InnovAiT, 0(0), 1–5 DOI: 10.

1177/1755738016637627

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Management of vaginal
discharge
aginal discharge is a common symptom; it may be either physiological or

V pathological. The most common cause of vaginal discharge is physiological,

which is usually clear, non-offensive and non-pruritic. Pathological causes
of vaginal discharge include infections, both non-sexually as well as sexually
transmitted. It is imperative to assess these patients thoroughly for accurate
diagnoses and appropriate management.

The GP curriculum and woman’s health

Clinical module 3.06: Women’s health requires GPs to:

. Demonstrate knowledge of women’s health problems, conditions and diseases
. Recognise common signs and symptoms of, and know how to manage, gynaecological disease
. Demonstrate an understanding of the importance of risk factors in the diagnosis and management of women’s
problems
. Be able to advise on prevention strategies relevant to women e.g. safer sex
. Understand the importance of promoting health and a healthy lifestyle in women
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is low, and this results in thick and sticky mucus. As

Causes of vaginal oestrogen levels rise, the mucus gets clear and stretchy.
discharge
...........................................................
After ovulation, the mucus again becomes thick and
sticky (Dewhurst, Cowell, & Barrier, 1971). Normal secre-
tions of the vagina of an adult female comprises of cer-
The physiological causes of vaginal discharge fall broadly vical mucus, vaginal transudate, desquamated vaginal
into three categories. These are: epithelium and lactobacilli.
. Causes in newborn infants
. During the reproductive years At menopause, due to the fall in oestrogen levels, the
. At menopause amount of vaginal discharge decreases. Other physio-
logical causes of vaginal discharge include sexual activity
Most female infants produce a mucoid or clear vaginal and pregnancy-related discharge.
discharge (Altchek, 1984). This can sometimes be mixed
with a small amount of blood (in 10–15% babies), which There are numerous pathological causes of vaginal dis-
is a withdrawal bleed due to gradual decline of oestrogen charge. These include the non-infective and infective
levels, usually seen in early weeks of life. The discharge causes that are listed in Box 1. The most common cause
is usually not seen in childhood. of pathological vaginal discharge in women of childbear-
ing age is candidiasis (seen in 75% of women at some point
During the reproductive years the levels of hormones during their reproductive life). Trichomonas vaginalis
(oestrogen and progesterone) change throughout the accounts for 18–25% cases of vaginal discharge.
menstrual cycle (Aptar & Vihko, 1985). This can affect Pathological causes of vaginal discharge in pregnancy (bac-
the quality and quantity of cervical mucus, which is per- terial vaginosis, Trichomonas vaginalis), may be associated
ceived by women as a change in their vaginal discharge. with late miscarriage, preterm labour, premature rupture of
In the early phase of menstrual cycle, the oestrogen level membranes, low birth weight and postpartum endometritis.

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Box 1. Causes of pathological vaginal
discharge. Examination and
Non-infective point-of-care testing
...........................................................
. Cervical polyps and ectopy
. Foreign bodies e.g. retained tampon Physical examination should include inspecting the vulva,
. Vulvo-vaginal dermatitis (from the use of a speculum examination, and if there are concerns about
antiseptic douches, perfumes, bath additives) an upper genital tract infection, bimanual and abdominal
. Lichen planus exam. Point-of-care testing of the vaginal pH can also be
. Genital tract cancer, e.g. cancer of cervix, uterus used. Vaginal pH is less than 4.5 in candidal infections,
or ovary and more than 4.5 in Trichomonas and bacterial vagin-
. Urogenital/colovaginal fistula osis. Sexually transmitted infection (STI) screening
should also be considered in all sexually active women,
Infective; non-sexually transmitted including testing for syphilis and HIV.
. Bacterial vaginosis
. Candida albicans
. b-haemolytic Streptococcus
Infective; sexually transmitted Investigations
...........................................................
. Chlamydia trachomatis (serotypes D-K)
. Neisseria gonorrhoeae Women with a history of physiological vaginal discharge
. Trichomonas vaginalis do not warrant further investigations. However, in cases
. Human papillomavirus; this causes warts, but not of pathological vaginal discharge, further investigations
a discharge can be offered to diagnose the cause. In cases of
. Herpes simplex virus (primary/recurrent): Herpes severe infective vaginal discharge, in addition to the cul-
simplex causes ulcers, but does not normally ture of micro-organisms, investigations directed towards
cause a discharge systemic assessment (such as white cell count, C-reactive
protein, ultrasound scan of pelvis) should also be
Other initiated. In cases where a STI is suspected, a bi-
. Intra-uterine contraceptive devices may cause manual examination should be carried out as part of
physiological discharge (from the threads the assessment.
stimulating the vaginal mucosa) or pathological
discharge (if offensive and associated with dys- Three swabs (triple swabs) need to be taken to screen for
pareunia may be a marker for bacterial vaginosis). infection, with an understanding that most infections
. Non-specific vulvovaginitis (common in pre- should be diagnosed on history and examination with
pubertal girls) confirmation from laboratory investigations. Triple
swabs include the following:
. Swab 1: High vaginal swab from the posterior vaginal
fornix for Trichomonas vaginalis (TV), bacterial vagin-
osis (BV; heavy growth of anaerobes), candida (and
group B Streptococci)
. Swab 2: From the endocervix for Gonorrhoea
Assessment
........................................................... . Swab 3: From the endocervical cells for Chlamydia
A thorough clinical and sexual history should be It is imperative to correctly label the swabs including site of
taken. A note should be made of the following important swab, symptoms and signs and recent use of an antibiotic.
points: Eliciting cervical excitation or adnexal tenderness should
. Nature of the discharge (onset, duration, any change prompt a GP to prescribe empirical antibiotic treatment
in odour, colour, consistency) without waiting for swab results (Lazaro, 2013).
. Associated symptoms (these may include superficial
or deep dyspareunia, dysuria, abdominal pain, prur-
itus, pyrexia or abnormal bleeding)
. Medical conditions (e.g. diabetes, human immuno- Treatment
...........................................................
deficiency virus (HIV)) and concurrent medications
(e.g. antibiotics, steroids, immunosuppressant) Treatment of vaginal discharge should be directed to the
cause (Table 2). Table 2 lists the first-line treatment for
Symptoms suggesting that discharge is abnormal are candida, trichomonas and BV (Sherrard et al., 2011,
included in Table 1. Although the presentations 2014). Diagnosis of Gonorrhea on swab results should
described in Table 1 can be helpful in preliminary diag- prompt referral to a sexual health clinic. Treatment of
nosis and initiating treatment, it is important to note that Chlamydia includes doxycycline 100 mg twice daily for
several of these infections may co-exist (Ghosh, Rawre, 7 days (contraindicated in pregnancy) or azithromycin 1 g
Khanna, & Dhawan 2013), making treatment challenging. orally in a single dose. In case of contraindication to these

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Table 1. Symptoms and causes of vaginal discharge.
Type of discharge
Non-infective causes of vaginal discharge
Blood stained or brown
Serosanguinous discharge
Copious discharge and intermenstr-
ual bleeding
Foul or faeculent discharge
Serous discharge
Infective (sexually transmitted) vaginal discharge
Cloudy or yellow
Copious purulent discharge
Frothy, yellow or greenish, copious
and irritant
Infective (non-sexually transmitted) vaginal discharge
Thick, white, cheesy
White, grey, thin, adherent
Brownish, post-delivery/ miscar-
riage/termination
antibiotics, alternative regimens for use are erythromycin
500 mg twice daily for 10–14 days or ofloxacin 200 mg
twice daily or 400 mg once a day for 7 days. In cases of
uncomplicated infection, where an intrauterine
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Possible cause Other symptoms
First few weeks of life, menstrual Pelvic pain
irregularities or less often cervical or
endometrial cancer
Retained foreign bodies Foul-smelling discharge
Cervical polyps and ectopy Post-coital bleeding can be painless
Fistula (uro-genital/ colo-vaginal/ History of trauma or surgery is sug-
rectovaginal/ ano-vaginal) gestive. May be associated with
recurrent urinary tract infections
Allergic/chemical reactions History may be suggestive e.g. use
of douching, perfumes, antiseptics,
contact with latex and semen. May
be associated with itching/ rash/
bleeding
Neisseria gonorrhoea Intermenstrual bleeding, urinary
incontinence, pelvic pain. May also
be asymptomatic
Chlamydia trachomatis May be asymptomatic
Trichomonas vaginalis Pain and itching while urinating,
offensive smelling, new sexual
partner
Candida (albicans or glabrata) Oedema, pain and erythema around
the vulva, itching, superficial dys-
pareunia, may be associated with
pregnancy, diabetes, immunosup-
pression (steroids, HIV), recent
antibiotic treatment
Bacterial vaginosis Fishy odour, itching or burning,
redness and swelling of the vagina
or vulva, use of intrauterine contra-
ceptive device
Retained products of conception, Offensive smell, may be associated
endometritis with signs of sepsis
.................
contraceptive device is in place, there is no need to
remove the device. However, patients should be advised
to avoid genital/oral sexual activity until they and their
partner(s) have completed treatment (or wait 7 days if
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Table 2. Treatment of vaginal discharge.

Cause of discharge Treatment

Non-infective

Retained foreign bodies Removal of foreign body, a course of an antibiotic (in case of long- standing
impaction/secondary infection)

Cervical polyps and ectopy Excision of symptomatic polyps, cauterisation of ectropion

Allergic reactions Includes identifying and removing the cause, e.g. avoiding irritant bath additives
and soaps

Infective

Candidiasis . Clotrimazole vaginal insertion 500 mg  1 nocte. Cure rate of 80–95%

. Recurrent infection/sensitivity to topical antifungals: Fluconazole 150 mg stat.
Exclude co-existing infections, e.g. herpes genitalis, eczema, psoriasis
. Treatment of asymptomatic cases is not recommended

TV . Metronidazole 400 mg twice a day for 5 days (oral). Cure rate of 90%
. Treatment of sexual partners is recommended

BV . Metronidazole 400 mg twice a day for 5 days (oral). Cure rate of 70–80% with
one course. Commonly recurs
. Recurrent infection/systemic side-effects: Metronidazole gel daily for 7 days
(intravaginal)
. Male partners do not require treatment

treated with azithromycin). Clear and accurate written In prepubertal girls, persistent vaginal discharge is often
........................................................................................................

information should be provided. incorrectly diagnosed as Candidiasis, which is rare in this

age group. It is important to rule out sexual abuse in any
Untreated pathological vaginal infection can ascend to young girl with a vaginal discharge, particularly if swabs
the upper reproductive tract and cause pelvic inflamma- are positive for STIs. Postmenopausal women presenting
tory disease and in the long-term can lead to reduced with excessive vaginal discharge also warrant a pelvic
fertility (Ness et al., 2005). A retained foreign body can ultrasound scan for endometrial assessment to exclude
also cause toxic shock syndrome. endometrial cancer. Postmenopausal vaginitis may be
due to vaginal atrophy, and responds well to topical
oestrogen (daily for 2 weeks and then twice a week for
3 months).

Persistent vaginal
Key points
discharge
........................................................... . Vaginal discharge is a common presenting
symptom
In women with a persistent vaginal discharge, it is import- . The most common cause of vaginal discharge is
ant to re-explore the nature of the discharge. Both recur- physiological
rent thrush and BV are significant problems for many . Thorough history (clinical and sexual) and clinical
women. Personal habits may exacerbate these problems; examination helps in accurate diagnosis and
advise women to avoid tight synthetic clothing, douches, correct treatment
and perfumed products/soaps (Nyirjesy, 2014). It is . Further investigations and treatment are warranted
also important to explore the possibility of the hidden for women who are sexually active, or those with
diagnosis of depression, anxiety or psychosexual recurrent symptoms or those refractory to
dysfunction. treatment

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References and further information . Ness, R. B., Hillier, S. L., Kip, K. E., Soper, D. E.,
. Altchek, A. (1984). Paediatric vulvovaginitis. Stamm, C. A., & McGregor, J. A. (2005). Bacterial
Journal of Reproductive Medicine, 29(6), vaginosis and risk of pelvic inflammatory disease.
359–375 Obstetrical & Gynecological Survey, 60(2), 99–100
. Aptar, D., & Vihko, R. (1985). Hormone patterns in . Nyirjesy, P. (2014). Management of persistent
the first menstrual cycles. Flamigni P., & Givens J. vaginitis. Obstetrics Gynecology, 124(6),
(eds) Adolescence in females. Chicago, IL: Year 1135–1146. doi: 10.1097/AOG.00000000000
Book Publications, pp.215–222 00551
. Dewhurst, C. J., Cowell, C. A., & Barrier, L. C. . RCGP. Clinical module 3.06: Woman’s health.
(1971). The regularity of early menstrual cycles. Retrieved from www.rcgp.org.uk/training-exams/
BJOG: An International Journal of Obstetrics & gp-curriculum-overview/online-curriculum/caring-
Gynaecology, 78(12), 1093–1095. doi: 10.1111/ for-the-whole-person/3-06-womens-health.aspx
j.1471-0528.1971.tb00231.x . Sherrard, J., Donders, G., White, D., Jensen, J. S.,
. Ghosh, A., Rawre, J., Khanna, N., & Dhawan, B. & European IUSTI. (2011). European (IUSTI/WHO)
(2013). Co-infections with Ureaplasma parvum, guideline on the management of vaginal discharge.
Mycoplasma hominis and Chlamydia trachomatis International Journal of STD and AIDS, 22(8), 421–
in a human immunodeficiency virus positive 429. doi: 10.1258/ijsa.2011.011012
woman with vaginal discharge. Indian Journal . Sherrard, J., Ison, C., Moody, J., Wainwright, E.,
Medical Microbiology, 31(2), 190–192. doi: Wilson, J., & Sullivan, A. (2014). United Kingdom
10.4103/0255-0857.115231 national guideline on the management of
. Lazaro, N. (2013). Sexually transmitted infections Trichomonas vaginalis. International Journal of
in primary care. Retrieved from www.bashh.org/ STD and AIDS, 25(8), 541–549. doi: 10.1177/
documents/Sexually%20Transmitted%20Infections 0956462414525947
%20in%20Primary%20Care%202013.pdf

Dr Liam Piggott
Department of General Surgery, Royal Cornwall Hospital Trust, Truro, Cornwall
Email: liam.piggott@doctors.org.uk

Farah Lone
Consultant Obstetrician and Gynaecologist, Royal Cornwall Hospital

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