Causes
Vaginal discharge is a subjective complaint and cannot be accurately quantified.
If vaginal discharge has changed in quantity or nature then it may need investigating. Patients experiencing this common complaint may feel distressed.
Though vaginal discharge is often non-STI related, consider additional STI risk.
Non-pathological discharge may be physiological or iatrogenic (such as hormonal contraception related).
A degree of vaginal discharge that changes with the menstrual cycle can be normal, but a change in the nature or volume of the discharge or other genital or pelvic symptoms suggests a pathological cause. Genital or pelvic symptoms could include:
- dyspareunia
- pelvic pain
- itch
- irregular bleeding
- vaginal malodour
Common causes of vaginal discharge
Infective
- Bacterial vaginosis
- Candidal vulvovaginal infection
- Streptococcal or haemophilus bacterial infections – especially premenarchal and postmenopausal, or if late pregnancy
Infective and sexually transmitted
- Chlamydia trachomatis
- Neisseria gonorrhoeae;
- Mycoplasma genitalium
- Trichomonas vaginalis
Non-infective
- Retained foreign body in the vagina, for example - a tampon. Discharge is often malodorous.
- Cervical polyps or ectropion
- Atrophic vaginitis
- Inflammatory skin conditions affecting the vaginal mucosa, for example desquamative inflammatory vaginitis
- Malignancy of the genital tract
- Vaginal fistulae
Clinical presentation
| Diagnosis | Inspection of vulva | Inspection of vagina and cervix |
|---|---|---|
| Bacterial vaginosis | Minimal inflammatory changes in vagina and vulva, excessive discharge may be seen on inspection | White homogenous vaginal discharge, raised vaginal pH > 4.5, fishy smell from vagina, no inflammatory changes, but occasionally coexists with symptomatic candida |
| Candidal vulvovaginitis | Inflammatory vulvovaginitis, thick curd like discharge sometimes visible externally |
Thick white discharge, vulval and vaginal inflammation, fissuring of vulval skin, pH < 4.5 Discharge not always typical |
| Trichomonas vaginalis |
Vulval contact irritation if excessive Yellowish bubbly discharge |
Vaginitis and sometimes ecto-cervicitis (strawberry cervix), pH > 4.5 |
|
Atrophic vaginitis (post-menopausal) |
Atrophic vulvovaginal changes such as pallor, patchy redness, hypo-oestrogenisation | Vaginitis, superficial dyspareunia, contact vaginal wall bleeding, loss of vaginal rugae, occasionally a mustard coloured discharge pH >4.5 |
| Retained tampon or other material | Retained product in vagina, normal vulva | Offensive discharge, product seen and felt in vagina |
| Herpes Simplex Virus (HSV) | Vulval /perianal ulcers or fissures | Cervicitis or cervical ulcers with blood stained or purulent discharge possible vaginal ulcers |
| Chlamydia, gonorrhoea, Mycoplasma genitalium | Vulva is normal but may have visible discharge | Possible muco-purulent cervicitis, may be normal, may have PID on exam. That is, pelvic tenderness, discharge may be seen coming from cervix, cervix may bleed with cotton tip touch. |
Diagnosis
History
Take a thorough history from your patient. Establish in what way the discharge is different to normal. For example, is the discharge:
- odorous
- cyclical
- blood stained
- coloured
Establish what other symptoms are present. For example:
- lower abdominal pain
- dyspareunia: superficial or deep
- irregular vaginal bleeding: intermenstrual or post-coital bleeding (PCB)
- itching around the genital area
- urinary symptoms: frequency, pain
Take a menstrual history:
- last menstrual period and cycle regularity
- contraception and whether its hormonal or not
- pregnancies and whether currently pregnant
- vaginal hygiene practices
- past history of BV or other vaginal infections and recurrence pattern
Assess for risk of STIs
- current and recent sexual partners
- sex with or without condoms
Clinical hints
- Blood-stained discharge may indicate cervicitis: chlamydia, gonorrhoea, Mycoplasma genitalium or herpes
- Vulval symptoms such as superficial dyspareunia, vulval itch, pain or irritation suggest vulvovaginitis (candida)
- No associated symptoms and the only complaint being excessive discharge with malodour suggests BV
- The presence of BV may increase the likelihood of STI/PID so this needs to be considered if the history is suggestive
Examination
- Palpate the abdomen and inguinal lymph nodes
- Examine the vulva for dermatitis, fissures, ulcers or erosions
- Speculum examination (if not in pain) for visualisation of the cervix and vagina and excluding a foreign body, pH testing
- Pelvic examination unless no risk of clinical PID or pregnancy
Investigations
| Test | Site/ specimen | Comments |
|---|---|---|
| Gram stain and culture | Vulval swab | If there are signs of vulvitis, looking for candida and possibly HSV |
| Gram stain without wet prep | Vaginal swab |
If pH< 4.5 Detects candida and BV |
| Gram stain plus wet prep | Vaginal swab |
If pH> 4.5 Detects BV and trichomonas |
| PCR |
Vaginal swab First void urine |
Trichomonas |
| NAAT |
First void urine High vaginal swab |
Detects chlamydia and gonorrhoea Mycoplasma genitalium: include MG testing if cervicitis or PID |
| NAAT | Endocervical swab |
Gonorrhoea MG |
| PCR | Swab of lesion | Herpes or syphilis if fissures or ulcers found |
| CST | Cervical sample | If indicated |
Streptococcal infection can very occasionally cause vaginal discharge and should be considered
Management
For detailed treatments of individual conditions refer to specific treatment guidelines:
Clinical education: Vaginal discharge
This presentation on vaginal discharges includes discussion on clinical presentations and case studies, laboratory confirmation and treatment options.
Disclaimer
We recognise that gender identity is fluid. In our treatment guidelines, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines.
The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.