Makindo Medical Notes

Vaginal discharge is a common presentation in clinical practice, and it can be caused by various infections or physiological processes. The discharge may be normal or abnormal, and the assessment of its characteristics—such as colour, odour, consistency, and associated symptoms like itching or pain—can help differentiate between common causes like bacterial vaginosis, candidiasis, trichomoniasis, or sexually transmitted infections (STIs).

Clinical History

1. Onset and Duration: Determine when the discharge started and whether it is continuous or intermittent.
2. Characteristics of Discharge:
   • Colour (e.g., white, yellow, green)
   • Consistency (e.g., thick, watery, curdy)
   • Odour (e.g., fishy, musty)
   • Amount (light or heavy discharge)
3. Associated Symptoms:
   • Itching or burning sensation
   • Pelvic or abdominal pain
   • Bleeding outside of menstruation
   • Dysuria (painful urination)
4. Sexual History:
   • Number of sexual partners
   • Use of protection (e.g., condoms)
   • History of sexually transmitted infections (STIs)
5. Medical and Obstetric History:
   • Recent use of antibiotics or contraceptives
   • History of vaginal infections or gynaecological conditions
   • Menstrual cycle pattern and changes

Physical Examination

1. General Inspection: Look for signs of systemic infection (e.g., fever) or discomfort.
2. Abdominal Examination: Palpate for tenderness or masses, particularly in the pelvic area.
3. External Genital Examination: Inspect for redness, lesions, or signs of inflammation.
4. Speculum Examination:
   • Assess vaginal walls and cervix for discharge, lesions, or signs of infection.
   • Note the colour, consistency, and odour of the discharge.
5. Bimanual Examination: Palpate for cervical motion tenderness, uterine size, or adnexal masses.

Investigations

1. Microscopy and Culture:
   • Wet mount to check for Trichomonas, yeast, or bacterial vaginosis.
   • Gram stain and culture for bacterial infections.
2. pH Testing: Measure vaginal pH to help identify bacterial vaginosis or trichomoniasis (pH > 4.5 is suggestive).
3. NAAT (Nucleic Acid Amplification Tests): For diagnosing STIs, such as chlamydia or gonorrhoea.
4. Full Blood Count (FBC): To assess for infection if systemic symptoms are present.
5. Consider Additional Testing:
   • Pap smear if indicated by screening guidelines.
   • HIV and syphilis serology if there is high-risk behaviour or suspected STI.

Possible Causes of Vaginal Discharge

• Infectious Causes:
  • Bacterial Vaginosis: Thin, grey discharge with a fishy odour.
  • Yeast Infection (Candidiasis): Thick, white, “cottage cheese”-like discharge, often with itching.
  • Trichomoniasis: Yellow-green, frothy discharge with a strong odour, often accompanied by itching.
  • Chlamydia/Gonorrhoea: May present with increased discharge; commonly asymptomatic.
• Non-Infectious Causes:
  • Hormonal changes (e.g., pregnancy, oral contraceptives)
  • Allergic reactions (e.g., to soaps, douches, or contraceptives)
  • Foreign body (e.g., retained tampon)
  • Atrophic vaginitis (often in postmenopausal women)

5. Management

1. Treat Underlying Cause:
   • Antibiotics for bacterial infections (e.g., metronidazole for BV or trichomoniasis)
   • Antifungal therapy for yeast infections (e.g., fluconazole or topical azoles)
2. Patient Education:
   • Avoid irritants (e.g., scented products, douches)
   • Practice safe sex and use protection to reduce STI risk
   • Encourage hygiene practices without excessive washing, which can disrupt normal flora
3. Follow-up: Reassess if symptoms persist after treatment or if symptoms recur.
4. Referral: Consider referral to gynaecology for recurrent infections or unexplained symptoms.

Clinical Approach

• Nature of Discharge: Ask about the colour, consistency, and odour of the discharge.
• Associated Symptoms: Check for itching, pain, dysuria, or dyspareunia (pain during intercourse).
• Sexual History: Inquire about recent sexual activity, use of contraception, and history of STIs.
• Menstrual History: Ask about the timing in relation to the menstrual cycle.
• Recent Antibiotic Use: This may predispose to candidiasis.
• Inspection: Examine the external genitalia for signs of inflammation, lesions, or discharge.
• Speculum Examination: Evaluate the cervix and vaginal walls. Observe the discharge for colour, consistency, and amount.
• Bimanual Examination: Assess for tenderness or masses, which may indicate pelvic inflammatory disease (PID).

Quick Guide

Cause	Clinical Features	Investigations	Management
Bacterial Vaginosis (BV)	Thin, grey or white discharge Fishy odour, especially after sex Absence of itching or irritation	Microscopy of vaginal smear: clue cells Whiff test with potassium hydroxide (KOH) pH testing (>4.5)	Metronidazole 500 mg orally twice a day for 7 days Alternative: Clindamycin vaginal cream
Candidiasis (Thrush)	Thick, white, cottage cheese-like discharge Severe itching and irritation Red, swollen vulva	Microscopy: yeast cells or pseudohyphae pH testing (normal 4-4.5)	Fluconazole 150 mg single oral dose Topical antifungal agents (e.g., clotrimazole)
Trichomoniasis	Frothy, yellow-green discharge Foul-smelling vaginal discharge Itching, burning, and irritation	Wet mount microscopy (motile trichomonads) Nucleic acid amplification tests (NAATs) pH testing (>4.5)	Metronidazole 2 g orally as a single dose Treat sexual partners to prevent reinfection
Chlamydia	May be asymptomatic Abnormal vaginal discharge Pelvic pain and bleeding after intercourse	Cervical swab or urine test for NAAT Routine STI screening	Azithromycin 1 g orally as a single dose Alternative: Doxycycline 100 mg twice a day for 7 days Treat sexual partners
Gonorrhoea	Thick, yellow or green discharge Painful urination Pelvic pain	Cervical swab or urine test for NAAT Gram stain or culture for Neisseria gonorrhoeae	Ceftriaxone 500 mg IM single dose Azithromycin 1 g orally as a single dose Treat sexual partners
Atrophic Vaginitis (Postmenopausal)	Dryness and irritation Thin, watery discharge Vaginal soreness	Clinical assessment (dryness, thin vaginal mucosa) pH testing (>4.5)	Topical oestrogen therapy (e.g., oestradiol cream) Lubricants and moisturisers for symptom relief

Investigations

• pH Testing: pH above 4.5 suggests bacterial vaginosis or trichomoniasis, while pH below 4.5 suggests candidiasis.
• Microscopy: Wet mount to check for trichomonads, yeast cells, or clue cells.
• STI Testing: Consider nucleic acid amplification tests (NAATs) for gonorrhoea and chlamydia.
• Whiff Test: Application of potassium hydroxide (KOH) to detect a fishy odour (suggests bacterial vaginosis).

Management

• Bacterial Vaginosis: Metronidazole 500 mg twice daily for 7 days.
• Candidiasis: Fluconazole 150 mg orally as a single dose or topical antifungals.
• Trichomoniasis: Metronidazole 2 g orally as a single dose; treat sexual partners.
• STI Management: Appropriate antibiotics for gonorrhoea or chlamydia; treat sexual partners.

Note: Always consider patient education on safe sexual practices and regular STI screening in sexually active individuals. Referral for further investigation may be required in persistent or recurrent cases.