InnovAiT, Vol. 2, No. 9, pp. 510516, 2009
1093/innovait/inp128
Vaginal discharge
V
aginal discharge is a common presenting symptom encountered in day-to-
day practice. From the time of puberty, the vagina is colonized by lactobacilli
and other bacteria. Commensal lactobacilli metabolize glycogen in the vaginal
epithelium to produce lactic acid, maintaining an acidic environment in the vagina
(pH less than 4.5) and providing defence against infection.
The GP curriculum and vaginal discharge
The GP curriculum statement on womens health (10.1)
lists vaginal discharge as a key symptom within its
knowledge base. GPs must be able to demonstrate that
they can assess women presenting to the GP surgery
with vaginal discharge and treat any causes found
appropriately.
Curriculum statement 11 (Sexual health) requires GPs to
be able to take a sexual history from a woman. It lists
assessment of unusual or different vaginal discharge
within its knowledge base, including taking of appropriate
swabs to conrm diagnosis. Within the knowledge base,
bacterial vaginosis, candidal vulvovaginitis, gonorrhoea
and Trichomonas vaginalis infections are specically
listed as common and important conditions that GPs
should be able to manage.
Vaginal discharge can be physiological or pathological (see
Box 1). In women of reproductive age complaining of vaginal
discharge, the most common cause is physiological, but
infective and other causes should be excluded. Before
puberty and after menopause the vaginal epithelium is thin,
atrophic and has a higher pH, all of which predispose to
infection.
Aetiology
Physiological discharge
A normal physiological discharge is white or clear and non-
offensive. It consists of transudate from the vaginal walls,
squames containing glycogen, polymorphs, lactobacilli,
cervical mucus, residual menstrual uid, and secretions from
the greater and lesser vestibular glands.
Type and quantity of physiological discharge varies
throughout life.
O Newborn infants may have a small amount of vaginal
discharge, sometimes mixed in with a little blood, due to
high levels of circulating maternal oestrogen. This should
disappear by two weeks of age.
The Author 2009. Published by Oxford University Press on behalf of the RCGP. All rights reserved.
For permissions please e-mail: journals.permissions@oxfordjournals.org
510
doi:10.
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Box 1. Causes of vaginal discharge
Physiological
Infective (non-sexually transmitted)
O Bacterial vaginosis
O Candida
Infective (sexually transmitted)
O Trichomonas vaginalis
O Chlamydia trachomatis
O Neisseria gonorrhoeae
Non-infective
O Foreign bodies (e.g. tampons, condoms, ring pessary)
O Cervical polyps and ectopy
O Genital tract malignancy
O Fistulae
O Allergic reactions
O During the reproductive years, the uctuating levels
of oestrogen and progesterone throughout the
menstrual cycle affect the quality and quantity of
cervical mucus, which is perceived by women as a
change in their vaginal discharge. Initially when
oestrogen is low, the mucus is thick and sticky. As
oestrogen levels rise, the mucus gets progressively
clearer, wetter and more stretchy. After ovulation,
there is an increase in the thickness and stickiness of
O
the mucus once more.
Around the menopause, the normal amount of vaginal
discharge decreases as oestrogen levels fall.
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.
 InnovAiT

Non-sexually transmitted Box 2. Criteria to diagnose BV

infections Amsels criteria (three out of four must be present):

O White discharge

O pH greater than 4.5

Bacterial vaginosis
O Fishy odour (with addition of potassium hydroxide to
Bacterial vaginosis (BV) is the most common cause of infective
the discharge)
vaginal discharge. It is characterized by an overgrowth of
O Clue cells (vaginal epithelial cells surrounded by bacteria)
anaerobic organisms that replace normal lactobacilli, leading
to an increase in vaginal pH (greater than or equal to 4.5).
Note: Many research studies use Nugent or Hay/Ison
criteria to diagnose BV. These are complex laboratory
Gardnerella vaginalis is commonly found in women with BV,
criteria based on the microscopic appearance of the
but the presence of Gardnerella alone is insufcient to
discharge and cannot be applied in the GP surgery.
constitute a diagnosis of BV. Other organisms associated

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with BV include Prevotella species, Mycoplasma hominis
and Mobiluncus species.
The discharge is thin and has a characteristic offensive or shy
odour (Table 1). Clue cells are vaginal epithelial cells so heavily
coated with bacteria that the border is obscured (Fig. 1). In
clinical practice, BV is diagnosed using Amsels criteria (Box 2).
BV can occur and remit spontaneously; it is associated with
early age at rst intercourse and a higher number of sexual
partners. However, BV is not considered to be an STI.
The recommended treatment for BV is oral metronidazole
[400500 mg twice daily (bd) for 57 days, or as a single
2 g dose]. The single dose may improve compliance but may
be less effective at 4 weeks follow-up. Alternative regimens
include the following:
O intravaginal metronidazole gel (0.75%), 5 g application
nightly for 5 days
O intravaginal clindamycin cream (2%), 5 g application
nightly for 7 days
O oral clindamycin 300 mg bd for 7 days or
O tinidazole 2 g as a single oral dose.
Women using combined hormonal contraception should be
advised to use additional contraceptive protection (e.g.
condoms) during the antibiotic course and for 7 days afterwards
and to avoid alcohol when taking metronidazole. Routine
testing and treatment of sexual partners is not recommended.
Genital thrush
Candida albicans is a vaginal commensal found in 1020%
of asymptomatic women. Acute vulvovaginal candidiasis
(VVC), or genital thrush, is the second most common cause
of infective vaginal discharge and is caused by an overgrowth
of yeasts, usually C. albicans (8095% of cases) or Candida
glabrata (5%). Candidiasis occurs most commonly when the
vagina is exposed to oestrogen, especially in women aged
2030 years and in pregnancy. The lifetime incidence of VVC
is 5075%, and around 50% of women who have had an
acute attack will have a further episode.
VVC is characterized by a thick, white, non-offensive
discharge and may be associated with vulval itch or soreness,
supercial dyspareunia or external dysuria. Diabetes mellitus,
immunosuppression, antibiotics and corticosteroids treatment

Table 1. Summary of signs and symptoms associated with common infective causes of vaginal discharge in
women of reproductive age

Bacterial vaginosis Candida Trichomoniasis

Symptoms Thin discharge Thick discharge Scanty to profuse or

frothy yellow discharge

Offensive or shy odour Non-offensive Offensive

Associated symptoms: Associated symptoms: Associated symptoms:

No itch Vulval itch or soreness Vulval itch
Supercial dyspareunia Dysuria
External dysuria Low abdominal pain

Signs Discharge coating vagina Normal ndings or vulval Vulvitis and vaginitis
and vestibule erythema, oedema, So-called strawberry
No vulval inammation ssuring, satellite lesions cervix (uncommon 2%)

Vaginal pH Greater than/equal to 4.5 Less than 4.5 Greater than/equal to 4.5
Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. FFPRHC and BASHH Guidance. The man-
agement of women of reproductive age attending non-genitourinary medicine settings complaining of vaginal discharge. J Fam Plann
Reprod Health Care (2006) 32(1): p. 3342.
Reproduced with permission of the Faculty of Sexual and Reproductive Healthcare.

511
 Figure 1. Clue cells.
Copyright 2009. Center for Young Womens Health, Childrens Hospital Boston

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All rights reserved. Used with permission. www.youngwomenshealth.org

may precipitate VVC, but there is no good evidence that

hormonal contraception increases the risk of VVC, nor is there
evidence that tampons, sanitary towels or vaginal douching
cause candidiasis. Candidiasis is not sexually transmitted.

Antifungal treatment can be given if VVC is suspected and

there is low risk of STIs or while awaiting results when swabs
have been taken. Give as a single 500-mg pessary, 200-mg
nightly for 3 days or 100-mg nightly for 6 days. The efcacy of
treatment depends on the total dose given, rather than duration.
A single high dose is as effective as a divided dose given over
several days and compliance may be improved. Women should
be advised that latex condoms, diaphragms and cervical caps
might be damaged by some topical antifungal treatments.

Sexually transmitted
infections
Trichomonas vaginalis
Trichomonas vaginalis (TV) is a agellated protozoan that
causes vaginitis. It is characterized by a shy-smelling
vaginal discharge that may be associated with itching,
Figure 2. Strawberry cervix.
soreness and dysuria (due to urethral infection). Punctate Reproduced with permission from Seattle STD/HIV
mucosal haemorrhages can occur on the cervix, giving the Prevention Training Center.
appearance of a strawberry cervix (Fig. 2); however, this is
only seen in 10% of cases. Diagnosis is conrmed with high
In the absence of treatment 1014% of infected women
vaginal swabs (HVS).
develop pelvic inammatory disease (PID). PID can result in
tubal infertility, ectopic pregnancy and chronic pelvic pain.
Although there is a spontaneous cure rate of 2025% for TV,
The risk of developing PID increases with each recurrence of
recommended treatment is oral metronidazole 400 mg bd
Chlamydia trachomatis infection, as does the risk of
for 57 days or as a single 2-g oral dose. Inform women that
reproductive sequelae. Chlamydia trachomatis can be
TV is an STI and initiate contact tracing, partner notication
detected using samples taken from the endocervix and
and treatment for all sexual partners that the woman has
vulva, or urine if a nucleic acid amplication technique is
encountered in the previous 6 months.
used. All patients diagnosed with chlamydia should be
encouraged to have screening for other STIs.
Chlamydia trachomatis
Chlamydia trachomatis, the most common bacterial STI in The recommended treatment regimen for chlamydial infection
the UK, is asymptomatic in 80% of women. However, is with doxycycline 100 mg bd for 7 days (contraindicated in
women may present with vaginal discharge (due to pregnancy) or azithromycin 1 g orally given as a single dose.
cervicitis), abnormal bleeding (post-coital or intermenstrual), Alternative regimens include erythromycin 500 mg bd for 1014
lower abdominal pain, dyspareunia or dysuria. days or ooxacin 200 mg bd or 400 mg once daily for 7 days.

512

Neisseria gonorrhoeae
Gonorrhoea is the second most common bacterial STI in the
UK. Up to 50% of women with Neisseria gonorrhoeae infection
will complain of vaginal discharge. The discharge is due to
cervicitis rather than vaginitis. Neisseria gonorrhoeae may co-
exist with other genital tract pathogens such as TV, candida
and C. trachomatis. It infects the columnar cells of the
endocervix and so an endocervical swab should be taken and
sent to the laboratory for analysis if gonorrhoea is suspected.
Microscopy of Gram-stained genital specimens allows direct
visualization of N. gonorrhoeae as monomorphic gram-negative
diplococci with polymorphonuclear leucocytes (Fig. 3).
The recommended treatment for uncomplicated anogenital
gonorrhoea is with ceftriaxone 250 mg intramuscularly (IM)
as a single dose. Cexime 400 mg oral as a single dose or
spectinomycin 2 g IM as a single dose are alternatives.
Other causes of vaginal
discharge
There are many other causes of vaginal discharge that should
be considered. These include the following:
O foreign bodies (e.g. retained tampons, condoms, vaginal
sponges)
O cervical ectopy or polyps
O genital tract malignancy
O stulae, and
O allergic reactions to lubricants, deodorants and disinfectants
Assessment of a woman
presenting with vaginal
discharge
When a woman presents with a vaginal discharge, it is
important to nd out what her concerns are. For example,
she may be concerned that she has an STI or cancer, and
these worries should be addressed accordingly. The
assessment of a woman complaining of vaginal discharge is
summarized in Fig. 4.
Figure 3. Extracellular and intracellular Gonococci
CDC/Joe Millar.
InnovAiT
Take a full clinical and sexual history with a particular note on
the nature of the discharge. Ask what has changed, and about
onset and duration of symptoms. Enquire about the discharge
colour, odour and consistencyand its cyclicity in relation to
the womans menstrual cycle. Check if there are any associated
symptoms, for example itch, supercial or deep dyspareunia,
lower abdominal pain, dysuria, abnormal bleeding or pyrexia.
Look for potential triggers of symptoms in the history, such as
recent use of antibiotics or corticosteroids, recent unprotected
intercourse and other medical conditions such as diabetes or
immunocompromised states. Sexual history is vital to assess the
risk of STIs. Women are at high risk of STIs if they are under the
age of 25 years, have had a change in partner in the last year or
have had more than one sexual partner in the last year.
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In addition to the clinical and sexual history, physical
examination and pH provide supporting information, which
may help you to reach a diagnosis. However, a woman may
be empirically treated at rst presentation, based on her
symptoms and without taking swabs, if she is at low risk for
STIs and without symptoms indicative of upper reproductive
tract infection. The presence of itch makes candida the
likeliest cause and an antifungal treatment is most
appropriate. An offensive odour makes BV the likeliest cause
and metronidazole is then the treatment of choice.
Examination is required if the discharge
O is recurrent or persists despite empiric treatment
O is blood stained
O is associated with abdominal pain, fever, deep
dyspareunia or irregular bleeding, or
O occurs in a post-menopausal woman
Physical examination should include abdominal palpation for
pain or tenderness; inspection of the vulva for obvious
discharge or vulvitis; speculum examination to check the
vaginal walls and cervix, to exclude the presence of foreign
bodies and to examine the amount, consistency and colour of
the discharge; and bimanual pelvic examination to assess the
woman for adnexal and uterine tenderness and tenderness
associated with movement of the cervix (cervical excitation).
During speculum examination, take a HVS for microscopy and
culture and endocervical swabs for chlamydia and gonorrhoea.
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 Downloaded from rcgp-innovait.oxfordjournals.org at Universidade de Pernambuco on December 10, 2010
Figure 4. Flow chart for the assessment of women attending non-genito-urinary medicine settings
complaining of vaginal discharge.
Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. FFPRHC and
BASHH Guidance. The management of women of reproductive age attending non-genitourinary medicine
settings complaining of vaginal discharge. J Fam Plann Reprod Health Care (2006) 32(1): p. 3342.
Reproduced with permission of the Faculty of Sexual and Reproductive Healthcare.

If the swabs are not transported immediately to the laboratory,
they should be stored at 4C for no longer than 48 hours.
The presence of lower abdominal pain, cervical excitation
and adnexal tenderness in association with abnormal vaginal
discharge implies PID. It is vital to advise patients to avoid
sexual intercourse until they and their partners have
completed treatment if an STI is suspected.
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
For women with recurrent BV, consider suppressive therapy
with 5 g metronidazole intravaginal gel (0.75%) twice weekly
for 46 months after an initial 10 day treatment, or 400 mg
metronidazole orally bd for 3 days at the start and end of
menstruation. Advise women to avoid use of douches,
shower gels, antiseptic agents and shampoo in the bath.
Acidifying gel may reduce relapse rates and maintain acidic
vaginal pH at 1 month follow-up.

514

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-tting synthetic clothing.
Consider using an induction and maintenance regimen for 6
months. Induction regimens involve daily use of vaginal
imidazoles (usually clotrimazole) or oral uconazole or
itraconazole for 612 days. The maintenance regimen (half-
dose) should comprise weekly treatments for 6 months duration
(oral uconazole 100 mg weekly, clotrimazole pessary 500 mg
weekly or oral itraconazole 400 mg weekly). If further symptoms
occur, induction and maintenance treatment may need to be
restarted and continued for a longer period (12 months).
Recurrent TV
Recurrent TV is usually due to re-infection, but consideration
should be given to the possibility of drug resistance.
Vaginal discharge in
pre-pubertal girls
Vaginal discharge is the most common reason for referral of a
pre-pubertal girl to a gynaecologist. Vaginal discharge in a
young girl can cause parental anxiety. The vulval and vaginal
skin in a pre-pubertal female is hypo-oestrogenic, thin and
delicate with a neutral pH. The anus is anatomically very close
to the vagina. These factors predispose to inammation and
infection. Non-specic bacterial vulvovaginitis is the most
frequent cause; however, less common causes must be excluded
(Box 3). In a young child an important cause of vaginal
discharge may be an ectopic ureter. Sexual abuse should always
be considered in girls with recurrent or persistent vaginal
Box 3. Causes of vulvovaginitis with vaginal
discharge in pre-pubertal girls
Non-specic with mixed bacterial ora (most
common cause)
Local infectioncauses include the following:
O Group A beta-haemolytic Streptococcus
O Haemophilus inuenzae
O Candida
Systemic infectioncauses include the following:
O Varicella
O Measles
O Rubella
O Diphtheria
O Shigella
Vulval dermatitiscauses include the following:
O Soap
O Bubble bath
O Playing in a sandpit
O Prolonged contact of urine and faeces with the skin
O Irritants; for example perfume, clothing dye
O Foreign bodies
InnovAiT
discharge. Vulval hygiene and the use of appropriate emollients
form the cornerstone of successful management (Box 4).
Box 4. Treatment of vulvovaginitis in a
pre-pubertal girl
O Ensure that the bottom is completely clean after
defaecation
O Avoid constipation
O Wipe from front to back
O Avoid soaps and bubble baths
O Ensure that the vulval area is properly dry after bathing
O Ensure legs are wide apart when passing urine
Avoid tight clothing, especially jeans
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O
O Wear cotton underwear
O Do not wear underwear in bed
O Use gentle emollients and barrier creams
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. If BV is
identied as a cause of vaginal discharge in pregnancy, it should
be treated. Treatment regimens include: Oral metronidazole
400mg twice daily for 5 days; metronidazole gel 5 g nightly for
5 nights; oral clindamycin 300 mg twice daily for 7 days; or
clindamycin cream for 3 days.
VVC in pregnancy
VVC is common in pregnancy. Treatment is the same as for
non-pregnant 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 no indication for routine screening for TV in
pregnancy. However, treatment with oral metronidazole
(400 mg bd for 7 days) is indicated if TV is diagnosed. There
is increasing evidence that TV may be associated with
preterm delivery and low birth weight.
Chlamydia in pregnancy
The recommended regimen for treatment of chlamydia
infection in pregnancy is erythromycin 500 mg four times
a day for 7 days or erythromycin 500 mg twice a day for
14 days. Due to higher positive chlamydia tests after
515
 treatment in pregnancy, attributed to either less
efcacious treatment regimen, non-compliance or re-
infection, it is recommended that pregnant woman must
have a test of cure 5 weeks after completing therapy
(6 weeks later if given azithromycin).
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.
Key points
O Vaginal discharge is a common presenting symptom
in the GP surgery
O Among women of reproductive age complaining of
vaginal discharge, the most common cause is
physiological, but infective and other causes should
be excluded
O When taking swabs to establish a diagnosis, if there
is a delay in transportation, vaginal swabs should be
refrigerated at 4C for no longer than 48 hours
O BV and vaginal candidiasis are the most common
causes of infective vaginal discharge but neither is
sexually transmitted
O Infections with Trichomonas vaginalis, C. trachomatis
and N. gonorrhoeae are sexually transmitted. Contact
tracing should be undertaken and partners treated to
prevent re-infection
O Offer Chlamydia screening to all sexually active
under-25-year olds
Dr Sreekala Seepana
GP Trainee, Diana, Princess of Wales Hospital, Grimsby
E-mail: drsreekala@yahoo.com
Dr Sudhakar Allamsetty
GP, Grimsby
516
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