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
- 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?
- High vaginal swab (ant fornix)
- wet film or gram stain microscopy, hyphae and spores
- MC&S (charcoal swab or plate)
- 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)
Microscopy (wet film or gram stain) – clue cells
- 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
High vaginal swab – post fornix, mobile trichomonads seen on wet prep, TV PCR if available, some POCTs available, culture
- 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
Most common bacterial STI
No immediate test, cannot be cultured
VV swab for NAAT testing (not endocervical)
- 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)
VV NAAT test
Culture (cervix/urethra) if suspected and before rx due to resistance
Gram stain: gram neg intracellular diplococci
- 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