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
- Infections not associated with sex: Group B streptococcal vaginitis, bacterial vaginosis, Candida albicans
- Non-infectious causes: hormonal contraception, physiological, cervical ectropion and cervical polyps, malignancy, foreign body (e.g. retained tampon), dermatitis, fistulae, allergic reaction, erosive lichen planus, desquamative inflammatory vaginitis, atrophic vaginitis in lactating and postmenopausal women
- STI: Chlamydia trachomatis, Mycoplasma genitalium, Neisseria gonorrhoea, Trichomonas vaginalis, herpes simplex virus (HSV).
Clinical presentation
| Symptoms | Comments/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).
| Infection | Site/Specimen | Test |
|---|---|---|
| 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-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. |
Microscopy, gram stain and culture |
| Chlamydia | Endocervical swab OR Self-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. OR FPU |
NAAT |
| M. genitalium | Endocervical swab OR Self-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. OR FPU |
NAAT |
| Gonorrhoea |
Endocervical swab OR Self-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. OR FPU |
NAAT.
|
| 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
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
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. genitalium, trichomoniasis, 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.