Vaginal discharge is a common presenting symptom in any physician’s office. Vaginal discharge may be physiological or pathological. Although abnormal vaginal discharge often prompts women to seek screening for sexually transmitted infections (STIs), vaginal discharge is poorly predictive of the presence of an STI.1Clinicians need to be aware of emerging epidemiological data, the different presentations of vaginal discharge, and how to approach their management so that the symptom can be treated according to its aetiology.2
Vaginal discharge is a common gynaecological condition among women of childbearing age that frequently requires care. It derives from physiological secretion of cervical and Bartholin’s glands and desquamation of vaginal epithelial cells resulting from bacterial action in the vagina.3The amount of mucus produced by the cervical glands varies throughout the menstrual cycle. Vaginal discharge that suddenly differs in colour, odour, or consistency, or significantly increases or decreases in amount, may indicate an underlying problem like an infection.4 Increased amount of vaginal discharge can be due to emotional stress, ovulation, pregnancy or sexual excitement.
Many women have what they perceive as an abnormal vaginal discharge at some point in their lives, but usually it is just a normal physiological discharge. This is a white or clear, non-offensive discharge that varies with the menstrual cycle. The quality and quantity of vaginal discharge may alter in the same woman in cycles and over time. Factors that can influence physiological discharge are:-
- Hormonal contraceptions
- Menopause2) Local facors
- Personal hygiene and habits
Pathological vaginal discharge can be further divided by specific age groups which are prepubertal group, reproductive group and menopause group.
Common causes of pathological vaginal discharge for each age group are:-
Nonspecific bacterial vaginitis
Foreign bodies (ex: IUCD, tampon, condom)
Cervical or endometrial carcinoma
Allergic to local irritant
FB (ex: vaginal pessary)
Common causes of infections:-
- Candidiasis: Acute vulvovaginal candidiasis / recurrent vulvovaginal candidiasis
- Bacterial vaginosis
- Chlamydia trachomatis
- Neisseria gonorrhoea
- Pelvic inflammatory disease
Principles of management
- Characteristics of the discharge - Onset, duration, colour, odour, consistency.
- Any associated symptoms - Itch, dyspareunia, abdominal pain, abnormal vaginal bleeding or pyrexia is more likely to indicate sexually transmitted infection.
- Sexual history - Is patient at increased risk of sexually transmitted infection (age <25 years, new sexual partner or more than one sexual partner in past year, previous sexually transmitted infection)
- Contraceptive use
- Concurrent medications and previous treatments
- Medical conditions such as diabetes, immunocompromised state.
- Non-infective causes of discharge such as allergic reaction, known cervical ectopy or polyps, genital tract malignancy, foreign body (such as tampons).
- Abdominal palpation for tenderness or mass.
- Inspect the vulva for discharge, erythema, ulcers, other lesions or skin changes.
- Bimanual pelvic examination for adnexal or uterine tenderness or mass, and for cervical motion tenderness (this can indicate pelvic inflammatory disease).
- Speculum examination to inspect vaginal walls, cervix, and characteristics of discharge.
- Take endocervical swabs if there is risk of sexually transmitted.
- High vaginal swabs are of limited diagnostic value except in pregnancy, post-instrumentation, failed treatment, recurrent symptoms, or to confirm candidiasis.
Bacterial vaginosis is the most common cause of infective vaginal discharge. It causes profuse and fishy smelling discharge without itch or soreness. This condition is characterised by an overgrowth of anaerobic bacteria and occurs and remits spontaneously. Asymptomatic bacterial vaginosis in non-pregnant women does not require treatment. The condition is associated with poor pregnancy outcomes, endometritis after miscarriage, and pelvic inflammatory disease. Antibiotics are the mainstay of therapy for bacterial vaginosis. Medications include metronidazole, clindamycin, and metronidazole vaginal gel.
The prevalence of asymptomatic carriage of Candida in women is 10%. Symptoms are vulval itch and soreness and thick white non-offensive discharge. There is no evidence that combined oral contraceptives cause candidiasis. Asymptomatic vulvovaginal candidiasis does not need treatment. Vulvovaginal candidiasis can be acute or recurrent. Recurrent vulvovaginal candidiasis diagnosed when there are 4 or more episodes of VVC in 1 year.
Chlamydia trachomatis is the most common sexually transmitted infection caused by a bacterium. Chlamydia can cause a purulent vaginal discharge, but it is asymptomatic in 80% of women. It was thought that 10-40% of untreated chlamydial infections will result in pelvic inflammatory disease. This has recently been challenged by a large observational study, which reported that only 5.6% of women developed this disease,6 and by a small prospective study that reported an even lower rate of 1%.7 Chlamydia is treated with either single dose of Azithromycin or twice daily dose of Doxycycline.
Neisseria gonorrhoea may present with a purulent vaginal discharge but is asymptomatic in up to 50% of women. Major symptoms include vaginal discharge, dysuria, intermenstrual bleeding, dyspareunia and mild lower abdominal pain. The true prevalence and epidemiology in the general community is not known. Gonorrhoea may be complicated by pelvic inflammatory disease.Culture is the most common diagnostic test for gonorrhoea, followed by the deoxyribonucleic acid (DNA) probe, and then the polymerase chain reaction (PCR) assay and ligand chain reaction (LCR).
Trichomonasvaginalis can cause an offensive yellow vaginal discharge, which is often profuse and frothy, along with associated symptoms of vulval itch and soreness, dysuria, and superficial dyspareunia, but many patients are asymptomatic. The true prevalence and epidemiology in the general community is not known. Usually an oral antibiotic called metronidazole (Flagyl) is given to treat trichomoniasis.
Persistent Vaginal Discharge
It would be difficult to proceed further for women who complain of persistent vaginal discharge with repeated negative STI screen results. When minimal discharge is evident, it is worth discussing again personal hygiene practices and douching, the basis for physiological discharge, and inquiring whether there are psychosexual difficulties as a result of the patient's continued symptoms.
If use of spermicides and lubricants are contributing to symptoms, alternative contraception choices should be discussed. An extensive cervical ectropion can cause heavy mucoid discharge. After the menopause, atrophic vaginal changes may predispose women to infective vaginitis. Intravaginal oestrogen replacement, with pessaries or cream, gradually improves the condition of the vaginal epithelium and reduces the susceptibility to infection.
Underlying gynaecological disease must be considered in all women with unexplained persistent vaginal discharge. Gynaecological neoplasms, such as benign endocervical and endometrial polyps, can present with vaginal discharge, and malignancy needs to be excluded.
Many women self-diagnose and self-treat episodes of vaginal infection with over the counter treatments. Some women may subsequently present with history of recurrence and never having had this diagnosis confirmed by any microbiological tests. It is important to confirm the diagnosis and to ensure a full sexual health screen has been done to exclude concurrent infection. Management of vaginal discharge requires an empathic approach with reassurance and psychological support as necessary.
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Population-Based SurveyTânia Maria M. V. da Fonseca,1 Juraci A. Cesar,2 Raúl A. Mendoza-Sassi,2
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BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4975 (Published 13 August 2013)
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clinical PID after one-year follow up. Int J STD AIDS 2002;13(suppl 2):12-8.