History - Itching -Odor -color of discharge -spotting after intercourse.

-painful intercourse

Yeast causes : intense itching with a cheesy, dry discharge. Gardnerella : a foul-smelling, thin white discharge. Trichomonas : irritation and frothy white discharge. Foreign body (lost tampon) : foul-smelling black discharge. Cervicitis : nondescript discharge with deep dyspareunia Chlamydia : purulent vaginal discharge, post-coital spotting, and deep dyspareunia. Gonorrhea : purulent vaginal discharge and deep dyspareunia. Cervical ectropion : mucous, asymptomatic discharge.

Symptoms of vaginitis include abnormal vaginal discharge, pruritus, irritation, burning, soreness, odor, and, less commonly, dyspareunia, bleeding, and dysuria. The degree to which these symptoms are present depends upon the extent of inflammation. Candida vulvovaginitis, as an example, often presents with scant discharge but marked inflammatory symptoms (pruritus and soreness), while many cases of bacterial vaginosis are asymptomatic or present with only malodorous vaginal discharge and no inflammatory complaints (see specific sections below). Dyspareunia is a common feature of atrophic vaginitis.
Is there abdominal pain? Abdominal pain is suggestive of pelvic inflammatory disease and suprapubic pain is suggestive of cystitis, both are rare with vaginitis. (See "Clinical features and diagnosis of pelvic inflammatory disease" and "Acute uncomplicated cystitis and pyelonephritis in women".) What are the patients sexual practices? What is the gender of her sex partner? Risk of sexually transmitted infections differs in same sex couples. Has there been exposure to a new sexual partner? A new sexual partner increases the risk of acquiring sexually transmitted diseases such as Trichomonas vaginalis, or cervicitis related to Neisseria gonorrhoeae or Chlamydia trachomatis. (See "Screening for sexually transmitted diseases".) When did the symptoms start in relation to menses? Candida vulvovaginitis often occurs in the premenstrual period, while trichomoniasis often occurs during or immediately after the menstrual period. What medications (prescription and nonprescription) are being used? Antibiotics and high-estrogen contraceptives may predispose to candida vulvovaginitis; increased physiologic discharge can occur with estrogen-progestin contraceptives; pruritus unresponsive to antifungal agents suggests vulvar dermatitis. What are the patient's hygienic practices (eg, daily use of panty liners, feminine products)? Conscientious analysis of the woman's personal practices is the best way to detect potential irritants and allergens in her environment and habits unhealthy for the vulvar skin. Mechanical, chemical, or allergic irritation may cause vulvar symptoms mistakenly attributed to an infectious source. (See "Dermatitis of the vulva".) Is the menopausal patient receiving hormonal therapy (HT)? Taking systemic HT (oral, skin) does not guarantee adequate vaginal estrogen levels.

-the onset of the discharge, its appearance, amount, odor (if any), and any associated symptoms. -The relation of the discharge to phase of menstrual cycle, coitus, and use of medication (especially antibiotics) should be noted. -Details about associated symptoms such as dysuria, pruritus, pain, dyspareunia, and skin rash . - Use of a pad or a tampon can be a precipitating factor or a sign of excessive discharge. - detailed sexual history aids in understanding whether she is at particular risk for any infections; useful information includes possible exposure to sexually transmitted diseases and whether the patients partner has a complaint of penile discharge or les ion. - Known allergies need to be reviewed in conjunction with the use of spermicidal preparations and douches. - Patients should be asked about the use of foreign bodies and bubble baths, soaps, or genital deodorants. - A history of a previous vaginal inf ection, diabetes, or the recent use of antibiotics or corticosteroids needs to be considered in a search for alterations in vaginal flora or host defenses. - Any self-treatment should be carefully inquired about because antifungal medication is now readily available over the counter. - Women with chronic or recurrent discharge also turn to a wide range of alternative treatments, including oral and vaginal acidophilus pills, oral and vaginal yogurt, and douches with vinegar and boric acid. -Vaginal discharge may range in color from clear to gray, yellow, greenish, or milky-white and
may have an unpleasant smell. Not all women with bacterial vaginosis will have symptoms, but bacterial vaginosis typically produces a discharge that is thin and grayish-white in color. It is usually accompanied by a foul, fishy smell. Trichomonas infection produces a frothy, yellow-green vaginal discharge with a strong odor. Associated symptoms can include discomfort during intercourse and urination, as well as irritation and itching of the female genital area. Gonorrhea may be not produce symptoms in up to 50% of infected women, but it can also cause burning with urination or frequent urination, a yellowish vaginal discharge, redness and swelling of the genitals, and a burning or itching of the vaginal area. Like gonorrhea, chlamydia infection may not produce symptoms in many women. Others may experience increased vaginal discharge as well as the symptoms of a urinary tract infection if the urethra is involved.

A vaginal yeast infection is usually associated with a thick, white vaginal discharge that may have the texture of cottage cheese. The discharge is generally odorless. Other symptoms can include burning, soreness, and pain during urination or sexual intercourse.

Physical Exam Inspect carefully for the presence of lesions, foreign bodies and odor. Palpate to determine cervical tenderness.

Yeast : has a thick white cottage-cheese discharge and red vulva. Gardnerella : has a foul-smelling, thin discharge. Trichomonas : has a profuse, bubbly, frothy white discharge. Foreign body : obvious and has a terrible odor. Cervicitis : has a mucopurulent cervical discharge and the cervix is tender to touch. Chlamydia : a friable cervix but often has no other findings. Gonorrhea : a mucopurulent cervical discharge and the cervix may be tender to touch. Cervical ectropion : looks like a non-tender, fiery-red, friable button of tissue surrounding the cervical os. Infected/Rejected IUD : demonstrates a mucopurulent cervical discharge in the presence of an IUD. The uterus is mildly tender. Chancroid : appears as an ulcer with irregular margins, dirty-gray necrotic base and tenderness. The vulva usually appears normal in bacterial vaginosis. Erythema, edema, or fissure formation suggest candidiasis, trichomoniasis, or dermatitis. The characteristics of the vaginal discharge may help distinguish the etiology of vaginal complaints (table 2). Trichomonas is classically associated with a greenishyellow purulent discharge; candidiasis with a thick, white, adherent, "cottage cheese-like" discharge; and bacterial vaginosis with a thin, homogeneous, "fishy smelling" gray discharge. However, the appearance of the discharge is extremely unreliable and should never form the basis for diagnosis [4]. Cervical inflammation is suggestive of cervicitis, rather than vaginitis. The cervix in women with cervicitis is usually erythematous and friable, with a mucopurulent discharge. However, cervical erythema in this condition should be distinguished from ectropion, which represents the normal physiologic presence of endocervical glandular tissue on the exocervix. Ectropion is not friable and is more common in women taking estrogen-progestin contraceptives. The volume of physiologic discharge may be higher in women with ectropion. Abdominal or cervical motion tenderness is suggestive of PID. (See "Clinical features and diagnosis of pelvic inflammatory disease".)

Ectropion, Erosion or Eversion Cervical ectropion is very common, particularly in younger women and those taking BCPs. It usually causes no symptoms and need not be treated. If it is symptomatic, producing a more or less constant, annoying, mucous discharge, cervical cauterization will usually eliminate the problem. Cervicitis Some patients with cervicitis note a purulent vaginal discharge, deep dyspareunia, and spotting after intercourse, while others may be symptom-free. The cervix is red, slightly tender, bleeds easily, and a mucopurulent cervical discharge from the os is usually seen.

Chlamydia Most women harboring chlamydia will have no symptoms, but others complain of purulent vaginal discharge, deep dyspareunia, and pelvic pain. There may be no significant pelvic findings, but a friable cervix, mucopurulent cervical discharge, pain on motion of the cervix, and tenderness in the adnexa are suggestive. Foreign Body Women with this problem complain of a bad-smelling vaginal discharge which is brown or black in color. The foreign body can be felt on digital exam or visualized with a speculum. Gardnerella (Hemophilus, Bacterial Vaginosis) The patient with this problem complains of a bad-smelling discharge which gets worse after sex. While this problem is commonly called "Gardnerella," it is probably the associated anaerobic bacteria which actually cause the bad odor and discharge. Gonorrhea Many (perhaps most) women harboring the gonococcus will have no symptoms, but others complain of purulent vaginal discharge, pelvic pain, and deep dyspareunia. There may be no significant pelvic findings, but mucopurulent cervical discharge, pain on motion of the cervix, and tenderness in the adnexa are all classical. Infected IUD Patients with this problem usually notice mild lower abdominal pain, sometimes have a vaginal discharge and fever, and may notice deep dyspareunia. The uterus is tender to touch and one or both adnexa may also be tender. PID: Mild Gradual onset of mild bilateral pelvic pain with purulent vaginal discharge is the typical complaint. Fever <100.4 and deep dyspareunia are common. Moderate pain on motion of the cervix and uterus with purulent or mucopurulent cervical discharge is found on examination. PID: Moderate to Severe With moderate to severe PID, there is a gradual onset of moderate to severe bilateral pelvic pain with purulent vaginal discharge, fever >100.4 (38.0), lassitude, and headache. Symptoms more often occur shortly after the onset or completion of menses. Excruciating pain on movement of the cervix and uterus is characteristic of this condition. Hypoactive bowel sounds, purulent cervical discharge, and abdominal dissension are often present. Pelvic and abdominal tenderness is always bilateral except in the presence of an IUD. Trichomonas This microorganism, with its four flagella to propel it, is not a normal inhabitant of the vagina. When present, it causes a profuse, frothy white or greenish vaginal discharge. Itching may be present, but this is inconsistent. Yeast (Monilia, Thrush) Vaginal yeast infections are common, monilial overgrowths in the vagina and vulvar areas, characterized by itching,dryness, and a thick, cottage-cheese appearing vaginal discharge. The vulva may be reddened and irritated to the point of tenderness. Yeast thrives in damp, hot environments and women in such circumstances are predisposed toward these infections. Women who take broad-spectrum antibiotics are also predisposed towards these infections because of loss of the normal vaginal bacterial flora.

Yeast organisms are normally present in most vaginas, but in small numbers. A yeast infection, then, is not merely the presence of yeast, but the concentration of yeast in such large numbers as to cause the typical symptoms of itching, burning and discharge. Likewise, a "cure" doesn't mean eradication of all yeast organisms from the vagina. Even if eradicated, they would soon be back because that is where they normally live. A cure means that the concentration of yeast has been restored to normal and symptoms have resolved. NORMAL VAGINAL PHYSIOLOGY AND FLORA In reproductive aged women, normal vaginal discharge consists of 1 to 4 mL fluid (per 24 hours), which is white or transparent, thick, and mostly odorless. This physiologic discharge is formed by mucoid endocervical secretions in combination with sloughing epithelial cells, normal bacteria, and vaginal transudate. The discharge may become more noticeable at times, such as during pregnancy, use of estrogen-progestin contraceptives, or at midmenstrual cycle close to the time of ovulation. It can be somewhat malodorous and accompanied by irritative symptoms

The history and findings on physical examination in women with vaginitis are relatively nonspecific. Nevertheless, certain features often suggest a particular diagnosis (table 3), which should be confirmed in the office by microscopic examination of vaginal secretions and, if necessary, culture. (See 'General diagnostic approach' above.) Trichomonas is classically associated with a greenish-yellow purulent discharge; candidiasis with a thick, white, adherent, "cottage cheese-like" discharge; and bacterial vaginosis with a thin, homogeneous, "fishy smelling" gray discharge. However, the appearance of the discharge is unreliable and should never form the basis for diagnosis. (See 'Physical examination' above.)

Pathological discharge
Abnormal vaginal discharge is characterized by a change in colour, consistency, volume or odour of the discharge. It may be associated with symptoms such as itch, soreness, dysuria, pelvic pain or intermenstrual or post-coital bleeding. Although abnormal vaginal discharge often prompts women to seek screening for sexually transmitted infections (STIs), vaginal discharge is poorly predictive of the presence of an STI.

Box 2. Criteria to diagnose BV

White discharge pH greater than 4.5 Fishy odour (with addition of potassium hydroxide to the discharge) Clue cells (vaginal epithelial cells surrounded by bacteria)

Recurrent vaginal discharge

Psychosexual problems and depression may occur in women with recurrent vaginal discharge. In all cases, potential underlying causes such as diabetes mellitus,

immunosuppression, corticosteroid therapy or concurrent antibiotic use should be considered.

Recurrent BV Advise women to avoid use of douches, shower gels, antiseptic agents
and shampoo in the bath.

Recurrent VVC For women with recurrent VVC (four or more episodes in 12 months)
advise women to avoid douching, local irritants, perfumed products and tight-fitting synthetic clothing.

Vaginal discharge in pregnancy

The quality and quantity of vaginal discharge often changes during pregnancy with most women producing more discharge during pregnancy. It is important to distinguish between vaginal discharge and premature rupture of membranes during pregnancy, as the management is quite different.

BV in pregnancy BV in pregnancy is associated with late miscarriage, preterm labour,

premature rupture of membranes, low birth weight and post-partum endometritis. Routine screening during pregnancy is not currently recommended, but current guidelines support screening for women with a previous preterm birth (prior to 28 weeks gestation) or second-trimester miscarriage.

VVC in pregnancy VVC is common in pregnancy. Treatment is the same as for nonpregnant women but may need to be of longer duration (i.e. 7 days). Oral antifungals should be avoided in pregnancy because of potential teratogenicity.

TV in pregnancy There is increasing evidence that TV may be associated with preterm

delivery and low birth weight.

Vaginal discharge following miscarriage or delivery

Patients presenting with vaginal discharge following miscarriage or delivery should be fully investigated and empirically treated while awaiting results of swabs. BV is associated with endometritis and PID following abortion, but retained products of conception should be considered in all women, particularly in the presence of a heavy growth of coliforms.

Vaginal discharge in post-menopausal women

After the menopause, atrophic vaginal changes may predispose women to infective vaginal discharge. Gynaecological malignancies and retained intrauterine contraceptive devices should also be considered as possible causes. Any women presenting with a post-menopausal bleed should be referred for further investigation to be seen within 2 weeks, for exclusion of endometrial cancer or other gynaecological malignancy.