This document discusses the management of vaginal discharge. It outlines what constitutes normal versus abnormal discharge and describes the vaginal flora and factors that can disrupt it. Several specific causes of abnormal discharge are examined in depth, including atrophic vaginitis, various forms of infectious vaginitis, and irritant vaginitis. Diagnostic criteria and treatment approaches are provided for conditions like bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis, and chlamydia. Other issues addressed include cervicitis, foreign bodies, and strategies for preventing vaginal infections.

1. Max MongelliMax Mongelli
Senior Consultant and Associate ProfessorSenior Consultant and Associate Professor
Department of Obstetrics & GynaecologyDepartment of Obstetrics & Gynaecology
Nepean HospitalNepean Hospital
MANAGEMENT OFMANAGEMENT OF
VAGINAL DISCHARGEVAGINAL DISCHARGE

2. Normal DischargeNormal Discharge
Slight discharge isSlight discharge is
normalnormal
Increased 2 weeks beforeIncreased 2 weeks before
mensesmenses
May increase duringMay increase during
ovulationovulation
Clear or whiteClear or white
Non-irritatingNon-irritating
No odourNo odour

3. Abnormal DischargeAbnormal Discharge
ItchingItching
IrritationIrritation
Unpleasant odourUnpleasant odour
Burning during micturitionBurning during micturition

4. Vaginal FloraVaginal Flora
Complex ecological environmentComplex ecological environment
Bacteria: up to 100 M cfu/mlBacteria: up to 100 M cfu/ml
5-10 types of m/o can often be cultured5-10 types of m/o can often be cultured
Commonly: lactobacilli, corynebacterium,Commonly: lactobacilli, corynebacterium,
streptococci, candidastreptococci, candida

5. Vaginal FloraVaginal Flora
Normal pH< 4.5Normal pH< 4.5
Formation of lactic acid byFormation of lactic acid by
lactobacillilactobacilli
Production of hydrogen peroxideProduction of hydrogen peroxide
Inhibits overgrowth of potentialInhibits overgrowth of potential
pathogenspathogens

6. Causes of abnormalCauses of abnormal
dischargedischarge
VaginitisVaginitis
CervicitisCervicitis
Endometritis / P.I.D.Endometritis / P.I.D.
Urine/faecesUrine/faeces
Foreign bodiesForeign bodies

7. VaginitisVaginitis
AtrophicAtrophic
InfectiousInfectious
IrritantIrritant

8. Atrophic VaginitisAtrophic Vaginitis
Estrogen deficiencyEstrogen deficiency
More than 40% of post-menopausal womenMore than 40% of post-menopausal women
Common even with HRTCommon even with HRT
May occur in pre-menopausal womenMay occur in pre-menopausal women
Condition may not be disclosed toCondition may not be disclosed to
health care providershealth care providers

9. Atrophic VaginitisAtrophic Vaginitis (2)(2)
Itching, burning, watery dischargeItching, burning, watery discharge
Dyspareunia / apareuniaDyspareunia / apareunia
Post-coital bleeding / fissuresPost-coital bleeding / fissures
Increased susceptibility to secondaryIncreased susceptibility to secondary
infectioninfection
Frequency/dysuria/hematuriaFrequency/dysuria/hematuria

10. Atrophic VaginitisAtrophic Vaginitis (3)(3)
ManagementManagement
Exclude other causes (eg UTI)Exclude other causes (eg UTI)
Vaginal estrogen therapyVaginal estrogen therapy
-Low dose (eg 50 mcg E2)-Low dose (eg 50 mcg E2)
Lubricants/MoisturizersLubricants/Moisturizers
Sexual activity/dilatorsSexual activity/dilators
Stop smokingStop smoking

11. Infectious VaginitisInfectious Vaginitis
BacteriaBacteria
FungiFungi
ProtozoaProtozoa
VirusesViruses

12. Irritant VaginitisIrritant Vaginitis
Harsh soapsHarsh soaps
Feminine hygiene deodorant spraysFeminine hygiene deodorant sprays
Perfumed toilet paperPerfumed toilet paper
Deodorant tamponsDeodorant tampons
Commercial douchesCommercial douches
SpermicidesSpermicides
Fabric softenersFabric softeners

14. CervicitisCervicitis
Erythema, edema, friableErythema, edema, friable
Yellow/green cervicalYellow/green cervical
secretionssecretions
> 10 WC /oil immersion field> 10 WC /oil immersion field
‘mucopus’‘mucopus’
Chlamydia most common causeChlamydia most common cause

16. Bacterial VaginosisBacterial Vaginosis
May be transmitted sexuallyMay be transmitted sexually
Change in balance of bacterial floraChange in balance of bacterial flora
Gardnerella, bacteroides,Gardnerella, bacteroides,
mobiluncus, mycoplasmamobiluncus, mycoplasma
May be linked to IUCD’sMay be linked to IUCD’s

17. BV: FeaturesBV: Features
May be asymptomaticMay be asymptomatic
Fishy smell, worse after SIFishy smell, worse after SI
Clue cells on microscopyClue cells on microscopy
Decreased acidityDecreased acidity
Possible role in poor pregnancyPossible role in poor pregnancy
outcomeoutcome

20. BV: TreatmentBV: Treatment
Only if symptomaticOnly if symptomatic
MetronidazoleMetronidazole
ClindamycinClindamycin
No need to treat partnerNo need to treat partner

21. VulvovaginalVulvovaginal
CandidiasisCandidiasis
May affect up to 75% of allMay affect up to 75% of all
womenwomen
Overgrowth of candidaOvergrowth of candida
Itching, burning, irritationItching, burning, irritation
+/- vaginal discharge+/- vaginal discharge
Thick, white, occ. WateryThick, white, occ. Watery
Treat with topicalTreat with topical
antifungalsantifungals

24. Recurrent VVCRecurrent VVC
- exclude other causes of- exclude other causes of
vaginitisvaginitis
- more common: candida glabrata,- more common: candida glabrata,
tropicalistropicalis
- exclude immune suppression- exclude immune suppression
- no need to treat partner- no need to treat partner

25. Antifungals for RVVCAntifungals for RVVC
- Fluconazole 100 mg once weekly- Fluconazole 100 mg once weekly
- Itraconazole 50-100 mg daily- Itraconazole 50-100 mg daily
- Ketoconazole 100 mg daily- Ketoconazole 100 mg daily
- Clotrimazole 500 mg pessaries- Clotrimazole 500 mg pessaries
weeklyweekly

26. TrichomoniasisTrichomoniasis
Protozoan: trichomonasProtozoan: trichomonas
vaginalisvaginalis
Infection of urogenital tractInfection of urogenital tract
Found in 3-12% of womenFound in 3-12% of women
STDSTD
Often asymptomaticOften asymptomatic

28. TV: symptomsTV: symptoms
Heavy yellow-green or greyHeavy yellow-green or grey
dischargedischarge
Unpleasant odourUnpleasant odour
DyspareuniaDyspareunia
Lower abdominal painLower abdominal pain
Painful urinationPainful urination

29. TV: diagnosisTV: diagnosis
Saline microscopy ofSaline microscopy of
dischargedischarge
‘Strawberry Cervix’‘Strawberry Cervix’
Gram or Acridine OrangeGram or Acridine Orange
stainstain
OR CulturesOR Cultures
PAP smearPAP smear

30. TV: complicationsTV: complications
Increased risk of HIVIncreased risk of HIV
transmissiontransmission
Preterm delivery / LBWPreterm delivery / LBW
infantsinfants
Post-hysterectomy cellulitisPost-hysterectomy cellulitis

31. TV - Symptoms in menTV - Symptoms in men
-Infertility-Infertility
-Balanitis-Balanitis
-Prostatitis-Prostatitis
-Epididymitis-Epididymitis

32. TV: treatmentTV: treatment
Treat both partnersTreat both partners
MetronidazoleMetronidazole
Avoid alcoholAvoid alcohol

33. ChlamydiaChlamydia
60-80% of infected women60-80% of infected women
asymptomaticasymptomatic
Dysuria/frequencyDysuria/frequency
DischargeDischarge
PCB, dyspareuniaPCB, dyspareunia
Rectal pain/dischargeRectal pain/discharge

34. Chlamydia: diagnosisChlamydia: diagnosis
CultureCulture
Direct fluorescenceDirect fluorescence
antibodiesantibodies
Elisa immunoassayElisa immunoassay
PCRPCR

35. Chlamydia:Chlamydia:
complicationscomplications
PIDPID
PerihepatitisPerihepatitis
Ectopic pregnancyEctopic pregnancy
Neonatal conjunctivitis /Neonatal conjunctivitis /
pneumoniapneumonia

36. Chlamydia: treatmentChlamydia: treatment
Doxycycline 100 mg BD x 10DDoxycycline 100 mg BD x 10D
Erythromycin 500 mg QID x 10DErythromycin 500 mg QID x 10D
Sulfamethoxazole 1 g BD x 10DSulfamethoxazole 1 g BD x 10D
Azithromycin 1 g statAzithromycin 1 g stat

37. Colon Bacilli VaginitisColon Bacilli Vaginitis
Repeated contamination ofRepeated contamination of
vulvar areavulvar area
Commonly in childrenCommonly in children
Poor hygienePoor hygiene
E. Coli most common pathogenE. Coli most common pathogen
Oral ampicillinOral ampicillin
Teach proper hygieneTeach proper hygiene

38. Herpes SimplexHerpes Simplex
VirusVirus
Usually affects vagina andUsually affects vagina and
vulvavulva
Symptoms: severe pain -Symptoms: severe pain -
prurituspruritus
Dysuria or retentionDysuria or retention
Occasionally sec.Occasionally sec.
bacterial infectionbacterial infection
Oral acyclovirOral acyclovir
Exclude immunosuppressionExclude immunosuppression

40. Foreign bodiesForeign bodies
Chronic foul-smellingChronic foul-smelling
dischargedischarge
Forgotten tampons ( > 6 hrs)Forgotten tampons ( > 6 hrs)
Forgotten swabsForgotten swabs
Rarely toxic shock syndromeRarely toxic shock syndrome

41. Preventing vaginalPreventing vaginal
infectionsinfections
Routine cleanlinessRoutine cleanliness
Cotton underwearCotton underwear
Avoid nylon, tight pantyhoseAvoid nylon, tight pantyhose
Avoid douchingAvoid douching
Avoid irritant chemicalsAvoid irritant chemicals
Safe sex practicesSafe sex practices
General health careGeneral health care