Vaginal Discharge

In our second ‘GUM’ special Dr Katie Boog talks us through vaginal discharge.

For more information don’t forget to check out the BASHH website.

Katie once again was kind to share her notes for this episode with us:

What causes vaginal discharge?

Discharge is normal:  Lubrication, Cervical mucus changes with hormones – contraception, cycle, age

We only worry if it changes

What type of changes?

Change in colour e.g. from clear/white to yellow/green/blood stained

Change in consistency/volume

Change in smell

Associated with itch or pain

Does a change in discharge mean an STI?

Can do but not always.

Changes can be due to:

Infection (STI or not), washing practices, foreign bodies (retained tampon, condom), growths (degen fibroids, malignancy), fistulae

Chlamydia and gonorrhoea usually asymptomatic in women

More likely to be thrush or BV

BV is most common cause of abnormal discharge

The history and examination will give you a lot of clues as to the most likely cause, often able to treat on the day rather than wait for the results

So what features in the history help you decide?

Smell – likely to be BV or TV

BV – thin, white/grey. Smelly, not sore or itchy.  Worse after sex and after period

TV – Smelly, itchy, may have dysuria. Can be thick or thin. Classically frothy and yellow but only <1/3rd

Itchy – likely to be TV or thrush

Thrush – thick, white, lumpy, itchy, sore (vulva, vagina or both), may have dysuria and dyspareunia

Increased discharge and abdo pain or deep dyspareunia – might be STI/PID

Gonorrhoea – might be yellow/green discharge most women are asymptomatic

Blood stained discharge – STI (cervicitis), PO contraception, cervical cancer

Also look at risk factors

What are the risk factors?

Chlamydia/gonorrhoea: new sexual partner, under 25

TV: new partner

BV: douching, smoking, black ethnicity, new partner, receptive cunnilingus (though not STI)

Thrush: diabetes, pregnancy, perfumed products, synthetic clothing

How should we examine/what tests should we do?

Examine vulva: signs of discharge, inflammation, excoriations, fissures, ulcers

VV swab for CT/NG

Speculum:

-          Look for a foreign body

-          Assess for vaginitis

-          Review cervix for cervicitis/abnormalities/growth/strawberry cervix  (rarely HSV lesions)

-          High vaginal swab for BV/thrush/TV (microscopy or MC&S)

-          Endocervical for microscopy and MC&S if suspect gonorrhoea

Bimanual if suspect PID

How do we diagnose and manage the infections?

Thrush:

Diagnosis:

-          High vaginal swab (ant fornix)

-          wet film or gram stain microscopy, hyphae and spores

-          MC&S (charcoal swab or plate)

Advice:

-          Not an STI, partner does not need notified or treated

-          Avoid tight fitting clothing, irritants

-          Wash with an emollient/soap substitute

Treat with an azole: oral (fluconazole, stat dose, CI in pregnancy) or vaginal (pessary or cream)

Sometimes need clotrimazole/hydrocortisone (external)

BV:

Diagnosis:

Microscopy (wet film or gram stain) – clue cells

PH >4.5

Charcoal swab

Advice:

-          Partner does not need treated

-          Essentially an imbalance in vaginal bacteria

-          Stop douching/excessive washing. Wash only with water and no internal washing

-          Treat with oral metronidazole, metronidazole gel (0.75% 5/7), clindamycin cream (2% 7/7)

-          No ETOH with metro +48 hours

TV:

Diagnosis:

High vaginal swab – post fornix, mobile trichomonads seen on wet prep, TV PCR if available, some POCTs available, culture

Advice:

-          Screen for other STIs

-          Sexual contacts from the last 4 weeks should be treated (+ screen for other STIs)

-          No sex until 7/7 both treated

-          Metronidazole (first line) or Tinidazole

-          Advice re ETOH

Chlamydia:

Most common bacterial STI

No immediate test, cannot be cultured

VV swab for NAAT testing (not endocervical)

Positive test:

-          Advise STI

-          Partner notification and testing/treatment

-          Doxycycline 7/7 (no longer azithro due to MG) – CI in preg: erythro 7/7

-          No sex until both partners treated

-          Regular screening, safe sex, can get again (more episodes = increase likelihood of longterm sequelae eg infertility, chronic pelvic pain)

Gonorrhoea:

VV NAAT test

Culture (cervix/urethra) if suspected and before rx due to resistance

Gram stain: gram neg intracellular diplococci

Advice:

-          STI, partner notification and testing/treatment

-          No sex until both partners treated

-          Ensure cultured before rx

-          Treatment: changing due to resistance, check BASHH

-          TOC 2/52