Vaginal discharge

Overview

  • The most common cause of vaginal discharge in women of reproductive age is normal physiological discharge
  • Consider other causes with history, examination and investigations.

Possible causes

Clinical presentation

SymptomsComments/Considerations
Discharge

Physiological: white/clear, non-offensive, varying with menstrual cycle (ectropion may be mucoid)
Bacterial vaginosis: thin, grey-white coloured, offensive/fishy odour
Candidiasis: thick, white, non-offensive
Chlamydia & M. genitalium: minimal discharge or purulent (cervicitis)
Gonorrhoea: purulent (cervicitis)
Trichomoniasis: offensive green/yellow, scanty to profuse and frothy (vaginitis)
Bleeding – intermenstrual or postcoital Chlamydia, M. genitalium, gonorrhoea, cervical ectropion, or polyps, malignancy, vaginitis.
Presence can suggest pelvic inflammatory disease (PID).
Itch Candidiasis, trichomoniasis, vulvovaginal dermatitis.
Superficial dyspareunia Candidiasis, dermatitis, lichen planus.
Deep dyspareunia

Chlamydia, M. genitalium, gonorrhoea.
Presence suggests upper genital tract infection.
Lower abdominal pain Chlamydia, gonorrhoea, trichomoniasis.
Presence suggests upper genital tract infection.
Dysuria Chlamydia, trichomoniasis, candidiasis, herpes and dermatitis can present with external dysuria, fissuring.
Presence can suggest upper genital tract infection.
Systemic symptoms Presence indicates upper genital tract infection.
Indicators

Bacterial vaginosis: unclear.
Candidiasis: spontaneous, recent antibiotics, pregnancy, immunosuppression.
Chlamydia: age <30 years, new partner or >1 partner in 12 months preceding, known contact.
Gonorrhoea: age <30 years, new partner or >1 partner in 12 months preceding, known contact, co-infection with other pathogen; high risk population (e.g. remote indigenous community).
M. genitalium: age <30 years, new partner or >1 partner in 12 months preceding, known contact.
Trichomoniasis: new partner, partner origin from endemic region.
Dermatitis: irritants, eczema.

Diagnosis

Take a history and perform a physical examination, including inspection of external genitalia, speculum examination of cervix and vagina, and bimanual palpation.  Specifically, examine for signs: characteristics of discharge (colour, thin/thick, distribution, volume and odour), cervicitis, vaginitis, vulvitis, ulceration, upper genital tract infection – pelvic inflammatory disease (PID).

InfectionSite/SpecimenTest
Bacterial vaginosis  
Vaginal swab Microscopy and gram stain

Whiff test (release of fishy odour on adding alkali (10%KOH)

pH test (pH> 4.5 indicative of bacterial vaginosis)
Candidiasis High vaginal swab
OR
Self-collected vaginal swab
Microscopy, gram stain and culture

Chlamydia Endocervical swab
OR
Self-collected  vaginal swab
OR
FPU
NAAT

M. genitalium Endocervical swab
OR
Self-collected  vaginal swab
OR
FPU
NAAT
Gonorrhoea

Endocervical swab
OR
Self-collected  vaginal swab
OR
FPU

NAAT.


If NAAT test result is positive, take swab at relevant site(s) for culture, before treatment.

Trichomoniasis High vaginal swab
OR
FPU
NAAT (High vaginal swab OR FPU)
pH (High vaginal swab)
FPU – First pass urine
NAAT – Nucleic Acid Amplification Test
 

Specimen collection

Clinician collected |
Self-collection

Investigations

Clinical indicators for testing vaginal discharge:

  • High risk for STI
  • Failed previous treatment
  • Post termination of pregnancy, post-partum, and pregnant women
  • Recent intrauterine device (IUD) insertion
  • Signs or symptoms suggestive of upper genital tract infection (pelvic inflammatory disease (PID))
  • Diagnosis uncertain
  • Woman’s request.

Special considerations

Perform cervical screening if overdue, abnormal bleeding, or suspicious findings on examination.

Management

Treat the discharge based on what cause is identified. See bacterial vaginosis, candidiasis, chlamydia, gonorrhoea, M. genitaliumtrichomoniasis, pelvic inflammatory disease (PID).

Treatment advice

  • Treat as per guidelines for diagnosis made after consideration of risk and assessment findings: initially presumptively, and then based on results when these become available
  • Intravaginal azoles and clindamycin can damage latex condoms
  • Avoid alcohol with metronidazole.

Other immediate management

  • Consider other STI testing if assessment indicates risk or suspected or proven sexually transmitted infection
  • Consider advice and/or referral if complicated presentation, systemically unwell or diagnosis uncertain
  • Provide patient with factsheet.

Contact Tracing

  • No contact tracing is required for non-sexually transmitted infections
  • Contact tracing for chlamydia, gonorrhoea, trichomoniasis  and is a high priority and should be performed in all patients with confirmed infection.

See Australasian Contract Tracing Manual for more information.

Follow up

If confirmed STI, follow up provides an opportunity to:

  • Confirm patient adherence with treatment and assess for symptom resolution
  • Confirm contact tracing procedures have been undertaken or offer more contact tracing support
  • Provide further sexual health education and prevention counselling.

Even if all test results are negative, use the opportunity to:

  • Reassess for resolution of symptoms
  • Educate about condom use, risk minimisation
  • Vaccinate for hepatitis A, hepatitis B, human papillomavirus (HPV), if susceptible
  • Discuss and activate reminders for regular screening tests according to risk
  • Educate about normal genital skin care.

For test of cure (TOC) and retesting advice see:

Auditable outcomes

  • 100% of patients who consent to genital examination are examined
  • 100% of patients diagnosed with bacterial vaginosis are treated with an appropriate antibiotic regimen
  • 100% of patients presenting with pathological vaginal discharge attend for follow up after initial presentation.
Last Updated: Friday, 01 April 2016