Vaginal discharge

Probability diagnosis

Normal or excessive physiological discharge

Vaginitis:

• bacterial vaginosis (40–50%)

• candidiasis (20–30%)

• Trichomonas (10–20%)

Serious disorders not to be missed

Neoplasia:

• cancer (cervix, uterus, vagina)

• fistulas

STIs/PID (i.e. cervicitis):

• gonorrhoea

• Chlamydia

• herpes simplex—types 1 and 2

Sexual abuse, esp. children

Tampon toxic shock syndrome (staphylococcal infection)

Streptococcal vaginosis (in pregnancy)

Pitfalls (often missed)

Chemical vaginitis (e.g. perfumes)

Retained foreign objects (e.g. tampons, IUCD)

Endometriosis (brownish discharge)

Ectopic pregnancy (‘prune juice’ discharge)

Poor toilet hygiene

Pelvic fistula

Genital herpes (possible)

Cervical polyp

Bartholinitis

Atrophic vaginitis

Threadworms

Latex allergy (e.g. condoms)

Masquerades checklist

Diabetes

Drugs

UTI (association)

Is the patient trying to tell me something?

Needs careful consideration; possible sexual dysfunction.

Key history

The history should include:

• nature of discharge: colour, odour, quantity, relation to menstrual cycle, associated symptoms

• exact nature and location of irritation

• sexual history: arousal, previous STIs, number of partners and any presence of irritation or discharge in them

• use of chemicals, such as soaps, deodorants, pessaries and douches

• pregnancy possibility

• drug therapy

• associated medical conditions (e.g. diabetes).

Key examination

• Inspection with good light includes viewing the vulva, introitus, urethra, vagina and cervix

• Look for the discharge and specific problems such as polyps, warts, ectropion, prolapses and fistulas

• Full pelvic examination in a postmenopausal woman

Key investigations

• pH test with paper of range 4–6

• Amine or ‘whiff’ test

• Wet film microscopy of a drop of vaginal secretions

• Full STI workup including high vaginal swab

Diagnostic tips

• Vaginal discharge is an uncommon symptom before puberty.

• It is common to overlook the problems caused by hygienic preparations including deodorant soaps and sprays and contraceptive agents especially spermicidal creams.