VAGINAL DISCHARGE

Vaginal discharge is one of the commonest gynaecological problems that

presents in primary care and outpatient gynaecology clinics. While there is a
long list of infectious and non-infectious causes, the focus of this presentation
are the three most common infective causes which are Bacterial vaginosis,
vulvovaginal candidiasis, and trichomonas vaginalis.

Pathological vaginal discharge

Infective discharge

Other reasons for discharge

Common causes

Common causes

Organisms:

Retained tampon or condom

Cand Chemical irritation

ida
albic
ans

Trich Allergic responses

omon
as
vagin
alis

Chla Ectropion
mydi
a
trach
omati
s

Neiss Endocervical polyp

eria
gonn
orrho
eae

Conditions
Bacterial vaginosis

Intrauterine device
AtropHic changes

Acute pelvic inflammatory disease

Postoperative pelvic infection

Less common Causes

Post-abortal sepsis

Physical trauma

Pueperal sepsis

Vault granulation tissue

Less common causes

Vesiovaginal fistula

Human papillomavirus

Rectovaginal fistula

Primary syphilis

Neoplasia

Mycoplasma genitalium
Ureaplasma urealyticum
Escherichia coli

Lactobacilli: Lactobacilli are the predominant organism within the vagina and
they ensure that the pH of the vagina is kept low (acidic).
Bacterial Vaginosis (BV): BV is the most common cause of abnormal
vaginal discharge. It is caused by an overgrowth of predominantly anaerobic
organisms (esp. gardnerella vaginalis). They replace the lactobacilli and
bring about an increase in the vaginal pH. Often asymptomatic; it is
associated with thin white

homogeneous discharge which can be malodorous. Presence of BV has

been associated with post abortion endometritis, increased risk of late
spontaneous miscarriage and preterm birth.
Vulvovaginal Candidiasis: Vulvovaginal candidiasis is caused by an
overgrowth of candida (90% candida albicans). Usually symptomatic, it
classically causes a discharge and vulval irritation.
Trichomonas Vaginalis (TV): TV is a flagellated protozoan. It is a
sexually transmitted infection which usually causes an offensive vaginal
discharge.
SYMPTOMS OF VAGINAL INFECTIONS
Bacterial vaginosis
Candidiasis
Approximately 50%
assymptomatic
Offensive fishy-smelling
discharge

10-20% asymptomatic
Vulval itching
Vulval soreness

Trichomoniasis
10-50% asymptomatic
Offensive vaginal
discharge
Vulval itching/irritation

Vaginal discharge (nonoffensive)

Superficial dyspareunia

Dysuria
Rarely low
abdominal
discomfort

CLINICAL SIGNS OF VAGINAL INFECTIONS

Bacterial vaginosis
Candidiasis

Trichomoniasis

Vulval erthema
Thin white homogenous
discharge, coating walls of
vagina and vestibule

Vulval erythema

Absence of vaginitis

Vulval fissuring

Vaginitis

Vaginal discharge may

be curdy (non-offensive)

Vaginal discharge in up to
70%, frothy and yellow in
10-30%
Approximately 2%
strawberry cervix visible
to the naked eye
5-15% no abnormal signs

Satellite skin lesions

Vulval oedema

DIAGNOSTIC TESTS FOR VAGINAL INFECTIONS

Candidiasis
Whiff test release Bacterial
of fishy odour on
adding
alkali (10% vaginosis
Positive
Negative
Vaginal
>
4.5
All pH
ranges
KOH)pH

Trichomoniasis
Usually
positive
> 4.5

Pseudohyphae (4060% cases)

Blastospores
(addition
of KOH to
Saline microscopy
the wet smear
of vaginal discharge
lyses epithelia cells Flagellated protozoa
Clue cells (95%
TREATMENT
AND MANAGEMENT
from lateral vaginal
and may make
of causes)
wall
(40-80%
hypae more
apparent
cases)
Bacterial vaginosis:
Metronidazole 500mg bd orally for 7 days OR
Metronidazole 2g orally in single dose OR

Gram
stain of clindamycin cream 2% onceSpores/
Intravaginal
a day for 7 days OR
vaginal
discharge
pseudohyphae
from
Intravaginal
clindamycin gel (0.75%)(65%
onceofdaily
forof5 days
lateral
more
vaginal wall
symptomatic
(clindamycin
and metronidazole have equal efficacy
comparing oral and vaginal
cases)
formulations)
Vulvovaginal candidiasis:
Intravaginal and oral therapies provide equally effective treatments.
Intravaginal treatments include clotrimazole vaginal tablet 500 mg once or

200 mg once daily for 3 days OR

Oral preparations include Fluconazole 150mg as a single dose.

Trichomonas Vaginalis:
Metronidazole 500mg orally bd for 7 days OR
Metronidazole 2g orally in a single dose
The management and treatment of TV does include further screening for STIs and
partner notification and treatment.

Recurrent vaginal discharge:

Recurrent bv is a common problem. It is reasonable, in some cases, to give a
prolonged maintenance dose of metronidazole but there is still a high recurrence
rate. There is weaker evidence of the possible benefits of a acidifying gel to
reduce
the number of recurrences or/and intravaginal application of lactobacilli.
Recurrent
candidiasis is also difficult to treat. Long term maintenance regimens have been
tried. One option would be the use of oral fluconazole weekly for 6 months.

Gambar 1. Clue cell

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