approach to vaginal discharge

1. Prerit Devkota
1st year Resident,
EMR/GP,
PAHS

2. Introduction
 Secretions produced by the glands of vaginal wall and
cervix that drain from the vaginal opening
 Common presentation of women to the Gyne OPD
 Can be physiological or pathological
 Related with some common STIs

3. Normal Vaginal Discharge
 1-4 mL fluid/day ,white or transparent, thick or thin, and mostly
odorless
 pH : 4 - 4.5
 Contents:
 Mucoid endocervical secretions in combination with sloughing
epithelial cells, normal vaginal flora, and vaginal transudate
 Not accompanied by pruritus, pain, burning or significant
irritation, erythema, local erosions, or cervical or vaginal
friabilit.

4. Disruption of the normal vaginal
ecosystem
•sexually transmitted diseases,
•antibiotics,
•foreign body,
•estrogen level,
•use of hygienic products,
•pregnancy,
• sexual activity,
•contraceptive devices

5. Physiological Vaginal Discharge
LEUCORRHOEA:
 Non – infective,
 Non – blood stained,
 Whitish or yellowish discharge
of mucus from the vagina
A) Physiologic excess:
 Puberty
 Pregnancy
 During sexual excitement
B) Cervical leucorrhoea:
 Non infective cervical lesions
like cervical ectopy, mucous
polyp
C) Vaginal leucorrhoea:
 Increased pelvic congestion
(uterine prolapse, acquired
retroverted uterus, OCP)
 Regular douching of vagina

6. Pathological Vaginal Discharge
 Inflammatory vaginal
discharge:
 Vulovovaginitis
 Cervicitis
 Endometritis
 Puerperial or senile
 Secondary infection of
wounds, abrasion
 Neoplastic
 Urinary and feculent
discharge:
 Presence of a fistula

7. Approach to Vaginal Discharge

8. Non – infective causes
Physiological Others
 Menstrual cycle variations-
Midcycle discharge
 Sexual arousal
 Pregnancy
 Cervical polyps
 Foreign bodies – eg:retained
tampon,
 Vulval dermatitis
 Chemical irritation
 IUCD use
 Oral contraceptive use

9. Infective causes
STIs Non-STIs
 Chlamydia
 Gonorrhoea
 Herpes simplex
 Trichomonasis
 Vulvovaginal candidiasis
 Bacterial vaginosis

10. Patient’s Presentation
 Change in the volume, color, or odor of vaginal discharge
 Pruritus
 Burning
 Irritation
 Erythema
 Dyspareunia
 Spotting
 Dysuria

11. Initial Diagnostic Evaluation
1.History :
 Discharge: quantity,color,consistency,odour???
 Bacterial vaginosis: malodorous, thin, grey (never yellow)
 Candidiasis: scanty , thick, white, odorless, and often curd-like
 Trichomoniasis: purulent, malodorous discharge, which may be
accompanied by burning, pruritus, dysuria, frequency, and/or
dyspareunia.

13. Initial Diagnostic Evaluation
 Burning, irritation, or other discomfort :
 Candida : pruritus and soreness
 BV : minimal inflammation and minimal irritative symptoms
 Pruritus :
 infection, allergy, or dermatosis
 Persistent or chronic focal pruritus – neoplasia or malignancy
 Vaginal bleeding :
 not consistent with infectious vaginitis
 evaluate for erosive causes of vaginitis (eg, erosive lichen planus) or a uterine source
 Pain :
 inflammatory causes of vaginitis or nonvaginal sources, such as pelvic floor myofascial
pain or vulvodynia

14. Initial Diagnostic Evaluation
 Dysuria or dyspareunia :
 inflammatory disorders such as infection or allergy as well vulvovaginal atrophy
 Timing of symptoms :
 Candidal : often in premenstrual period
 Trichomoniasis and BV often occur during or immediately after the menstrual
period
 STIs: soon after sexual intercourse
 Vaginal fistula: after gynecologic surgery such as hysterectomy
 Estrogen status :
 Low estrogen levels - vulvovaginal atrophy - symptoms of atrophic vaginitis
 vaginal dryness and dyspareunia
 Menopausal women, postpartum, lactating, or taking antiestrogenic drugs,
systemic hormone therapy

15. Initial Diagnostic Evaluation
2.Physical examination :
 To assesses the degree of vulvovaginal inflammation,
 Characteristics of the vaginal discharge,
 Presence of lesions or foreign bodies
 Signs of cervical inflammation and pelvic or cervical motion
tenderness

16. Physical Examination
 Vulva :
 Normal vulva are consistent with BV or leukorrhea.
 Erythema, edema, or fissures – candidiasis, trichomoniasis, or dermatitis
 Atrophic changes – hypoestrogenemia and suggest the possibility of atrophic
vaginitis
 Scarring – chronic inflammatory process, such as erosive lichen planus,
mucous membrane pemphigoid rather than vaginitis
 Pain with application of pressure from a cotton swab ("Q-tip test") on the labia
or at the vaginal introitus – inflammatory process (candidiasis, dermatosis) or
vulvodynia (ie, vulvar pain of unclear etiology)

17. Physical Examination
 Speculum examination :
 To look vagina, any vaginal discharge, and the cervix
 A foreign body (eg, retained tampon or condom)
 Vaginal warts
 Granulation tissue or surgical site infection
 Necrotic or inflammatory changes – malignancy in lower or upper
genital tract

18. Physical Examination
 Vaginal discharge :
 Trichomoniasis : greenish-yellow purulent discharge
 Candidiasis : thick, white, adherent, "cottage cheese-like" discharge
 BV : thin, homogeneous, "fishy smelling" gray discharge
 Inflammation and/or necrosis : malignancy can result in watery,
mucoid, purulent, and/or bloody vaginal discharge.
 A sample of vaginal discharge is collected with a cotton-swab and
tested for pH and with microscopy

19. Physical Examination
 Cervix :
 Cervical inflammation with a normal vagina: cervicitis
rather than vaginitis
 erythematous and friable,
 mucopurulent discharge
 d/d :Ectropion
 represents the normal physiologic presence of endocervical
glandular tissue on the exocervix.
 common in women taking estrogen-progestin contraceptives
and during pregnancy

20. Physical Examination
 Bimanual examination :
 to assess for tenderness and/or abnormal anatomy
 pelvic or cervical motion tenderness : evaluate for pelvic
inflammatory disease
 adnexal masses could represent a cyst or malignancy

21. Diagnostic studies
 Vaginal pH :
 Application of pH paper/stick to lateral vaginal wall or posterior fornix
 Use swab stick and roll into pH paper
 An elevated pH in a premenopausal woman : BV (pH>4.5) or trichomoniasis (pH 5 to 6), and
helps to exclude Candida vulvovaginitis (pH 4 to 4.5)
 High estrogen state : pH (4 to 4.5)
 Low estrogen state : pH (>4.5); premenarchal and postmenopausal women; higher pH is due
to less glycogen in epithelial cells, reduced colonization of lactobacilli, and reduced lactic acid
production
 Vaginal pH may be altered (usually to a higher pH)
 contamination with lubricating gels, blood, douches, and intravaginal medications.
 in pregnant women : leakage of amniotic fluid raises vaginal pH

22. Microscopy:
 Saline wet mount :
 vaginal discharge is mixed with one to two drops of 0.9 % normal
saline solution at room temperature on a glass slide
 Normal vaginal discharge : predominance of squamous epithelial
cells, rare polymorphonuclear leukocytes (PMNs),
and Lactobacillus species
 Look for candidal buds or hyphae motile trichomonads epithelial
cells studded with adherent coccobacilli (clue cells) and increased
numbers of PMNs
 Potassium hydroxide wet mount :
 Addition of 10 % KOH to the wet mount of vaginal discharge
destroys cellular elements
 identify hyphae and budding yeast for the diagnosis of candidiasis

23. Candidal buds
Candidal hyphae
Motile trichomonads
Clue cells

24. Diagnostic Studies
 Cervical tests for STI :
 Neisseria gonorrhoeae and Chlamydia trachomatis must always be
considered in sexually active women with vaginitis
 women with STIs may go on to develop pelvic inflammatory disease
and its potential complications
 In a study of 581 vaginal specimens evaluated with molecular-
based testing, one-quarter of the specimens positive for BV
or Candida vulvovaginitis also tested positive for an STI
(Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas
vaginalis)
Landers DV, Wiesenfeld HC, Heine RP, et al. Predictive value of the clinical diagnosis of lower genital
tract infection in women. Am J Obstet Gynecol 2004; 190:1004.

25. Initial findings
 Alarm findings :
 obvious vulvar, vaginal, or cervical cancer
 probable pelvic inflammatory disease
 purulent vaginitis
 vulvovaginal ulceration
 vaginal fistulae
 refer for specialty evaluation and care
 Common diagnoses :
 70 % will be diagnosed with
 bacterial vaginosis (40 to 50 %),
 Candida vulvovaginitis (20 to 25 %), or
 trichomoniasis (15 to 20 %)
 STIs
 hypoestrogenic women – vulvovaginal atrophy
Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA 2004; 291:1368.

26.  25 to 40 % of patients with genital symptoms do not have a specific
cause identified on initial diagnostic evaluation.
?? If no diagnosis without initial
evaluation
Miller JM, Binnicker MJ, Campbell S, et al. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of
Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for
Microbiology. Clin Infect Dis 2018; 67:e1.

27. Secondary Approach
 rule out Candida vaginitis, bacterial vaginosis (BV), and
trichomoniasis
 no other source of vaginitis has been identified,then
 Minimal symptoms : repeat initial diagnostic evaluation
 Avoid emperic therapy: partial treatment,may aggravate
symptoms
 Repeat vaginal pH:
 If pH increased : vaginal atrophy, atrophic vaginitis, lichen planus,,
desquamative inflammatory vaginitis, and pemphigoid
 If pH is normal : contact or irritant dermatitis, seborrheic or
eczematoid dermatitis, psoriasis, or vulvodynia
 If the pH is decreased : evaluate for cytolytic vaginosis

28. Secondary Approach
 Detailed secondary history:
 Acuity and timing of symptoms : acute, chronic, or recurrent?
 acute - infectious etiology
 chronic process - inflammation unrelated to infection
 Associated symptoms : pelvic pain or systemic symptoms (eg, fever, nausea)?
 Pelvic pain - PID
 suprapubic pain - cystitis
 Sexual practices : new sexual partners – STIs such as Trichomonas vaginalis or cervicitis
related to Neisseria gonorrhoeae or Chlamydia trachomatis
 Medication history :
 Antibiotics predispose to candidal vulvovaginitis
 estrogen-progestin contraceptives - increase physiologic discharge
 pruritus and burning unresponsive to antifungal agents may be due to vulvovaginal dermatitis

29. Secondary Approach
 Medical history :
 history of an oral mucosal, ocular, cutaneous, or systemic disease that could
affect the vulvovaginal area?
 Herpes simplex virus and Behçet syndrome can cause vulvovaginal ulcers
 Diabetes : vulvovaginal candidiasis
 HIV : vaginal infections
 SJS/ TEN : severe vulvovaginal sequelae
 Surgical history –
 recent transvaginal surgery or repair of perineal lacerations from childbirth?

30. Bacterial Vaginosis:
Also known as nonspecific vaginitis or Gardenella Vaginitis
40-50% women of child bearing age and doesnot involve
cervix
 A shift in vaginal flora from Lactobacillus species to one of high
bacterial diversity, including facultative anaerobes
 Prevotella spp
 Mycoplasma hominis
 Mobiluncus spp
 Gardenerella vaginalis
Asymptomatic: 50-75%

31. Diagnosis
Amsel criteria: (at least three criteria must be present)
Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
Vaginal pH >4.5
Positive whiff-amine test: Fishy odor when a drop of 10% KOH is added to a sample of vaginal
discharge
Clue cells on saline wet mount
Sensitivity over 90% and specificity is 77%
Gram stain : gold standard
Culture : different vaginal flora;non-diagnostic

32. Treatment
Recommended Regimens: (CDC 2015)
Metronidazole 500 mg orally twice a day for 7 days
OR
Metronidazole gel 0.75%, one full applicator (5 g)
intravaginally, once a day for 5 days
OR
Clindamycin cream 2%, one full applicator (5 g) intravaginally
at bedtime for 7 days
Treatment of sex - partners

33. Candida vulvovaginitis:
 Most common causes of vulvovaginal itching and discharge
 Organisms:
 Candida albicans(85% to 90%)
 Candida glabrata
 Candida tropicalis
 Risk Factors:
 Diabetes Mellitus
 Antibiotic use
 Increased estrogen levels
 Immunosuppression
 Clinical features:
 Vulvar itching, burning, soreness, and irritation , dysuria or dyspareunia
 Erythema and edema of vulva and vaginal mucosa
 Scanty , white, thick, adherent to vaginal sidewalls, and clumpy (curd-like or cottage cheese-like) with
no or minimal odor
 Cervix usually appears normal.

34. Types
Uncomplicated vulvo-
vaginal candidiasis:
Complicated vulvo-vaginal
candidiasis:
 mild to moderate disease
 Fewer then 4 episode/ year
 Pseudohyphae/ hyphae visible
on microscopy
 Moderate to severe disease
 four or more episodes per year
 Budding yeast cell visible on
microscopy
 Adverse host factors( pregnancy,
DM, immunocompromised)
 Needs an intensive, longer
course of antifungal

35. Diagnosis
 Vaginal pH: 4 – 4.5
 Microscope:
 KOH prep : budding yeast, pseudohyphae, and hyphae
 Culture:
 Vaginal sample is obtained from lateral wall using a cotton-tipped swab
 inoculated into Sabouraud agar or Nickerson medium

36. Treatment
Uncomplicated VVC Complicated VVC
Topical agents:
Clotrimazole 1% cream, 5 g
intravaginally daily for 7–14 days OR
Miconazole 2% cream, 5 g intravaginally
daily for 3 days OR
Ticonazole 6.5% cream , 5 g
intravaginally, single dose OR
Teraconazole 0.4% cream, 5g
intravaginally for 7 Days
Oral Agent:
Fluconazole 150 mg orally in a single
dose

 7–14 days of topical therapy
AND
 Cap fluconazole ( 150mg/3days)
until symptoms resolve
 Followed by maintenance on
prophylactic doses of fluconazole
150mg weekly for 6 months

37. Trichomonas vaginitis
 Caused by flagellated protozoan Trichomonas vaginalis
 Clinical features:
 Discharge: Purulent, malodorous, thin
 burning, pruritus, dysuria, frequency, lower abdominal pain,
dyspareunia , post-coital bleeding
 Physical examination:
 Erythema of vulva and vaginal mucosa
 Green-yellow, frothy, malodorous discharge
 Punctate hemorrhages on vagina and cervix(strawberry cervix)

38. Diagnosis:
 Microscopy and pH:
 Motile trichomonas on wet mount is diagnostic of infection(60-
70%)
 Motion is jerky and spinning; remain motile for 10 - 20minutes
 Nucleic acid amplification test( Gold standard)
 NAATs detect RNA by transcription-mediated amplification(
PCR or reverse transcriptase )
 Highly sensitive and specific

40. Treatment:
 Recommended Regimen
 Metronidazole 2 g orally single dose OR
 Tinidazole 2 g orally single dose
 Alternative Regimen
 Metronidazole 500 mg orally twice a day for 7 days
 Recommended Regimen for Women with HIV Infection
 Metronidazole 500 mg orally twice daily for 7 days
 Other Management Consideration:
 Sexual Abstinence until their sex partners are treated
 Testing for other STDs including HIV should be performed
 Management of Sex Partners
 Follow-up:
 All sexually active women within 3 months following initial treatment

41. STIs
 Gonorrhea :
 gram –ve coccus Neisseria gonorrhoeae
 Treatment (CDC):
 Inj. Ceftriaxone 250 mg as a single intramuscular dose +
 Tab. Azithromycin 1 gm single dose or Doxycycline(100 mg) orally BD for 7 days
 Chlamydia :
 Caused by Chlamydia trachomatis
 Treatment :
 Azithromycin 1 gm single-dose
OR
Doxycycline 100 mg BD for 7days

42. References
 UpToDate 2019
 Novak’s Gynecology (13th edition)
 CDC 2015 guidelines
 Landers DV, Wiesenfeld HC, Heine RP, et al. Predictive value of the clinical diagnosis of lower
genital tract infection in women. Am J Obstet Gynecol 2004; 190:1004.
 Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA 2004; 291:1368.
 Miller JM, Binnicker MJ, Campbell S, et al. A Guide to Utilization of the Microbiology Laboratory
for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America
and the American Society for Microbiology. Clin Infect Dis 2018; 67:e1.

43. Thank you !!!!