Discharge

Question 1

What is vaginal discharge?

Answer 1

• Vaginal discharge is a common presenting symptom and may be either physiological or pathological.
• The most common causes of vaginal discharge are the normal physiological discharge, bacterial vaginosis and candida infections.
• Sexually transmitted infections (STIs) and non-infective causes should also be considered.

Question 2

What are the non-infective causes of discharge?

Answer 2

Physiological 
Cervical polyps and ectopy
Foreign bodies- retained tampon 
Vulval dermatitis 
Erosive lichen plants 
Genital tract malignancy 
Fistulae

Question 3

Physiological causes of discharge

Answer 3

• Newborn infants may have a small amount of vaginal discharge, sometimes mixed in with a little blood, due to high levels of circulating maternal oestrogen. This should disappear by 2 weeks of age.
• During the reproductive years, the fluctuating levels of oestrogen and progesterone throughout the menstrual cycle affect the quality and quantity of cervical mucus which is perceived by woman as a change in their vaginal discharge. Initially, when oestrogen is low, the mucus is thick and sticky.
• At menopause, the normal amount of vaginal discharge decreases as oestrogen levels fall.

Question 4

What are the infective causes of discharge?

Answer 4

• Non-sexually transmitted infection
BV is the most commonly seen in sexually active women.
Candidal infections- caused by an overgrowth of Candida albicans.
• STIs
Chlamydia trachomatis
Neisseria gonorrhoeae
Trichomonas vaginalis- particularly common in young women attending the GUM clinic and is frequently found in association with infection with N .gonorrhoeae.

Question 5

Which questions should you ask about the nature of the discharge?

Answer 5

(what has changed, odour, onset, duration, colour, consistency) and associated symptoms (these may include itch, superficial dyspareunia or dysuria, abdominal pain, deep dyspareunia, abnormal bleeding, pyrexia)

Question 6

Who has a higher risk of STI?

Answer 6

It is higher in women under the age of 25 and women who have a new sexual partner or have had more than one partner in the preceding 12 months. This can initially be assessed by simply asking the woman when she last had sex and then when she last had sex with anyone else.

Question 7

Which medications and medical condition should you consider in the assessment of discharge?

Answer 7

•Consider current contraceptive use and concurrent medications (eg, antibiotics, corticosteroids), previous treatments used (prescription and over-the-counter) and medical conditions (eg, diabetes, immunocompromised state).

Question 8

Which symptoms suggest that vaginal discharge is abnormal?

Answer 8

o A discharge that is heavier than usual.
o A discharge that is thicker than usual.
o Pus-like discharge.
o White and clumpy discharge.
o Greyish, greenish, yellowish or blood-tinged discharge.
o Foul-smelling (fishy or rotting meat) discharge.
o A discharge accompanied by bloodiness, itching, burning, a rash or soreness.

Question 9

Presentation of BV

Answer 9

Causes a thin, profuse and fishy-smelling discharge without itch or soreness.

Question 10

Presentation of candidiasis

Answer 10

Thick, typically curd like, white, non-offensive discharge which is associated with vulval itch and soreness.
May cause mild dyspareunia and dysuria.

Question 11

Presentation of C. trachomatis

Answer 11

May cause a copious purulent vaginal discharge but it is asymptomatic in 80% of women.

Question 12

Presentation of T. vaginalis

Answer 12

May cause an offensive yellow vaginal discharge, which is often profuse and frothy, associated with vulval itch and soreness, dysuria, abdominal pain and superficial dyspareunia.

Question 13

Presentation of N. gonorrhoea

Answer 13

May present with a purulent vaginal discharge but is asymptomatic in up to 50% of women.

Question 14

Presentation of retained foreign bodies

Answer 14

Result in a foul-smelling serosanguinous discharge. Diagnosis is confirmed on examination.

Question 15

Presentation of cervical polyps and ectopy

Answer 15

Tend to be asymptomatic but there may be increased discharge and intermenstrual bleeding. Diagnosis is made on speculum examination.

Question 16

Presentation of genital tract malignancy

Answer 16

Presentation varies and, in some cases, a persistent vaginal discharge not responding to conventional treatment may be the first clue. Diagnosis is made on examination and biopsy.

Question 17

Presentation of fistulae

Answer 17

History of trauma or surgery is suggestive. There may be a foul or feculent discharge in association with recurrent urinary tract infections.

Question 18

Presentation of allergic reactions

Answer 18

Diagnosis is suspected on taking the history - eg, use of irritant chemicals in douching, contact with latex and semen.

Question 19

BV in pregnancy

Answer 19

o Is associated with poor perinatal outcomes, particularly preterm birth.
o Routine screening during pregnancy for asymptomatic BV is not recommended as it has not been shown to reduce the risks of preterm birth. There may, however, be a role for screening women who are at high risk of preterm delivery and treating them before 20 weeks of gestation, but the evidence is conflicting.

Question 20

Thrush in pregnancy

Answer 20

o Common in pregnancy (30-40%) and often asymptomatic. There is no evidence of any harm to the foetus.

Question 21

Chlamydia in pregnancy

Answer 21

Incidence is highest in those aged under 20.

Does not affect pregnancy outcome but mother-to-baby transmission can occur at delivery, causing ophthalmia neonatorum in 15-25% or pneumonitis in 5-15% of newborns.

It may be associated with postpartum endometritis.

Question 22

Trichomonas in pregnancy

Answer 22

Increasingly thought to be associated with preterm delivery and low birth weight.

Question 23

Who can be treated for discharge without sampling?

Answer 23

Patients who present with typical symptoms suggestive of BV or vulvovaginal candidiasis, who are at low risk of an STI, can be treated without sampling.

Question 24

Which STI screening and swabs should be offered for vaginal discharge?

Answer 24

o Endocervical swab in transport medium (charcoal preferably) to diagnose gonorrhoea.
o Endocervical swab for a chlamydial nucleic acid amplification test (NAAT) to diagnose chlamydia.
o If examination is declined, a self-taken vulvovaginal swab for C. trachomatis and N. gonorrheae for NAAT may be an option and is more sensitive in women than urine testing.
o Blood tests for HIV and syphilis.

Question 25

Why is it important to do vaginal pH testing?

Answer 25

Can help discriminate between BV which reduces the normal acidity of the vagina (pH 4.5 or above) and vulvovaginal candidiasis (pH <4.5).

It cannot, however, be used to differentiate between BV and T. vaginalis.

Question 26

What are the complications of vaginal discharge?

Answer 26

• Untreated, some vaginal infections can spread to the upper reproductive tract and cause more serious illness and, in the long term, infertility.
• A retained foreign body has the potential of leading to toxic shock syndrome.
• Cervical polyps are generally harmless although may cause infertility if they grow very large