Vaginal Discharge

Question 1

22-year-old sexually active female reports vaginal discharge. How would you assess and manage?

Answer 1

Impression
There are a number of potential causes of vaginal discharge in a sexually active female.

DDx

• Physiological discharge
• infective: BV, candidiasis, STI (chlamydia, trichomoniasis, gonorrhoea, mycoplasma genitalium)
• non-infective: hormonal pill
• Bloody: malignancy?

Concerned about ruling out PID.

Question 2

Vaginal discharge - History

Answer 2

History

• Sx: discharge, onset, character (colour, consistency, smell, etc), does it change with cycle?
• Any associated features: urinary sx, abdo pain, fevers, dyspareunia, dysmenorrghagia, other PV bleeding.
• Sexual history: partners, practices, contraception, STI screening
• Menstrual history
• O&G hx. - CST?
• SNAP, meds, allergies, PMHx

Question 3

Vaginal discharge - Examination

Answer 3

Examination
- general appearance + vitals
- Abdominal examination: suprapubic tenderness,
- Pelvic examiantion
o Vulval assessment: erythema, discharge, smell
o Speculum: discharge visualisation, swab for further analysis, opportunistic CST if necessary
o Bimanual: Cervical motion tenderness, adnexal masses (TOA, malignancy)
- systems review for systemic features of infection

Question 4

Vaginal discharge - Investigations

Answer 4

Investigations
Key/diagnostic
- First pass urine and PCR for STIs
- Swab of discharge for wet prep and mount, MCS of discharge
- endocervical swab for chlamydia/gonorrhoea

• Bedside: as above
• Bloods: only if concerned about systemic illness
• Imaging: nil relevant unless suspicious of other pathology

Question 5

Vaginal discharge - Management

Answer 5

Management
Depends on the underlying aetiology.

Pharmacological

• Trichomoniasis: Metronidazole 2g PO single dose
• BV: Metronidazole
• Candidiasis: clotrimazole, nystatin, oral fluconazole
• Chlamydia: doxycycline or arithromycin
• Gonorrhoea: ceftriaxone 500mg
• Mycoplasma: doxycyline then azithromycin

Non-pharmacological
- contact tracing
   o 6 months for chlamydia
   o 2 months for gonorrhoea
- alert PHU if STI (notifiable diseases)
- arrange follow-up post-treatment STI screening for clearance