Vaginaldischarge

Overview

Themostcommoncauseofvaginaldischargeinwomenofreproductiveageisnormalphysiological
discharge
Considerothercauseswithhistory,examinationandinvestigations.

Possiblecauses
STI:Chlamydiatrachomatis,Mycoplasmagenitalium,Neisseriagonorrhoea,Trichomonasvaginalis,
herpessimplexvirus(HSV)
Infectionsnotassociatedwithsex:GroupBstreptococcalvaginitis,bacterialvaginosis,Candida
albicans
Noninfectiouscauses:physiological,cervicalectropionandcervicalpolyps,malignancy,foreignbody
(e.g.retainedtampon),dermatitis,fistulae,allergicreaction,erosivelichenplanusdesquamative
inflammatoryvaginitis,atrophicvaginitisinlactatingandpostmenopausalwomen.

Clinicalpresentation
Symptoms

Discharge

Comments/Considerations
Physiological:white/clear,nonoffensive,varyingwithmenstrualcycle
(ectropionmaybemucoid)
Bacterialvaginosis:thin,greywhitecoloured,offensive/fishyodour
Candidiasis:thick,white,nonoffensive
Chlamydia&M.genitalium:minimaldischargeorpurulent(cervicitis)
Gonorrhoea:purulent(cervicitis)
Trichomoniasis:offensivegreen/yellow,scantytoprofuseandfrothy(vaginitis)

Bleedingintermenstrual
orpostcoital

Chlamydia,M.genitalium,gonorrhoea,cervicalectropion,orpolyps,
malignancy,vaginitis.
Presencecansuggestpelvicinflammatorydisease(PID).

Itch

Candidiasis,trichomoniasis,vulvovaginaldermatitis.

Superficialdyspareunia

Candidiasis,dermatitis,lichenplanus.

Deepdyspareunia

Chlamydia,M.genitalium,gonorrhoea.
Presencesuggestsuppergenitaltractinfection.

Lowerabdominalpain

Chlamydia,gonorrhoea,trichomoniasis.
Presencesuggestsuppergenitaltractinfection.

Dysuria

Chlamydia,trichomoniasis,candidiasis,herpesanddermatitiscanpresentwith
externaldysuria,fissuring.
Presencecansuggestuppergenitaltractinfection.

Systemicsymptoms

Presenceindicatesuppergenitaltractinfection.

Triggers

Bacterialvaginosis:spontaneous.
Candidiasis:spontaneous,recentantibiotics,pregnancy,immunosuppression.
Chlamydia:age<30years,newpartneror>1partnerin12monthspreceding,
knowncontact.

Gonorrhoea:age<30years,newpartneror>1partnerin12monthspreceding,
knowncontact,coinfectionwithotherpathogenhighriskpopulation(e.g.
remoteindigenouscommunity).
M.genitalium:age<30years,newpartneror>1partnerin12months
preceding,knowncontact.
Trichomoniasis:newpartner,partneroriginfromendemicregion.
Dermatitis:irritants,eczema.

Diagnosis
Takeahistoryandperformaphysicalexamination,includinginspectionofexternalgenitalia,speculum
examinationofcervixandvagina,andbimanualpalpation.Specifically,examineforsigns:characteristicsof
discharge(colour,thin/thick,distribution,volumeandodour),cervicitis,vaginitis,vulvitis,ulceration,upper
genitaltractinfectionpelvicinflammatorydisease(PID).
Infection

Site/Specimen

Test

Bacterialvaginosis

Vaginalswab

Microscopyandgramstain
Whifftest(releaseoffishyodouron
addingalkali(10%KOH)
pHtest(pH>4.5indicativeof
bacterialvaginosis)

Candidiasis

Highvaginalswab
OR
Selfcollectedvaginalswab

Microscopy,gramstainandculture

Chlamydia

Endocervicalswab
OR
Selfcollectedvaginalswab
OR
FPU

NAAT

M.genitalium

Endocervicalswab
OR
Selfcollectedvaginalswab
OR
FPU

NAAT

Gonorrhoea

Endocervicalswab
OR
Selfcollectedvaginalswab
OR
FPU

Trichomoniasis

Highvaginalswab
OR
FPU

FPUFirstpassurine
NAATNucleicAcidAmplificationTest

NAAT.
IfNAATtestresultispositive,take
swabatrelevantsite(s)forculture,
beforetreatment.
NAAT(HighvaginalswabORFPU)
pH(Highvaginalswab)

Specimencollection
Cliniciancollected|Selfcollection

Investigations
Clinicalindicatorsfortestingvaginaldischarge:
HighriskforSTI
Failedprevioustreatment
Postterminationofpregnancy,postpartum,andpregnantwomen
Recentintrauterinedevice(IUD)insertion
Signsorsymptomssuggestiveofuppergenitaltractinfection(pelvicinflammatorydisease(PID))
Diagnosisuncertain
Womansrequest.

Specialconsiderations
Performcervicalscreeningifoverdue,abnormalbleeding,orsuspiciousfindingsonexamination.

Management
Treatthedischargebasedonwhatcauseisidentified.Seebacterialvaginosis,candidiasis,chlamydia,
gonorrhoea,M.genitalium,trichomoniasis.

Treatmentadvice
Treatasperguidelinesfordiagnosismadeafterconsiderationofriskandassessmentfindings:initially
presumptively,andthenbasedonresultswhenthesebecomeavailable
Intravaginalazolesandclindamycincandamagelatexcondoms
Avoidalcoholwithmetronidazole.

Otherimmediatemanagement
ConsiderotherSTItestingifassessmentindicatesriskorsuspectedorprovensexuallytransmitted
infection
Consideradviceand/orreferralifcomplicatedpresentation,systemicallyunwellordiagnosisuncertain
Providepatientwithfactsheet.

ContactTracing
Nocontacttracingisrequiredfornonsexuallytransmittedinfections
Contacttracingforchlamydia,gonorrhoea,trichomoniasisandisahighpriorityandshouldbe
performedinallpatientswithconfirmedinfection.
SeeAustralasianContractTracingManualformoreinformation.

Followup
IfconfirmedSTI,followupprovidesanopportunityto:
Confirmpatientadherencewithtreatmentandassessforsymptomresolution
Confirmcontacttracingprocedureshavebeenundertakenoroffermorecontacttracingsupport
Providefurthersexualhealtheducationandpreventioncounselling.
Evenifalltestresultsarenegative,usetheopportunityto:
Reassessforresolutionofsymptoms
Educateaboutcondomuse,riskminimisation
VaccinateforhepatitisA,hepatitisB,humanpapillomavirus(HPV),ifsusceptible
Discussandactivateremindersforregularscreeningtestsaccordingtorisk
Educateaboutnormalgenitalskincare
Fortestofcure(TOC)andretestingadvicesee:
Chlamydia
Gonorrhoea
Trichomoniasis.

Auditableoutcomes
100%ofpatientswhoconsenttogenitalexaminationareexamined
100%ofpatientsdiagnosedwithbacterialvaginosisaretreatedwithanappropriateantibioticregimen
100%ofpatientspresentingwithpathologicalvaginaldischargeattendforfollowupafterinitial
presentation.
LastUpdated:Friday,20February2015