abnormal vaginal discharge differentials
approach
| Headline | |
|---|---|
| History | physiological discharge? Infective cause? Non-infective? ➥ COCA ➥ Cyclical s/s? ➥ STI screen + sexual history ➥➥ Risk ax for STI (age<25, new sexual partner in last year, previous STI) ➥ Tried any treatments? Vaginal products? Washing practices? |
| Examination | abdo/external genitalia exam, speculum |
| Diagnostic investigations | pH: >4.5 – BV, trichomonas; <4.5 – candida ➥ High vaginal swab if higher risk ➥ High risk STI: test for chlamydia, gonorrhoea, trich |
| Differentials | Candida Chlamydia Bacterial vaginosis |
candidiasis
| Etiology | Candida albicans or non-albicans species. Incubation: 7-21d |
| Epidemiology | Risk factors: diabetes Not sexually transmitted |
| Clinical presentation | white, odourless, curdy discharge ± itching, superficial soreness |
| Diagnostic investigations | ➥ High vaginal swab if higher risk ➥ High risk STI: test for chlamydia, gonorrhoea, trichomonas |
| Management | Empirical fluconazole PO stat, clotrimazole PV stat ➥ No treatment needed if asymptomatic ➥ Avoid oral treatment if pregnant/breastfeeding ➥ Exclude eczema, lichen sclerosus, STIs ➥ Advise skin case e.g. no perfumed soaps ➥ Microbio testing if poor response |
trichomonas
| Headline | |
|---|---|
| Etiology | protozoal infection with Trichomas |
| Epidemiology | |
| Clinical presentation | green frothy discharge dysuria, dyspareunia |
| Pathogenesis | |
| Diagnostic investigations | 'strawberry' cervix |
| Management | metronidazole (400mg BD 5-7 days) |
bacterial vaginosis
| Headline | |
|---|---|
| Etiology | overgrowth of bacteria including Gardnarella |
| Epidemiology | Not sexually transmitted |
| Clinical presentation | thin, 'fishy-smelling' discharge |
| Pathogenesis | |
| Diagnostic investigations | - clue cells on microscopy: stippled vaginal epithelial cells - vaginal pH > 4.5 |
| Management | metronidazole (400mg BD 5-7 days) (or one off 2g) prevention: avoid smoking, vaginal douching and the use of antiseptics, bubble baths, or shampoos in the bath |