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Vaginal discharge is the most common reason for women to seek medical care and these symptoms are also seen by doctors in services like primary care, gynaecology, family planning and departments of genitourinary medicine. Doctors may suggest a sexually transmitted infection screening, if an abnormal vaginal discharge is reported by patients because it is prognostic of a sexually transmitted infection. Vaginal discharges can be classified or categorised as physiological or pathological (Mitchell, 2004). In general, 5% to 10% of women attending general practitioners suffer from a vaginal discharge and a considerable proportion of the women with this symptom attend gynaecological or contraceptive clinics and departments of venereology (Catterall, 1970).
Clinicians should be aware of the different causes, forms of vaginal discharge and the approach for the management of symptoms according to their aetiology (Spence and Melville, 2007). The World Health Organization (WHO) provided a method for the management of vaginal discharge in the three ways as listed below (WHO Guideline: p 24, 25, 26, 2003).
WHO methods for management of vaginal discharge:
Take history, Physical examination, risk assessment and treatment.
Take history, external, speculum and bimanual examination of patient, risk assessment, perform wet mount microscopy and treatment.
Take history, external, speculum and bimanual examination of patient, risk assessment and treatment.
The aim of this study is to develop a simplified flow chart with a comprehensive protocol for the management of the vaginal discharge in sexually active women.
Vaginal discharge may be induced by a range of physiological and pathological conditions. Vaginal discharge is mainly associated with three types of infection, such as candidiasis, bacterial vaginosis and trichomoniasis (Sherrard, 2001). The non-infective, non-sexually transmitted infections and sexually transmitted infection which cause vaginal discharge are all listed below (Spence and Melville: p1147, 2007).
Foreign bodies, such as retained tampon
Non-sexually transmitted infection
Sexually transmitted infection
We will discuss the main causes of vaginal discharge in detail in the following section.
Physiological vaginal discharge
Physiological vaginal secretion is nothing but cervical mucus and each woman has her own sense of normality for vaginal secretion as well as what is excessive. During her menstrual cycle the quantity and quality of vaginal discharge may vary in the same woman because the concentrations of progesterone and oestrogen change. Prior to ovulation cervical mucus becomes fertile (thinner, clearer, more stretchy, wetter and slippery) rather than the non-fertile type (Thicker and stickier) due to the increased oestrogen concentration. After ovulation, cervical mucus become thick, sticky and hostile to sperm due to the decreased concentration of oestrogen and increased concentration of progesterone. From puberty the vagina is colonised by Lactobacilli and other bacteria (anaerobic Streptococci, diphtheroids, coagulase-negative Staphylococci and alpha-haemolytic Streptococci) and overgrowth of some bacteria causes infection: Candida albicans, staphylococcus aureus and Î²-haemolytic streptococci (FFPRHC and BASHH Guidance, 2006).
Bacterial vaginosis (BV)
Bacterial vaginosis is the commonest infective cause of vaginal discharge and it represents 40-50% of cases in family practice (Sobel, 1997). The true prevalence of bacterial vaginosis is uncertain because around 50% cases are asymptomatic (Mitchell, 2004). Several factors are known to increase the risk of bacterial vaginosis, including younger age (mainly in women of childbearing age group) (Ralph et al, 1999), black ethnicity (Goldenberg et al, 1996), douching (Hawes et al, 1996), smoking (Hellberg et al, 2000), and use of the intra uterine devices as contraception (Avonts et al, 1990). Bacterial vaginosis is a polymicrobial clinical syndrome in which the normal hydrogen peroxide-producing Lactobacillus species are replaced by an anaerobic bacterium: Mycoplasma hominis and Gardnerella vaginalis in the vagina. Proteolytic enzymes are end products of the overgrowth of anaerobic microorganisms and they release a number of biological products such as polyamines. Polyamines elaborate foul-smelling trimethylamine after volatilization in the alkaline environment and they also promote the transudation of vaginal fluid with exfoliation of epithelial cells, resulting in a copious discharge. Gardnerella vaginalis which forms clue cells and adhere to exfoliated epithelial cells in the presence of an elevated pH (Sobel, 1997).
Candidiasis is the commonest infective cause of vaginal discharge. It affects around 75% of women during their reproductive life, 40-50% women suffer from two or more episodes of candidiasis (Mitchell, 2004) and 10-20% of women are asymptomatic with candidiasis (Sherrard et al, 2009, FFPRHC and BASHH Guidance, 2006). Vulvovaginal candidiasis is the second commonest infective cause of vaginal discharge and it is originated due to overgrowth of yeasts mainly Candida albicans (80-95% of cases) or Candida glabrata (5%) within the vagina. Candidiasis usually occurs in young women and during pregnancy because, during this period, the vagina is exposed to more oestrogen. Around 50% of women who have suffered from an acute attack of candidiasis will have a further episode. Lifetime incidence of candidiasis is 50-70% in women (FFPRHC and BASHH Guidance, 2006).
Trichomonas vaginalis is a flagellated protozoon which causes a sexually transmitted infection known as trichomoniasis. The WHO estimated that the worldwide prevalence of trichomoniasis is 170 million and in American women is around 3-5 million. The vaginal discharge in women with trichomoniasis is thin, profuse and pools in the vaginal vault. In trichomoniasis, a strawberry cervix results from punctuate haemorrhage (Khan et al, 2009).
Gonorrhoea is an infectious disease caused by gram-negative diplococcus Neisseria gonorrhoeae. The mucus membranes of the urethra, endocervix, rectum, conjunctiva and pharynx are the primary sites of infection and transmission occurs by direct inoculation of infected mucus secretion from one mucus membrane to another (Clinical Effectiveness Group, BASHH, 2005). Cases of gonorrhoea have declined since the peak in 2002 (STD statistics and STDs in the UK, 2010).
Genital chlamydia is the most frequently diagnosed sexually transmitted infection in UK genitourinary medicine clinics and its highest prevalence presents in the younger age groups. Each year around 89 million new cases of genital chlamydia infection occur worldwide and untreated infections cause complications such as: pelvic inflammatory disease tubal factory infertility, arthritis and ectopic pregnancy (NCSP, 2010).
To control the chlamydia infection early detection and proper treatment of asymptomatic infection are necessary and it will help to prevent the development of disease transmission, to achieve this goal The National Chlamydia Screening Programme (NCSP) was established in England in 2003 (NCSP, 2010).
Evaluation of vaginal discharge
The first step towards effective treatment is to confirm the cause of vaginal discharge. Vaginal discharge is caused by number of conditions which are described in previous sections. A detailed medical history of the patient is important to find out the appropriate cause of the vaginal discharge. In the below section, we will discuss the different stages/process in evaluation of vaginal discharge.
History taking is very important factor; it will provide characteristics of discharge such as its duration, colour, odour, consistency and presence of itch. Presence of pelvic pain, pelvic tenderness and fever indicate the likelihood of pelvic inflammatory disease. Further need of clinical examination and investigation is based on the history (Spence and Melville, 2007).
Abdominal palpations are performed for pain and tenderness. Inspection of the vulva is necessary to identify discharge and vulvitis. Speculum examination is important to assess the discharge and existence of foreign bodies; it is also helpful for examination of vaginal walls and cervix. Bimanual pelvic examination is performed to find out adnexal and uterine tenderness as well as cervical motion tenderness (FFPRHC and BASHH Guidance, 2006).
Exclusion of infective and other causes can help to confirm that a vaginal discharge is a physiological discharge. It is helpful to educate the patient about pathological and physiological discharges.
An intravaginal foreign body, if retained for a long duration, can lead to serious sequelae and significant morbidity therefore, to manage the vaginal discharge, removal of foreign body is important. In Simon et al., a 13 year old woman, was suffering from purulent and malodorous vaginal discharge which was resolved by antibiotic therapy but it was recurrent with each menstrual cycle. On clinical examination, the patient was found to have a blind ending vagina but even with the help of ultrasound and MRI no vaginal foreign body was found. Vaginoscopy is performed under anaesthesia and dense adhesions were found with a foreign body in the upper part of vagina. After removal of foreign body, the superior vagina was sutured to inferior vagina and mentor mold was placed in the vagina to maintain patency (Simon et al, 2003).
Refer to oncology
If the patient has intermenstrual bleeding, postcoital bleeding, consider as malignancy and refer to oncology within 2 week (Healthguides, 2010).
Lower abdominal tenderness or cervical motion tenderness
If sexually active women present with lower abdominal pain, tenderness or cervical motion tenderness they should be carefully evaluated for the presence of salpingitis, endometriasis and other elements of pelvic inflammatory disease (PID)(WHO, 2003).
Diagnosis based on clinical and sexual history (FFPRHC and BASHH Guidance, 2006, Sherrard, 2009, Health guides, 2010)
Suspected bacterial vaginosis
Approximately 50% of infected females are asymptomatic
Offensive, fishy-smelling vaginal discharge
Not commonly associated with soreness, itching or irritation
Thin, white, homogenous discharge which coats vaginal walls and vestibule
Vulval inflammation absent
Suspected vulvovaginal candidiasis
Thick white discharge
non-offensive vaginal discharge
pain during intercourse
pain while urinating
vulval erythema, oedema or fissuring
curd-like vaginal discharge
satellite skin lesion
Scanty to profuse or frothy yellow vaginal discharge
Abdominal discomfort occasionally present
Up to 70% of infected females have vaginal discharge
10-30% of infected females have classical frothy, yellow-green discharge
Vulvitis and vaginitis
Approximately 2% "strawberry" cervix visible to naked eye
Number of studies has been conducted to assess the efficacy of syndromic management to treat sexually transmitted infections. Syndromic management has been considered as practical way for treating sexually transmitted infections but still there is no universal consensus on its effectiveness, mainly for diagnosis of vaginal and cervical infection. To evaluate the efficacy of different syndromic algorithms, a review of published and unpublished studies has performed. They observed sensitivities for algorithms for vaginal discharge between 73%-93% among women with vaginal discharge and 29%to 86% for women with no vaginal discharge. A syndromic algorithm is not an independently effective screening tool to diagnose cervical infection in women because vaginal discharge is not effective indicator of cervical infection (Pettifor et al, 2000).
The success rate of VD algorithms mainly depends on the prevalence of infection within the target population therefore, management of cervical infection with VD algorithms is difficult but it will prove more successful among high risk women and symptomatic persons. Therefore, vaginal discharge algorithms are not efficient screening tools to detect cervical infection among low-risk populations (Pettifor et al, 2000). However, Vishwanath et al., concluded that "prevalence of cervical infection associated with chlamydia trachomatis was high among low risk women" (Vishwanath et al: p 305, 2000).
Thus, syndromic case management is missing a large number of asymptomatic cases and providing treatment in the absence of disease therefore, syndromic management is not an efficient tool to manage the causes of vaginal discharge.
Many different diagnostic tests need to be done to investigate the cause of vaginal discharge, these are described below;
Vaginal pH measurement is useful to assess the probability of infections such as bacterial vaginosis or trichomoniasis where pH â‰¥ 4.5 and for candidiasis where pH Ë‚ 4.5. For the diagnosis of bacterial vaginosis, a vaginal pH â‰¥ 4.5 is one of Amsel's criteria (FFPRHC and BASHH Guidance, 2006).
Microscopy is a routine investigation carried out for symptomatic patients and it helps to provide a diagnosis for the cause of vaginal discharge. In Bahram et al's study, for diagnosis of bacterial vaginosis they used Nugent's method which involved assigning a score between 0 and 10 based on the quantitative assessment of the Gram-stain for three different bacterial morphotypes,
large Gram-positive rods (indicative of Lactobacillus spp)
Small Gram-negative or variable rods (indicative of Gardnerella, Bacteroides and other anaerobic bacteria)
Curved, Gram-variable rods (indicative of Mobiluncus spp).
The Nugent's score between 0-3 represents normal vaginal flora, 4-6 represents 'intermediate vaginal flora' and where the score is between 7 and 10 consider for diagnosis of bacterial vaginosis. Visualization of motile trichomonas after sampling and presence of spores, hyphae, or yeast buds in the wet mount spear confirms the diagnosis of trichomoniasis. The accurate diagnosis of trichomoniasis is done; by adding potassium hydroxide in wet mount smear which removes the debris that obscures the hyphae (Bahram et al, 2009).
In Patel et al., candidiasis was diagnosed by reading gram-stained slides which considers the rating of the density of yeast cells seen per high power field (Patel et al, 2005). In most symptomatic cases, diagnosis of Neisseria gonorrhoeae is established by visualization of diplococci in leucocytes by performing microscopy of cervical, urethral and rectal exudates (Bignell, 2001).
A gram stain slide with high vaginal swab is prepared for microscopy, which exposes candida infection (pseudohyphae) or bacterial vaginosis (clue cells and other organisms with proportions of lactobacilli). To identify protozoa in trichomoniasis and pseudohyphae in candida infection, wet microscopy is useful, which is prepared by dipping a small amount of discharge into saline on a microscope slide (FFPRHC and BASHH Guidance, 2006).
In the UK culturing is the method of choice for the detection of Neisseria gonorrhoeae (2 cited by FFPRHC and BASHH Guidance, 2006). Culturing is also available for candida and trichomoniasis; if microscopy is uncertain in the identification of candida then culturing in Sabouraud's medium can be useful (8 cited by FFPRHC and BASHH Guidance, 2006). Culture using the InPouch TV culture kit can be used for diagnosis of Trichomonas vaginalis where it is incubated for 5 days at 37oC and observed daily for motile trichomonads (Patel et al, 2005).
In Young's study, modified New York City medium (MNYC) was compared with Thayer Martin (TM) medium for the cultural diagnosis of gonorrhoea and they observed that MNYC medium is a more efficient medium for the cultural diagnosis of gonorrhoea (Young, 1978).
Nucleic acid amplification test
In Patel et al's study chlamydial and gonococcal infections were diagnosed by using a PCR technique (Patel et al, 2005). The polymerase chain reaction is a more sensitive and reliable diagnostic tool in sexual health practice. Garrow and colleagues carried out a study at a remote part of north western Australia to diagnose Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis infection by using self obtained vaginal swabs. They concluded that self obtained vaginal swabs (SOLVS) are an acceptable and sensitive diagnostic sample and SOLVS PCR is a good, conventional test for identification of infections such as Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis (Garrow et al, 2002). The Roche Cobas Amplicor® Chlamydia trachomatis/Neisseria gonorrhoeae (CT/NG) PCR assay is capable of detecting both Chlamydia trachomatis and Neisseria gonorrhoeae (Leslie et al, 2003).
Chlamydia rapid test
Mahilum and colleagues conducted a performance evaluation study to test the performance of a new Chlamydia Rapid Test using vaginal swab specimens. Studies were carried out in three places in the United Kingdom: one at a young people's sexual health centre (site 1) and two at genitourinary medicine clinics (sites 2 and 3). The positive outcome rate for the polymerase chain reaction at site 1 was 8.4% (56/663), for site 2 was 9.4% (36/385) and for site 3 was 6% (18/301). For the Chlamydia Rapid Test, the sensitivity was 83.5% (91/109), specificity was 98.9% (1224/1238), the positive predictive value was 86.7% (91/105) and the negative predictive value was 98.6% (1224/1242) compared with the polymerase chain reaction assay. The sensitivity and specificity of the Chlamydia Rapid Test were 81.6% (40/49) and 98.3% (578/588) compared with the strand displacement amplification assay. They concluded that the Chlamydia Rapid Test with self collected vaginal swab has good sensitivity and specificity. The Chlamydia Rapid Test reduces the risks of persistent infection and its onward transmission because the results are available within 30 minutes which helps for immediate treatment. The Chlamydia Rapid Test is a potential alternative to a nucleic acid amplification test, due to its cost effectiveness in resource limited clinics. Chlamydia Rapid Test is a cost effective and reliable alternative to a nucleic acid amplification test for diagnosis of Chlamydia (Mahilum-Tapay et al, 2007).
The (Faculty of Family Planning and Reproductive Health Care) FFPRHC and (British Association for Sexual Health and HIV) BASHH provided the guidelines for laboratory testing of womens complaining of vaginal discharge. These guidelines are summarized in Table 1 below;
Table 1 Summary of laboratory processing of specimens from women complaining of vaginal discharge.Ref: FFPRHC and BASHH Guidance: p 34, 2006
Management of vaginal discharge
Management of the different causes of vaginal discharge are described below:
Oral metronidazole is the current treatment of choice for the bacterial vaginosis and it demonstrates 80 to 90% of cure rates in patients (Sweet, 1993) but it has unpleasant adverse effects such as gastrointestinal upset, metallic taste, rash over body and is contraindicated in pregnancy (Schmitt et al, 1992).
Schmitt and colleagues carried out a randomized and double blinded study with 48 women with symptomatic bacterial vaginosis. They were randomized to receive either 5g of 2% clindamycin vaginal cream daily or 500 mg oral metronidazole tablets twice a day for one week. After completion of therapy observers did not find any significant difference in cure rates: 72% for clindamycin and 87% for metronidazole. They concluded that clindamycin vaginal cream is an effective and safe alternative for oral metronidazole to cure bacterial vaginosis and the vaginal route of cream administration reduces the systemic side effects associated with oral metronidazole (Schmitt et al, 1992).
Ferris and colleagues carried out a randomized study to compare the efficacy of oral metronidazole, metronidazole vaginal gel and clindamycin vaginal cream. Around 101 women with symptomatic bacterial vaginosis were randomized to receive, 500 mg oral metronidazole twice daily for 7 days, 0.75% metronidazole vaginal gel 5 gm twice daily for 5 days or 2% clindamycin vaginal cream 5 gm once daily for 1 week. After completion of therapy there were no statistically significant differences found in the cure rates: 84.2% for oral metronidazole, 75% for metronidazole vaginal gel and 86.2% for clindamycin vaginal cream (p=0.548). All three therapies have shown nearly equivalent cure rates but patients reported more satisfaction with the intravaginal products (Ferris et al, 1995).
Woolley and Higgins carried out a randomized trial to compare the efficacy of clotrimazole, fluconazole and itraconazole in vaginal candidiasis. They randomized 229 women with acute vulvovaginal candidiasis to receive either a clotrimazole 500 mg pessary plus 1% of cream, 150 mg fluconazole single oral dose or 200 mg itraconazole twice a day oral dose for one day. The clinical cure rates were 80% for itraconazole, 80% for clotrimazole and 62% for fluconazole which indicates that itraconazole or clotrimazole are more effective in the treatment of acute vaginal candidiasis than fluconazole (Woolley and Higgins, 1995).
Fluconazole and itraconazole have shown good efficacy in the treatment of acute vulvovaginal candidiasis in study carried out by Punzio et al. In this study, 38 patients received 150 mg fluconazole single dose and 32 patients received itraconazole 200 mg per day for 3 days. After 21 days of treatment 13% relapse rate was observed in both group and cure rates were 76% and 66% in fluconazole and itraconazole group respectively (Punzio et al, 2003).
Trichomoniasis is one of the most common sexually transmitted infection and nitroimidazole drugs such as metrnidazole, ornidazole, tinidazole, nimorazole and carnidazole are used to treat this disease. In a meta-analysis of nitroimidazole, the majority of studies used tinidazole or metronidazole for the treatment of trichomoniasis. A number of studies have shown that any nitroimidazole drug given in short or prolonged duration provides cure rate in 90% of trichomoniasis cases (Gulmezoglu and Garner, 1998).
DuBouchet and colleagues carried out a randomized control trial to compare the efficacy and safety of metronidazole vaginal gel and oral metronidazole in Trichomonas vaginalis infection. Around 31 women with Trichomonas vaginalis infection were enrolled in this study and 15 of them received oral metronidazole (250 mg) three times daily and the other 16 applied 0.75% metronidazole vaginal gel twice daily for 1 week. All 15 women were cured with oral metronidazole but only 7 out of 16 women were cured with intravaginal metronidazole (DuBouchet et al, 1998).
A meta-analysis has shown that doxycycline and azithromycin are equally efficacious in the treatment of genital Chlamydia trachomatis infections. The cure rate for azithromycin was 97% and for doxycycline was 98%, no difference in adverse event rates was found (Chuen-Yen et al, 2002). A randomized controlled trial was conducted to compare the efficacy of amoxicillin and azithromycin for the treatment of pregnant women with Chlamydia trachomatis infection. Amoxicillin and azithromycin have shown similar treatment efficacy for curing chlamydia that is: 58% for amoxicillin and 64% for azithromycin (Jacobson et al, 2001).
Covino carried out a study to find out the efficacy of oflaxacin and ceftriaxone in the treatment of uncomplicated gonorrhoea caused by penicillinase-producing and non-penicillinase-producing strains. Around 89 patients with uncomplicated gonorrhoea were enrolled in this study and they received either a 400 mg oral ofloxacin single dose or 250 mg intramuscular ceftriaxone. Eradication of gonorrhoea occurred in all 47 patients who received ofloxacin and 41 patients of 42 who received ceftriaxone (Covino et al, 1990).
In Cavenee's study two hundred fifty-two pregnant women with gonorrhoea were enrolled and they were randomized to receive either 250 mg ceftriaxone intramuscularly, 2 g spectinomycin intramuscularly or 3 g amoxicillin orally plus 1 g probenecid orally in a ratio of 1:1:1. The overall cure rate was 235 out of 252 women, 80 of 84 women were cured with ceftriaxone, 75 of 84 women were cured with amoxicillin with probenecid and 80 of 84 women were cured with spectinomycin. Ceftriaxone and spectinomycin showed higher efficacy rate than amoxicillin with probenecid (Cavenee et al, 1993).
The (Faculty of Family Planning and Reproductive Health Care) FFPRHC and (British Association for Sexual Health and HIV) BASHH has provided the guidelines for the treatment of common causes (Bacterial Vaginosis, Candida & Trichomoniasis) of vaginal discharge, these are summarized in Table 2 and UK national guideline and Bignell have provided guideline to treat chlamydia and gonorrhoea which is summarized in Table 3.
Syndromic management of vaginal discharge is not an efficient approach for identifying women with cervical infections but it is helpful when used in developing countries where laboratory test facilities are not available. Signs and symptoms of pathological vaginal discharge can be treated according to its aetiology therefore, appropriate diagnosis with accurate diagnostic tests is important. The flowcharts developed and discussed in this article will help, not only to investigate the causes of vaginal discharge but to treat them with the best and most appropriate available treatments.