Vaginal discharge ⚠️
  • Vaginal discharge can be normal
  • Abnormal when there is an increased amount or changed colour, smell, soreness, itch
  • Caused by a range of infectious and non-infectious conditions such as gonorrhoea, chlamydia, trichomonas, candida (thrush), bacterial vaginosis, atrophic vaginitis
  • Less common causes include mycoplasma genitalium, herpes simplex, cancer or foreign body (eg retained tampon) 
  • STIs are common in women with risk factors
  • If pregnant consider ruptured membranes, intrauterine infection

Ask

  • Discharge — amount, colour, smell, duration (how long)
  • Itchy, sore
  • Pain on passing urine. Urinary symptoms can be caused by STIs or UTIs
  • Pregnant
  • Last menstrual period
  • Lower abdominal pain, pain deep inside with sex. If present — see Pelvic inflammatory disease
  • Other STI symptoms — swollen lymph nodes, genital lumps, ulcers, sore throat, rash, hair loss
  • Sexual partner/s — male, female, other, and if any from geographical area with penicillin-resistant gonorrhoea — Table 5.5
  • Foreign body (eg tampon, condom)

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 

Do

  • Full STI check
  • pH test if available — before putting swab into transport medium, touch sample onto pH paper (test unreliable if woman post-menopausal, semen or blood present)
  • If pH 4.5 or more (high) or pH test not done — treat for trichomonas and bacterial vaginosis straight away. Do not wait for test result
    • Give metronidazole oral — adult 2g, single dose
    • OR metronidazole oral — adult 400mg, twice a day (bd) for 7 days. Best for breastfeeding, take after baby fed
  • Contact tracing — telling partners
  • STI and safer sex education
  • Consider talking about contraception
  • Consider thrush
  • If foreign body suspected — do speculum exam (if skilled)

Do — if high risk of STI

High risk of STI — women with abnormal vaginal discharge and under 35 years

  • Treat for both gonorrhoea and chlamydia. Presentations very similar, syndromic management. Do not wait for laboratory or POC Test results if not immediately available
  • If woman and all sexual partners in last 3 months from a geographical area with penicillin SENSITIVE gonorrhoea — Table 5.5
    • Give azithromycin oral — adult 1g, single dose
    • AND amoxicillin oral — adult 3g, single dose
    • AND probenecid oral — adult 1g, single dose 
  • If woman and/or any sexual partner in last 3 months from a geographical area with penicillin RESISTANT gonorrhoea — Table 5.5 OR partners unknown 
    • Give azithromycin oral — adult 1g, single dose
    • AND ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
  • If allergy to penicillin or pregnant — medical/sexual health consult

Table 5.5 Geographical treatment areas for gonorrhoea  

Follow-up

  • Review after 1 week — test results, response to treatment and further education
  • If no improvement with treatment — medical/sexual health consult
  • If STI results positive — see STI management
    • Check HIV and syphilis serology done
  • Any woman who has had an STI is at high risk of getting more STIs
    • If positive test result, re-test in 3 months OR in 4 weeks if pregnant
    • Standard STI check

Candidiasis (thrush)

  • Usually caused by Candida albicans
  • Not sexually transmitted and contact tracing not needed
  • Often found in vagina without causing any problems (asymptomatic) 
    • More common if pregnant, weakened immune system, diabetes, long course of broad-spectrum antibiotics
    • Only treat if causing problems
  • Thrush can cause
    • Vulval itch or burning
    • White, thick curd-like discharge that sticks to vaginal walls
    • Very red inflamed vulva and vagina

Do

  • Talk with woman about keeping genital area clean and dry, salt water washes and wearing cotton underwear
  • Give clotrimazole vaginal pessary — 500mg, single dose
  • OR miconazole 2% cream for 7 days
  • If not better medical consult about fluconazole oral — adult 150mg, single dose.
    • Do not give if pregnant or breastfeeding
  • If woman has diabetes try to improve blood glucose control

Follow-up

  • Some women get recurrent thrush even when well. If recurrent or persistent thrush — important to check for diabetes and weakened immune system
    • BGL
    • Offer HIV serology
    • Medical consult about further tests. Consider Candida glabrata — arrange for MC&S

Woman with recurrent discharge caused by thrush needs management plan in file notes to stop repeated, unnecessary treatment for STIs

Bacterial vaginosis (BV)

  • Due to change in vaginal bacteria and causes high pH
  • Can cause abnormal vaginal discharge and unpleasant odour
  • Not sexually transmitted and contact tracing not needed
  • Often found in vagina without causing any problems (asymptomatic)

Do

If MC&S result shows 'clue cells' or other findings consistent with BV AND

  • If symptomatic 
  • If asymptomatic AND not pregnant or pregnant with no history of preterm labour — Do not treat
  • If pregnant with history of preterm labour — medical consult about management plan
  • If still symptoms after initial single dose treatment 
    • Give metronidazole oral — adult 400mg, twice a day (bd) for 7 days
    • Advise women to avoid douching (cleaning inside vagina)
  • No follow-up needed but if symptoms persist — medical consult