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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shankar Kumar, M.B.B.S. [2] Samah Obaiah Rinky Agnes Botleroo, M.B.B.S.


Synonyms and Keywords: Discharge from the vagina, Leukorrhea

Overview

Vaginal discharge is a common patient complaint that is paired with anxiety regarding sexually transmitted diseases. If a STD is detected, a search for all other STDs should be done. Advise the infected patient to inform all sexual partners of their diagnosis.Also there is normal vaginal discharge depends on periodic hormonal change[1]Vaginal discharge is a common complaint in primary care which can be a subjective complaint or an objective finding. So, it is important to differentiate between normal physiological discharge and pathological discharge. Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina. It is produced by the cells of the vagina and cervix. Normal vaginal discharge changes with the menstrual cycle, such as the character of the discharge is clearer with a stretchable consistency around ovulation, then may be thicker and slightly yellow during the luteal phase. Normal healthy discharge should not be associated with symptoms such as itching, redness and swelling, and does not have a strong odor. It is important to take complete history and ask about the associated symptoms like dysuria, dyspareunia, lower abdominal pain, itching, and fever. While considering the causes, it is necessary to distinguish between infectious and non-infectious. The infectious causes are infection with Candida albicans, Trichomonas vaginalis, Gardnerella vaginalis, Chlamydia trachomatis, Neisseria gonorrhea, Herpes Simplex Virus. Diagnosis must be confirmed by laboratory tests and cultures. Non-infectious causes include puberty, menstrual cycle, foreign body, cervical cancer, vaginal cancer, diabetes etc. Treatment depends on the cause of the discharge.

Causes

Common Causes

Classification

Normal vaginal discharge as in Neonatal, Pediatric, Puberty, Menstrual cycle[7], Pregnancy, and Menopause. -Abnormal vaginal discharge as


Laboratory findings

Initial tests include:

Other Diagnostic Studies

Type pH Discharge Odor Wet Mount
Trich >4.5 yellow-green, copious present motile, flagellated
BV >4.5 white-grey fishy clue cells
Candida <4.5 white, curd-like none pseudo-hyphae
GC mucopurulent varies PMNs
A.V. thin, gray, watery none few epithelial cells


Diagnosis

 
 
 
 
 
 
Patient with history of Vaginal discharge
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take complete history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about menstrual history :

❑ Age of menarche

❑ Last menstrual period

❑ Is the menstrual flow normal? How many pads she has to use in a day?

❑ Is there any foul smell or colour change?

❑ How many days does the menstruation stay?

Contraceptive history for example oral contraceptives, intrauterine device

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about general health :

❑ Ask about medical and drug history including recent antibiotic use and type of contraceptive use

❑ Assess for the possibility of a foreign body in situ

❑ Ask if there was any surgery or instrumentation to the genital region recently

❑ Is there any other health conditions like Diabetes Mellitus?

❑ Is there any history of fever, lower abdominal pain?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about colour, appearance of the discharge
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the discharge white or cream coloured, resembling "cottage cheese"?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check if they have the following complaints :

Pruritus

Vaginal burning, usually with increased vaginal discharge

❑ Vague but inoffensive odour

Dysuria, dyspareunia in patients with intense scratching and itching that led to skin excoriations

❑ Presence of vulval erythema, fissures

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask if the following factors are present
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Associated factors:

Glycosuria

Diabetes Mellitus

Obesity

Pregnancy

❑ Recent use of steroids/ antibiotics/ immunosuppressive agents

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examination of direct vaginal secretions or scrapping from vaginal wall via direct microscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
When a drop of 10% Potassium Hydroxide is added, typical myecelis or pseudo hyphae is seen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Candidiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the discharge greenish?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check if they have the following complaints :

Purulent, frothy discharge

❑ Foul smelling discharge with vulval soreness and irritation, if severe vulval oedema

❑ Punctate hemorrhagic area or strawberry cervix is path gnomic

Lower abdominal pain anddyspareunia may be seen in patients with long standing infection

❑ Male partners are usually asymptomatic except having penile pruritus after coitus

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Associated factors:

❑ Multiple sexual partners

❑ Increased level sexual activity

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wet mount test: a drop of vaginal secretion is mixed with saline and examined under microscope
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Trichomonads are recognized by their twitching motility
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vaginal pH > 5 helps to distinguish between trichomoniasis and candidiasis which has pH of less than 4.5
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Trichomoniasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the discharge thin, homogenous, bubbly?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
Herpes Simplex
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check if they have the following complaints :

❑ Malodorous, fishy discharge

❑ No itching or discomfort

❑ No inflammation of vulva

 
 
 
 
While it does not produce vaginal discharge itself, it causes cervicitis and vaginitis that are associated with severe leukorrhea
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Associated factors:

❑ Vary in intensity during menstrual cycle, worse at mid-cycle and especially after intercourse

❑ Partner and children of the patient may complain of odour that may need the use of frequent douches or perfumed bath

 
 
 
 
 
Diagnosis :

❑ Diagnosis is made from history and appearance of typical, multiple, painful vesicles

Culture is done to confirm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Whiff test: When a drop of 10% potassium hydroxide is added to a drop of vaginal secretion fishy amine odour is released
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vaginal pH > 5 with presence of clue cells are diagnostic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bacterial vaginosis (Gardnerella vaginosis)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mucopurulent discharge
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neisseria gonorrhoea
 
Chlamydia trachomatis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check if they have the following complains :

Mucopurulent cervicitis and urethritis

Dysuria, urethral irritation

❑Infection of peri-urethral glands and Bartholin's duct

❑ As infection progresses, patient may experience abdominal pain.

 
Check if they have the following complains :

❑ Watery, thinner discharge with dysuria and lower abdominal discomfort

Cervical friability and oedema with ectopy of cervix

❑ Infection of peri-urethral glands and Bartholin's duct

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnosis :

❑ Culture of endo-cervical specimen shows gram negative diplococci, Neisseria gonorrhoea

 
 
Diagnosis :

❑ First void urine and vaginal swabs are the recommended specimens for NAAT( Nucleic Acid Amplification Test) for diagnosis of Chlamydia trachomatis.[8]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

'Abbreviations: QHS : Every bedtime , BID: 2 times daily, TID: Three times a day, QID: Four times a day, IM :Intramuscular


Organisms Recommended Drugs Alternative drugs
Candidiasis

Over-the-Counter Intravaginal Agents[9]

  • Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days

OR

OR

  • Miconazole 2% cream 5 g intravaginally daily for 7 days

OR

  • Miconazole 4% cream 5 g intravaginally daily for 3 days

OR

OR

OR

OR


Prescription Intravaginal Agents:


  • Butoconazole 2% cream (single dose bioadhesive product), 5 g intravaginally in a single application

OR

  • Terconazole 0.4% cream 5 g intravaginally daily for 7 days

OR

  • Terconazole 0.8% cream 5 g intravaginally daily for 3 days

OR


Oral Agent:



Nystatin 1,00,000 unit tab vaginally QHS for 2 weeks[10]

Trichomoniasis

OR


OR

Bacterial Vaginosis

OR

  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days[12]

OR

  • Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days[12]

OR

OR

OR

Neisseria gonorrhoea


Amoxicillin orally 3 gm single dose
or
Ampicillin orally 3.5 gm single dose
or
Procaine PCN G 4.8 million IM single dose [10]


PLUS


Probenecid 1 gm orally single dose [10]


AND


Tetracycline 500 mg orally QID for 7 days
or
Doxycycline 100 mg orally BID for 7 days
or
Ceftriaxone 250 mg IM single dose[10]

Erythromycin 500 mg orally QID for 7 days[10]
or
Tetracycline 500 mg orally QID for 7 days[10]
or
Doxycycline 100 mg orally BID for 7 days[10]
or
Spectinomycin 2 gm IM single dose

Chlamydia trachomatis

Tetracycline 500 mg orally QID for 7 days[10]
or
Doxycycline 100 mg orally BID for 7 days[10]

Erythromycin base 500 mg orally QID for 7 days[10]
or
Erythromycin ethylsuccinate 800 mg orally QID for 7 days[10]
or
Sulfamethoxazole 1gm orally BID for 10 days

Herpes Simplex


Acyclovir[10]


Patient should be referred to a gynecologist if following are present. [13]

Treatment in pregnancy:

Acute pharmacotherapies

Bacterial Vaginosis

Candida and Chlamydia

Gonorrhea

Trichomonas

References

  1. Spence D, Melville C (2007). "Vaginal discharge". BMJ. 335 (7630): 1147–51. doi:10.1136/bmj.39378.633287.80. PMC 2099568. PMID https://www.ncbi.nlm.nih.gov/pubmed/18048541 Check |pmid= value (help).
  2. Hainer BL, Gibson MV (2011). "Vaginitis". Am Fam Physician. 83 (7): 807–15. PMID 21524046.
  3. Cettl L, Dvorak J, Felkel H, Feuereisl R (1979). "Results of simulation of non-homogeneous ventilatory mechanics for a patient-computer arrangement". Int J Biomed Comput. 10 (1): 67–74. doi:10.1016/0020-7101(79)90042-4. PMID http://www.ncbi.nlm.nih.gov/pmc/articles/pmc478688 Check |pmid= value (help).
  4. 4.0 4.1 4.2 Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/j.ogrm.2016.08.002 Check |pmid= value (help).
  5. Wathne B, Holst E, Hovelius B, Mårdh PA (1994). "Vaginal discharge--comparison of clinical, laboratory and microbiological findings". Acta Obstet Gynecol Scand. 73 (10): 802–8. doi:10.3109/00016349409072509. PMID https://pubmed.ncbi.nlm.nih.gov/7817733 Check |pmid= value (help).
  6. Spence D, Melville C (2007). "Vaginal discharge". BMJ. 335 (7630): 1147–51. doi:10.1136/bmj.39378.633287.80. PMC 2099568. PMID https://pubmed.ncbi.nlm.nih.gov/18048541 Check |pmid= value (help).
  7. Feingold KR, Anawalt B, Boyce A, Chrousos G, Dungan K, Grossman A; et al. (2000). "Endotext". PMID https://pubmed.ncbi.nlm.nih.gov/25905282 Check |pmid= value (help).
  8. Meyer T (August 2016). "Diagnostic Procedures to Detect Chlamydia trachomatis Infections". Microorganisms. 4 (3). doi:10.3390/microorganisms4030025. PMC 5039585. PMID 27681919.
  9. 9.0 9.1 "Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines".
  10. 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 10.11 Watson WJ, Demarchi G (August 1987). "Vaginal discharge: an approach to diagnosis and management". Can Fam Physician. 33: 1847–52. PMC 2218224. PMID 21263805.
  11. 11.0 11.1 11.2 11.3 11.4 "Trichomoniasis - 2015 STD Treatment Guidelines".
  12. 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 "Bacterial Vaginosis - 2015 STD Treatment Guidelines".
  13. Sim, M; Logan, S; Goh, LH (2020). "Vaginal discharge: evaluation and management in primary care". Singapore Medical Journal: 297–301. doi:10.11622/smedj.2020088. ISSN 0037-5675.

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