Vaginal discharge

Question 1

Probability diagnosis

Answer 1

Normal or excessive physiological discharge

Vaginitis:

• bacterial vaginosis (40–50%)
• candidiasis (20–30%)
• Trichomonas (10–20%)

Question 2

Serious disorders not to be missed

Answer 2

Neoplasia:

• cancer (cervix, uterus, vagina)
• fistulas

STIs/PID (i.e. cervicitis):

• gonorrhoea
• Chlamydia
• herpes simplex—types 1 and 2

Sexual abuse, esp. children

Tampon toxic shock syndrome (staphylococcal infection)

Streptococcal vaginosis (in pregnancy)

Question 3

Pitfalls (often missed)

Answer 3

• Chemical vaginitis (e.g. perfumes)
• Retained foreign objects (e.g. tampons, IUCD)
• Endometriosis (brownish discharge)
• Ectopic pregnancy (‘prune juice’ discharge)
• Poor toilet hygiene
• Pelvic fistula
• Genital herpes (possible)
• Cervical polyp
• Bartholinitis
• Atrophic vaginitis
• Threadworms
• Latex allergy (e.g. condoms)

Question 4

Masquerades checklist

Answer 4

Diabetes

Drugs

UTI (association)

Question 5

Is the patient trying to tell me something?

Answer 5

Needs careful consideration; possible sexual dysfunction.

Question 6

Key history

Answer 6

Nature of discharge:

• colour
• odour
• quantity
• relation to menstrual cycle
• associated symptoms

Exact nature and location of irritation

Sexual history:

• arousal
• previous STIs
• number of partners
• any presence of irritation or discharge in them

Use of chemicals, such as;

• soaps
• deodorants
• pessaries and
• douches

Pregnancy possibility

Drug therapy

Associated medical conditions (e.g. diabetes).

Question 7

Key examination

Answer 7

Inspection with good light includes viewing;

• the vulva
• introitus
• urethra
• vagina
• cervix

Look for the discharge and specific problems such as;

• polyps
• warts
• ectropion
• prolapses and
• fistulas

Full pelvic examination in a postmenopausal woman

Question 8

Key investigations

Answer 8

pH test with paper of range 4–6

Amine or ‘whiff’ test

Wet film microscopy of a drop of vaginal secretions

Full STI workup including high vaginal swab

Question 9

Diagnostic tips

Answer 9

Vaginal discharge is an uncommon symptom before puberty.

It is common to overlook the problems caused by hygienic preparations including;

• deodorant soaps
• sprays
• contraceptive agents especially spermicidal creams.