This document discusses the etiology and clinical presentation of various causes of vaginal discharge. It covers bacterial vaginosis, trichomoniasis, vulvovaginal candidiasis, chlamydia, gonorrhea, herpes simplex virus, atrophic vaginitis, cervical cancer, and physiological discharge. For each cause, it describes associated history, risk factors, examination findings such as discharge appearance and characteristics, and signs of infection or inflammation. Differential diagnoses and recommendations for testing and treatment are also provided.

1. VAGINAL DISCHARGE

2. ETIOLOGY
Bacterial vaginosis
• Bacterial vaginosis is characterized by a complex change in the
vaginal flora, which leads to a reduction of the normally
dominant hydrogen-peroxide-producing lactobacilli
• These lactobacilli are replaced by an increased concentration of
other organisms, especially anaerobes
• These organisms, which break down vaginal peptides into
amines and cause the typical discharge in patients with bacterial
vaginosis, produce large amounts of proteolytic carboxylase
enzymes

3. ETIOLOGY
Bacterial vaginosis
• Up to 30% of patients treated for bacterial vaginosis have a
recurrence within 3 months. Routine treatment of women with
asymptomatic bacterial vaginosis is not recommended, mainly
due to low response rates to treatment and increased incidence
of candidiasis after therapy
• However, treatment of asymptomatic women with bacterial
vaginosis does result in a lower rate of subsequent Chlamydia
infection
• Treatment of male partners of patients with bacterial vaginosis

4. ETIOLOGY
Bacterial vaginosis
• Bacterial vaginosis diagnosed early in pregnancy is a strong risk
factor for preterm labor, preterm premature rupture of
membranes, low birth rate, and spontaneous abortion. However,
treatment of patients with asymptomatic infection with
metronidazole does not prevent preterm birth

5. ETIOLOGY
Trichomoniasis
• It represents the most prevalent sexually transmitted infection
worldwide
• Trichomonas vaginalis is a flagellated protozoan usually found in
the vagina, urethra, and paraurethral glands of infected patients
• It is associated with a high prevalence of co-infection with other
STIs
• Most male partners of female patients with a diagnosis of
trichomoniasis are also infected; hence, it is recommended to

6. ETIOLOGY
Vulvovaginal candidiasis (VVC)
• Candida species are present in about 20% to 50% of vaginal flora
of healthy asymptomatic women; It is not considered an STI
• Candida albicans is the most common cause of VVC

7. ETIOLOGY
Vulvovaginal candidiasis (VVC)
• Vulvovaginal candidiasis is not related to number of recent
sexual partners but may b related to increased frequency of
intercourse
• Risk factors for VVC include poorly-controlled diabetes mellitus,
broad-spectrum antibiotics that inhibit growth of normal vaginal
flora, high estrogen levels (e.g., when using oral contraceptive
pills, when having estrogen therapy, or during pregnancy),
immunosuppression (including patients with HIV, in whom it is
associated with a higher incidence and persistence of disease),

8. ETIOLOGY
Vulvovaginal candidiasis (VVC)
Uncomplicated VVC is defined as an infection with the following
characteristics:
• Sporadic or infrequent VVC
• Mild to moderate symptoms
• Likely to be C albicans species
• Presence in an immunocompetent patient.
Recurrent VVC is:
• Defined as infection that occurs 4 or more times per year
• Seen in about 5% to 8% of patients.
Complicated VVC:
• Includes patients with recurrent or severe VVC, non-albicans candidiasis, or
uncontrolled diabetes, or those who are immunocompromised or pregnant
• Is characterised by an increased incidence of candidal species other than C albicans in
patients with HIV and patients with recurrent candidiasis.

9. ETIOLOGY
Less common infectious causes
• Other, less common infectious causes of vaginitis include
chlamydial infection, gonorrheal infection, herpes simplex virus,
streptococcal infection, genital schistosomiasis (reported in
Africa)
• The role of Mycoplasma as a cause of vaginal discharge is still
being defined

10. Cervicitis and vaginal discharge due to
gonorrhea

11. Cervicitis due to herpes simplex virus; erosive inflammation
with accompanying paracervical purulency is seen

12. ETIOLOGY
Non-infectious causes
Include allergy or contact dermatitis (e.g., latex, sperm, douching,
dyes), chemical irritants (e.g., soaps, tampons, pads, condoms),
inadequate hygiene, atrophic vaginitis (estrogen deficiency),
foreign body (e.g., tampons, pessary, contraceptive devices) post-
puerperal atrophic vaginitis

13. ETIOLOGY
Pediatric
• Compared with the vagina of a woman of reproductive age, the
vagina of a prepubertal patient has a neutral pH without
antibodies to protect it from infection, is shorter and closer to
the rectum, and is exposed to much lower estrogen levels
• For these reasons, this age group is at increased risk for
vulvovaginitis, accounting for about 70% of all gynecological
complaints

14. ETIOLOGY
Pediatric
• Vaginal discharge in this age group is usually not caused by
infection and almost never caused by a malignancy
• Common causes of vaginal discharge in girls younger than 6
years include foreign body (45%), sexual abuse (18%), and
unknown diagnosis (36%)

15. RED FLAGS
• Trichomoniasis
• Chlamydia trachomatis infection
• Neisseria gonorrhoeae infection
• Cervical cancer
• Carcinoma of the fallopian tube
• Foreign body in children
• Sexual abuse
• Transmitted maternal birth canal infection
• Lymphoma of genital tract

16. CLINICAL HISTORY AND EXAMINATION
The initial history should include:
• Any new sexual partners
• Use of new soaps or detergents
• Douching
• Contraceptive vaginal ring or intrauterine device use
• Symptoms such as pelvic pain, itching, quality/quantity/odor of discharge
• Bacterial vaginosis typically presents with a thin discharge and
fishy odor ('whiff test'). Trichomoniasis presents with a purulent
malodorous discharge. Vulvovaginal candidiasis presents with a
white, cottage cheese discharge and pruritus

17. CLINICAL HISTORY AND EXAMINATION
• Vaginal culture for vulvovaginal candidiasis: should be obtained
to confirm diagnosis in patients with typical clinical features but
normal pH and negative wet mount microscopy. Should also be
obtained for patients with recurrent symptoms.
• Vaginal culture for trichomoniasis: should be considered if pH is
>4.5, if there are high polymorphonuclear leukocytes but no
motile trichomonads on wet mount microscopy, or if microscopy
is not available

18. CLINICAL HISTORY AND EXAMINATION
Women at risk for sexually transmitted infections
• In women at risk for sexually transmitted infections (those with
new, multiple partners, or partners with multiple partners, as
well as women younger than 25 years old) and profuse yellowish
vaginal discharge, a pelvic examination should be performed and
cultures and assays for Neisseria gonorrhoeae or Chlamydia
trachomatis obtained in addition to routine tests
• If the discharge is accompanied by pelvic pain and/or cervical
motion tenderness, the patient should be treated for pelvic
inflammatory disease (PID) according to local guidelines

19. CLINICAL HISTORY AND EXAMINATION
Recurrent vaginal discharge
Patients with recurrent vulvovaginal candidiasis should have the
following excluded: diabetes mellitus and immunocompromised
states, as well as for other type of Candida (e.g., Candida glabrata
), because they can be resistant to antifungal agents used in the
management of Candida albicans

20. CLINICAL HISTORY AND EXAMINATION
Atrophic vaginitis
• If the woman is postmenopausal and epithelium appears pale,
smooth, and shiny, then clinical diagnosis of atrophic vaginitis
may be considered
• Other tests may include estrogen levels, which are typically low;
microscopy negative for infection; and ultrasound of vaginal
lining

21. CLINICAL HISTORY AND EXAMINATION
Physiological post puerperal atrophic vaginitis
History of recent child birth with characteristic discharge (lochia
rubra, serosa, or alba) is diagnostic
Herpes simplex virus
Multiple crops of painful, shallow ulcers may indicate herpes
simplex virus cervicitis, which can be confirmed with viral cultures
and assays

22. CLINICAL HISTORY AND EXAMINATION
Behcet's syndrome
Will present with other features of the syndrome (e.g., aphthous
ulcers, skin lesions, and uveitis) in addition to vaginal ulceration
and discharge. Typically diagnosed clinically
Lichen planus
May be difficult to distinguish from atrophic vaginitis if there are
no extravaginal symptoms. Presents with shiny papules, which are
typically intensely itchy. Biopsy of vaginal wall confirms diagnosis.

23. BACTERIAL VAGINOSIS
History
• 50% to 75% asymptomatic
• Fishy odor especially after
intercourse
• Off-white, thin, homogeneous
discharge
• Rarely dysuria and dyspareunia
• Risk factors including new
sexual partner or >3 in past
year, douching, cigarette
smoking
Exam
• Discharge typically
homogeneous, thin, grayish-
white and odorous

24. BACTERIAL VAGINOSIS
Milky or creamy vaginal discharge covering
external os

25. BACTERIAL VAGINOSIS
Thin, gray discharge

26. TRICHOMONIASIS
History
• Purulent, malodorous, thin
discharge
• Can also present with
burning, pruritus, dysuria,
frequency, and dyspareunia
• Symptoms may be worse
during menstruation
Exam
• Typically, erythema of the
vulva and vaginal mucosa
• Vaginal discharge (green-to-
yellow, frothy) and strawberry
cervix may be present

27. TRICHOMONIASIS
Yellowish discharge and petechiae on
cervix (strawberry cervix) suggestive of
trichomoniasis

28. TRICHOMONIASIS
Multiple petechiae on the cervix of a
women with trichomoniasis

29. TRICHOMONIASIS
Frothy greenish discharge suggestive of
trichomoniasis

30. TRICHOMONIASIS
Frothy, profuse discharge suggestive of
trichomoniasis

31. VULVOVAGINAL CANDIDIASIS
History
• Vulvar pruritus, pain,
burning, swelling, redness,
soreness, irritation,
dyspareunia
• Usually little discharge but if
present, appears white and
clumpy, curd-like; more
frequent in patients with
diabetes
Exam
• Erythema of the vulva, vaginal
mucosa, and vulva edema
• Candida albicans discharge
usually thick, cottage,
cheese-like, adherent to
vagina wall; but may be thin
and loose with Candida
glabrata usually little
discharge

32. VULVOVAGINAL CANDIDIASIS

33. VULVOVAGINAL CANDIDIASIS
Sticky cheesy white discharge suggestive of
candidiasis

34. VULVOVAGINAL CANDIDIASIS
Thick white clumps visible on the cervix
and vaginal wall indicate vaginal
candidiasis

35. CHLAMYDIA TRACHOMATIS INFECTION
History
• Often asymptomatic; or
purulent or mucopurulent
discharge from endocervix
• Intermenstrual or postcoital
bleeding, dysuria, urinary
frequency, dyspareunia,
vulvovaginal irritation;
• Pain and fever rare
Exam
• Signs of cervicitis: cervix
friable, erythematous and
edematous, with purulent or
mucopurulent discharge
exude from cervix
• Possible cervical motion
Tenderness
• Yellow opaque endocervical
discharge, easily induced
cervical bleeding

36. NEISSERIA GONORRHOEAE INFECTION
History
• Asymptomatic; or vaginal
pruritus and/or a
mucopurulent discharge
• Abdominal pain or
dyspareunia suggests
extension to upper tract; may
lead to pelvic inflammatory
disease, ectopic pregnancy,
infertility if untreated
Exam
• Cervix normal or with friable
mucosa and purulent
discharge

37. STD CERVICITIS
An inflamed cervix (cervicitis) that appears red (beefy) and swollen
with pus coming out of the cervix is commonly seen in chlamydia
or gonococcal infections

38. PHYSIOLOGICAL LEUCORRHOEA IN ADULTS
History
• Usually consists of 1 to 4 mL
discharge per 24 hours; typically
transparent (high estrogen) or
thick mucousy (concentrated,
low estrogen), and white-to-
yellowish
• Typically odorless, but can also
be slightly malodorous
• More noticeable with higher
estrogen states (e.g. at
ovulation, pregnancy, use of
estrogen-progestogen
contraceptives)
Exam
• Scant to moderate, clear to
white discharge; otherwise
normal
• Normal discharge will not be
associated with symptoms or
foul smell or any inflammation
of the cervix or vagina
• The amount and the consistency
of normal vaginal discharge
change with the phase of the
menstrual cycle, age, pregnancy
status, and use of oral
contraceptive pills

39. PHYSIOLOGICAL LEUCORRHOEA IN ADULTS
Normal thick mucoid discharge (Odorless) with pinky cervix

40. PHYSIOLOGICAL LEUCORRHOEA IN ADULTS
The visible part of the cervix protrudes into the vaginal canal and
is covered by smooth, pink, squamous epithelium

41. PHYSIOLOGICAL LEUCORRHOEA IN
CHILDREN
History
• A few months before
menarche (9-13 years old)
• Grey-white physiological
discharge due to increase in
estrogen levels
Exam
• scant transparent, mucousy,
and white-to-yellowish
discharge

42. HERPES SIMPLEX VIRUS (HSV) INFECTION
History
• Superficial sores or ulcers
over the vulva
• Sometimes watery vaginal
discharge
• Appears 7-11 days after
primary infection
• General malaise and fever
possible
• Central nervous system
involvement rare
Exam
• Multiple crops of painful,
shallow ulcers over the vulva,
vagina and cervix
• Which often coalesce then
heal spontaneously without
scarring

43. HERPES SIMPLEX VIRUS (HSV) INFECTION
Primary herpes,
male

44. HERPES SIMPLEX VIRUS (HSV) INFECTION
Herpes, female

45. HERPES SIMPLEX VIRUS (HSV) INFECTION
Herpes, female

46. ATROPHIC VAGINITIS
History
• Postmenopausal
• Itching, burning, discomfort,
dyspareunia
• Yellowish malodorous vaginal
discharge, or vaginal
bleeding
Exam
• Atrophic epithelium appears
pale, smooth, and shiny
• Inflammation with patchy
erythema, petechiae and
increased friability may be
present

47. POST PUERPERAL ATROPHIC VAGINITIS;
LOCHIA
History
• Recent childbirth, lochia rubra
(red) initially, then lochia serosa
(paler color) in the next few
days, lochia alba (white or
yellowish-white) from about the
10th day
• Itching, burning, discomfort,
dyspareunia
Exam
• Reddish discharge in first few
days, pinkish in next few days,
and whitish from approximately
10th postpartum day onward
• Findings of atrophic vaginitis
subsequently: epithelium
appears pale, smooth, and
shiny, and inflammation with
patchy erythema and increased
friability may be present

48. CERVICAL CANCER
History
• 4% present with vaginal
discharge
• Some can present with
malodorous vaginal discharge
indicating infection of a large,
necrotic tumour
• In late stage cervical cancer,
may have watery or foul-
smelling vaginal discharge
most likely from necrotic
Exam
• On speculum examination
possible watery, foul-
smelling discharge as well as
pelvic fungating mass

49. CERVICAL CANCER
The cervix is covered with a white discharge commonly seen in
vaginal candidiasis
There are multiple white raised lesions near the external os

50. CERVICAL CANCER
The discharge is cleaned and the lesions are better visible
They have a milky white color and raised margins; The SCJ is not visible
(After normal saline)

51. CERVICAL CANCER
An acetowhite area has developed on the TZ touching the SCJ
The acetowhitening is thin with irregular margins (After acetic
acid)

52. BEHCET'S SYNDROME
History
• Known hx of Behcet’s
syndrome; Recurrent
aphthous ulcers, genital
ulcerations occasionally
associated with vaginal
discharge, and uveitis leading
to blindness
Exam
• Recurrent genital ulcers in
vulva and vagina, which are
painful, and scarring
• Occasional vaginal discharge

53. EROSIVE LICHEN PLANUS
History
• Chronic eruption mostly on
flexor surfaces, mucous
membranes, and vulvar skin
• Lesions usually extremely
pruritic and sometimes
painful
Exam
• Violaceous, shiny papules
appearing mostly on flexor
surfaces, mucous
membranes, and vulvar skin
• Most lesions are located on
the inner aspects of the vulva,
especially on the labia minora
and vestibule