Vaginal Discharge

Sunbal Mukhtar ST5

12/11/2020
❏ Definition
❏ Causes
❏ Mangement with emphasis on recurrent
discharge and during pregnancy
❏ Case studies
 Normal Physiological Discharge

Thick and sticky for most of the cycle, but

becomes clearer, wetter, and stretchy for a short period

around the time of ovulation
Only the patient can be aware of her own “normal” amount and
type of discharge

increase:

Premenstrually

At time of ovulation

When commenced on HRT or hormonal contraception

Pregnancy
 Abnormal Vaginal Discharge

Characterized by

● Change of colour
● Consistency
● Volume
● Odour

and

may be

associated with symptoms

 Causes
Infective
Sexually Transmitted
Chlamydia trachomatis

Neisseria gonorrhoea
Trichomonas vaginalis (TV)
Herpes simplex virus
Infective
Non Sexually Transmitted Non infective

Foreign bodies (retained tampons, condoms,

Candida etc)

Bacterial vaginosis (BV) Cervical polyps and ectopy

Genital tract malignancy

Fistulae

Allergic reactions and genital dermatoses

Candidiasis
90% Candida albicans

Symptoms

Vulval itching, soreness, vaginal discharge and/or superficial dyspareunia

Signs

Erythematous change within the vulval skin

Fissuring
Oedema
Satellite lesions may occur on the inner thigh and lower abdomen
The vaginal discharge 'curdy', small pieces of milk curd or cottage
cheese-like material , a pale grey or white discharge.

10-20% asymptomatic No treatment

Management

Hygiene advice
● avoidance of perfumed products
● use of an emollient as a soap substitute
● avoidance of tight-fitting clothing and synthetic clothing.

Topical and oral azole therapies cure rate 80%

Asymptomatic male sexual partners do not require treatment.
Follow-up is not required unless symptoms persist, and no test of cure
is needed
Recommended regimen:
• Fluconazole* capsule 150mg as a single dose, orally

Recommended topical regimen (if oral therapy

contraindicated):

• Clotrimazole pessary 500mg as a single dose,

intravaginally

Alternative regimens:
• Clotrimazole vaginal cream (10%) 5g as a single
dose, intravaginally
• Clotrimazole pessary 200mg intravaginally at night for
3 consecutive nights
• Econazole pessary 150mg intravaginally as a single
dose or 150mg intravaginally at night for 3 consecutive
nights
Recurrent candida

•Four or more episodes of symptomatic candidosis in 1 year, with at

least partial resolution between episodes.
•Candida confirmed by culture or microscopy on at least two of the
occasions.
•<5% of healthy women.
•The nature of this condition poorly understood.
Underlying systemic illness, particularly diabetes
Frequent antibiotic use
• Currently available antimycotics are fungistatic rather than fungicidal,
prevent complete eradication of candida and lead to reinfection.
•Treatment strategies are empirical not supported by randomised trial
evidence.
Treatment
First-line treatment induction regimen of:
fluconazole 150 mg every 72 hours for three doses
Maintenance with:
fluconazole 150 mg weekly for 6 months.
Alternative Regimens:
• Induction:
topical imidazole therapy can be increased to 7-14 days according to
symptomatic response (Grade 2C)
• Maintenance for 6 months:
o Clotrimazole pessary 500mg intravaginally once a week
o Itraconazole 50-100mg orally daily*

Contraception should be reviewed, possible link with recurrent

candida and hyperoestrogenaemia.
A low-dose combined pill or Depo-Provera® better alternatives to a
high-dose combined pill.
Significance in pregnancy

● Asymptomatic colonisation is higher in pregnancy, at up to 40%;

symptomatic candidosis is more prevalent
● Asymptomatic women do not need treatment
● Topical treatment with azoles is recommended for symptomatic
women
● Longer courses are recommended – a 4-day course has a 50%
cure rate and a 7-day course cures over 90% of cases
● Oral treatment is contraindicated
● There is no evidence to support the treatment of asymptomatic
sexual partners
Recommended regimens

• Clotrimazole pessary 500mg intravaginally at night for up to 7

consecutive nights
Alternative regimens
• Clotrimazole vaginal cream (10%) 5g intravaginally at night for up to 7
consecutive nights
• Clotrimazole pessary 200mg intravaginally at night for up to 7
consecutive nights

Recommended regimen (recurrent VVC in pregnancy)

• Induction: topical imidazole therapy can be increased to 10-14 days

according to symptomatic response
• Maintenance: Clotrimazole pessary 500mg intravaginally weekly

Recommended regimens (acute and recurrent VVC in breastfeeding)

• Treatment regimens using topical imidazoles for non-pregnant
women with acute and recurrent VVC
Bacterial vaginosis (BV)

Most common cause of abnormal vaginal discharge in women of reproductive

age (BASHH 2012)

Up to 50% of women asymptomatic.

Anaerobic organisms, including Gardnerella vaginalis, Mycoplasma and Prevotella
species

STI?
PID?
Pregnancy associated complications?
late miscarriage, preterm delivery, preterm rupture of membranes and postpartum
endometritis
Symptoms and signs
Fishy, offensive, thin watery discharge that often coats the vagina and introitus

Hay/Ison, or Amsel's criteria

General hygiene advice

Avoidance of douching
Not using shower gel, shampoo or antiseptic agents in the bath

Treatment
For symptomatic women
women who have been diagnosed with current BV who are undergoing
relevant surgical procedures
Regimens

Oral metronidazole 400 mg BD for 5–7 days

OR 2 g stat dose

Or topical preparations, such as metronidazole 0.75% gel PV once daily for 5 days

Or clindamycin 2% cream PV for 7 days.

Alternatively,

Tinidazole 2G single dose (A).

Or

Clindamycin 300 mg twice daily for 7 days

Recurrent or persistent BV
Difficult to eradicate

Treatment with longer-term topical metronidazole for up to six months

or with a combination of metronidazole and acigel but effectiveness is variable.
Suppressive 0.75% metronidazole vaginal gel

In one placebo controlled randomized trial

0.75% metronidazole vaginal gel twice a week for 16 weeks superior to placebo

with 70% of women being relapse-free compared to 39%

Free of recurrence 12 weeks after stopping treatment,

only 34% of patients compared to 22% of controls.

Probiotics
Pregnancy

Breast feeding

Termination of pregnancy

HIV Infection

Sexual partners

Follow up
Trichomoniasis
Flagellated protozoan

It can be found in the vagina, urethra, paraurethral glands, sub

preputial sac and penile lesions

Up to 50% of infected women are asymptomatic

STI?
PID?
Pregnancy associated complications?
Symptoms & Signs
Vaginal discharge, vulval itching, dysuria or an offensive odour

Vaginal discharge present in 70% of cases – classical frothy, yellow

discharge in 20–30% of cases

but discharge may be thick or thin, profuse or scanty, or of varying

colours

vulvitis and vaginitis - dyspareunia

The so-called 'strawberry cervix' with its characteristic vascular pattern

only present in 2% of cases
Management
General advice

Sexual partner(s) should be treated simultaneously

Patients should be advised to avoid sexual intercourse for at least 1 week and until they
and their partner(s) have completed treatment and follow-up

Screening for coexistent STI both men and women

Regimes
Metronidazole 2 g orally in a single dose or
Metronidazole 400–500 mg twice daily for 5–7 days

Alternative

Tinidazole 2g orally in a single dose more expensive

Persistent or recurrent TV
Is due to inadequate therapy, re-infection, or resistance.

Check:

Compliance and exclude vomiting of metronidazole . Sexual history for possibility of re-infection and ask

if partner(s) have been treated

Repeat course of 7-day standard therapy

Metronidazole 400–500 mg twice daily for 7 days (Evidence level III) – in those who failed to respond to a first course
of treatment, 40% responded

Higher-dose course of nitroimidazole

Metronidazole or tinidazole 2 g daily for 5–7 days

or Metronidazole 800 mg three times daily for 7 days (Evidence level III) 70% responded
Pregnancy

Breast feeding

HIV-positive individuals

Sexual partners

Follow up

Allergy
 Chlamydia

Chlamydia is the most common bacterial STI in the UK and the most
common, preventable cause of infertility worldwide

Prevalence of chlamydial infection as being between 1.5–10% in 15–24

Risk factors for the acquisition of chlamydial infection include:

● young age (<25 years)
● a new sexual partner within the past year
● multiple sexual partners
● condomless sex.
Symptoms & Signs

The majority asymptomatic.

Approximately 10% of women with untreated chlamydia will develop pelvic inflammatory
disease (PID) within 12 months of becoming infected. These women may also complain
of:
● pelvic pain (usually bilateral)
● deep dyspareunia
● secondary dysmenorrhoea
● general malaise
● pyrexia.

Reiter's syndrome

Rectal chlamydia
Testing
A NAAT (nucleic acid amplification test) is the gold-standard test for detecting
chlamydia
For women, a vulvovaginal swab (VVS) is the specimen of choice.
A NAAT swab 5 cm into the vagina rotated for 10 and 30 seconds. Self-
collected or clinician-collected.
If clinician-collected, it should still be taken as a vulvovaginal swab, with the
swab inserted prior to speculum insertion.
A VVS is more sensitive than an endocervical swab or a 'first catch' urine in
women.
window period
 Counselling
● Information natural history, transmission, treatment options, complications
● A full STI screen
● Treatment and contact tracing for sexual partners within the previous 6 months
● Advice on safe sex (condoms and avoiding sexual intercourse for 7 days following
commencement of treatment in both partners)
● Referral to genitourinary medicine clinic

Antibiotic treatment
Recommended regimens (uncomplicated urogenital infection):
● Doxycycline 100 mg twice daily for 7 days (contraindicated in pregnancy).
● Azithromycin 1 g orally as a single dose, followed by 500mg once daily for two days.

Alternative regimens include:

● Ofloxacin 200 mg twice daily or 400 mg once daily for 7 days (contraindicated in pregnancy)
● Erythromycin 500 mg twice daily for 10–14 days.
 Pregnancy
The incidence is uncertain; suggested to be at 6%, according to one study.
Untreated chlamydial infection in pregnancy
•Miscarriage
•Premature delivery
•Fetal growth restriction/low birth weight
•Stillbirth
•Opthalmia neonatorum, lower respiratory tract infections and pneumonia
Antibiotic treatment deemed safe in pregnancy includes:
azithromycin 1 g on day then 500 mg on day 2 and 500 mg on day 3 (BASHH advises that adverse
pregnancy outcomes are unlikely with this dose of azithromycin lack of data. Better
tolerated and more effective than erythromycin
● erythromycin 500 mg four times daily for 7 days or twice daily for 14 days
 Test of cure and follow-up

A test of cure is not recommended

unless the patient is
Pregnant
or concern about treatment compliance
or the patient has been re-exposed.
Test of cure 5 or 6 weeks with azithromycin
in pregnancy, nearing delivery no earlier than 3 weeks after treatment.
Follow up to check that they have completed their course of treatment, that their
partner has been notified and treated, to reinforce health education messages
and to repeat treatment if necessary
A 34-year-old woman attends the gynae pre-assessment clinic to
discuss hysteroscopy for intermenstrual bleeding. Prior to referral,
her GP had arranged screening swabs which came back as
positive for chlamydia. The patient completed the 7-day course of
doxycycline but her IMB has persisted. The GP has not supplied
you with further information about the patient's sexual history.
What should you ask the patient?
What should you ask the patient?

● Complete a full sexual history to assess whether or

not the patient also requires testing for other sexually
transmitted infections or at other anatomical sites
● Ask about her treatment - did she complete the
course? Were there any problems with compliance or
side effects?
● Was contact tracing completed? If so, was/were her
partner(s) treated at the same time? Were all
partners treated?
● Did she abstain from intercourse until she and her
partner(s) had completed treatment?
She tells you she has had a regular male partner for 1
year. They do not use condoms as he does not like
them. She has not had any other sexual partners for
approximately 2 years. She has never been tested for
sexually transmitted infections in the past. She did not feel
able to tell her partner and so as far as she is aware,
he has not been tested or treated. They have continued to
have unprotected sex
 Things to consider:
● Explain to the patient that she may have been/could be reinfected by her partner. It is
important that he is also treated or she will continue to be reinfected.
● What is it that worries her about telling her partner? Are there any gender-based violence
concerns?
● Explain to the patient that the infection could have come from either partner and may have
been present since before they got together, therefore does not mean either partner has been
unfaithful.
● Would she benefit from being referred to the local sexual health service to assist with partner
notification? This can be done annonymously (may not be helpful in this case). They can work
out a best course of action for telling the partner/offer to see them together/can give further
advice and support.

It is likely the patient has been reinfected. A second course of treatment could be given, or she
could choose to be tested again and await the results. However, there is little benefit treating the
patient again if her partner is not treated and they continue to have condomless sex.
 Neisseria gonorrhoea
Second most common bacterial STI

<50% of women are symptomatic

usually with non-specific vaginal discharge
lower abdominal discomfort
and/or dysuria

positive NAAT (nucleic acid amplification test), or

positive culture

'Super' gonorrhoea
 Treatment
● The first-line treatment where antimicrobial sensitivities are NOT known
prior to treatment:
○ 1 g ceftriaxone IM as a single dose (safe in pregnancy) (dual therapy
is no longer recommended).

● If antimicrobial sensitivities are KNOWN and it is sensitive to ciprofloxacin,

then:
○ 500 mg ciprofloxacin PO as a single dose

Test of cure
Due to the emerging problem of antibiotic resistance, test of cure is
recommended in all cases
 Case Study

A 22-year-old nuliparous woman attended the Accident

and Emergancy department at her local hospital
complaining of feeling hot and shivery, experiencing lower
abdominal/pelvic pain and heavy, green and offensive,
vaginal discharge, which had been getting worse over the
past 3 days. She had recently entered into a new
relationship with a 26-year-old work colleague, who is
married with three young children.
1. The A&E officer suspects pelvic inflammatory disease and calls you (SPR in
O&G) to review the patient. What further questions (directly relevant to likely
diagnosis of pelvic inflammatory disease) would you wish to ask?

1. symptoms suggestive of PID – dyspareunia, nature, site and duration of pain, any
abnormal menstrual bleeding
2. menstrual history – LMP, inter-menstrual or postcoital bleeding, risk of pregnancy
3. a detailed sexual history, which would include recent sexual contacts, contraception
(barrier or not), and has partner had any symptoms?
4. past gynaecological history/previous pelvic infections or STIs
5. check for allergies to antibiotics.
1. When you examine this patient, what signs would suggest pelvic
inflammatory disease?

● pyrexia >38°C/tachycardia
● lower abdominal signs of peritonism – localised tenderness,
guarding and rebound
● abnormal vaginal discharge/red/inflamed cervix on speculum
examination
● cervical excitation/tenderness and pain elicited on bimanual pelvic
examination, also adnexal fullness or tenderness.
 1. List the investigations that you would undertake immediately to
confirm the diagnosis. What further investigations may be required if
symptoms persist?

Immediate investigations:
● vaginal or cervical NAAT test for chlamydia and gonorrhoea ± culture swab if
gonorrhoea suspected, depending on local prevalence and local availability of testing
● IPT to exclude pregnancy
● (FBC/CRP/ESR – non-specific but frequently used to support clinical diagnosis).

Investigations that may be required if symptoms and signs persist or in more severe cases
where pelvic abscess formation is suspected:
● TA/TV US scan
● diagnostic laparoscopy.
 Would you wait for the results of these investigations prior to
initiating treatment?
Answer: No. You should not wait

What antibiotic regimen would you use to treat this patient?

● 500 mg ceftriaxone intramuscularly (single dose) + doxycycline 100 mg twice daily for 14
days + metronidazole 400 mg twice daily for 14 days
● For more severe disease, intravenous antibiotic regimens as outlined in the BASHH guideline
● In rare cases where continuing pregnancy is confirmed, special care has to be taken to avoid
possible teratogenicity.
● Laparoscopic/laparotomy/radiological drainage of pelvic abscess may need to be considered
in tubo-ovarian abscesses.
1. List the possible longer term sequellae of pelvic inflammatory
disease.

● Infertility
● Ectopic pregnancy
● Pelvic abscess
● Chronic pelvic pain.
● Adhesions
Thank You
 Any questions?
http://www.bashhguidelines.org

https://cks.nice.org.uk