seven days (contraindicated in pregnancy); azithromycin 1 g orally in a single dose (WHO recommends azithromycin in pregnancy but the BNF advises against its use unless no alternatives are available).¹
• Gonorrhoea; cefixime 400 mg as a single oral dose or ceftriaxone 250 mg intramuscularly as a single dose.¹
• Trichomonas vaginalis; metronidazole 2 g orally in a single dose or metronidazole 400-500 mg twice daily for five to seven days.¹
• Patients will be fully screened for concurrent STDs and treated as appropriate (e.g. oral metronidazole 400-500 mg bd for 5-7 days or stat 2 gm dose for trichomoniasis).
• Partners will need to be identified, screened and treated too.

Non infective causes of vaginal discharge

• Retained foreign bodies:
  • Most can be manually removed but these may occasionally be very small (fibrous material or small beads in a child's vagina, a small piece of torn condom) and so not readily visible and require a lavage (in children this may require sedation).
  • Where larger or irregularly shaped objects cause spasm of the vaginal walls, sedation or anaesthesia may also be needed.
  • A short course of antibiotics may be needed if the object was there long enough to cause secondary infection.
• Cervical polyps and ectopy; excision of larger symptomatic or suspicious looking polyps may be necessary.
• Allergic reactions; treatment includes identifying and removing the cause.

Management of recurrent discharge^3,5

The general advice is the same as for acute infection but particular care must be taken in several respects:

• It is necessary to go through the symptoms, signs and examination process rigorously to ensure pathology hasn't been missed (e.g. an STD in the case of a patient being treated for bacterial vaginosis).
• Explore personal hygiene habits that may contribute to the disruption of normal vaginal flora (such as douches).
• If the patient has an intrauterine contraceptive device in situ, an alternative form of contraception should be considered.
• Think of possible underlying associated problems such as diabetes, immunosuppression or concurrent antibiotic administration.
• Additional use of acetic acid preparations may be useful.
• Be aware of the psychosexual problems and depression that can be associated with recurrent episodes of vaginal discharge.

Management of persistent discharge³⁵

• In some cases, repeated examination and screening yield no positive results, yet the patient still complains of vaginal discharge.
• It is then appropriate to explore with her the nature of the discharge and relate this to normal physiological discharge, go over personal hygiene habits (avoid douches, perfumed products and tight synthetic clothing) and to gently look into the possibility of the 'silent' complaint such as depression, anxiety or psychosexual dysfunction.
• Post-menopausal atrophic changes may predispose women to repeated episodes of vaginitis which may respond well to hormonal creams or pessaries.

• Untreated simple vaginal infection can spread to the upper reproductive tract and cause more serious illness and in the long term, infertility.
• The same can be said of a retained foreign body with the potential of developing toxic shock syndrome.
• Cervical polyps are generally harmless although may cause infertility if they grow very large.
• There are specific complications associated with infective discharge in pregnancy as outlined above.

• Bacterial vaginosis has a 70-80% cure rate with the above regimen after one course of treatment (but commonly recurs).
• Candida has a cure rate of 80-95%.
• Trichomoniasis has a 95% cure rate.

• Good basic personal hygiene (cleanliness without the use of douches and perfumed chemical agents) with avoidance of tight synthetic clothing
• Treatment of sexual partners