Vaginal Discharge

General remarks

Important causes of vaginal discharge

Vulvovaginal candidiasis

Foreign body

Vulvovaginal trichomoniasis

Bacterial vaginosis

Mucopurulent cervicitis and gonococcal cervicitis

Pelvic inflammatory disease

Cervical or endometrial malignancy

Cervical ectropion

Physiological vaginal discharge

Other vulval Infections and STIs

Streptococcal infection

Worm infection

Scabies

Public lice

Herpes simplex

Chancroid

Granuloma inguinale

Lymphogranuloma venereum

Syphilis

Vulval warts

---

General remarks

• Vaginal discharge does not automatically mean there is PID or bacterial vaginosis
• History & examination must be appropriate & complete
• History: duration of discharge, exact description of discharge & associated symptoms
• Inspect the cervix & vagina with a speculum and a good light
• Do a Pap smear if not recently done
• Cancer is an uncommon but very important cause of vaginal discharge
• Consider ultrasound & endometrial biopsy in older patients (>45 years)
• Search for a cause of vaginal discharge, one may not be found, resulting in syndromic or empirical treatment, or no treatment at all

Important causes of vaginal discharge

• Vaginal candidiasis
• Trichomoniasis
• Bacterial vaginosis
• Mucopurulent cervicitis
• Pelvic inflammatory disease
• Cervical or endometrial malignancy
• Cervical ectropion
• Foreign body
• Physiological discharge

VULVOVAGINAL CANDIDIASIS (VVC, THRUSH)

This is caused by infection with the fungus Candida albicans/ glabrata/ cerviciensis

Diagnosis

• Irritation or soreness, with or without discharge. Episodes may be intermittent & recurrent or continuous or after each menstruation
• Usually the discharge appears like curdled milk or may be scanty with only a little redness of the vulva & vagina
• Exclude diabetes or HIV infection poorly controlled in patients with severe or recurrent thrush
• Consider association with antibiotics
• Wet prep: pseudo hyphae (albicans) or spores may be seen or on Pap smears

Management

1. Clotrimazole long-acting pessary (Canesten ‘1’) given as a single dose
2. Alternatives include clotrimazole, econazole (Pevaryl) or miconazole (Daktarin) vaginal creams, applied daily before bedtime for 7 days
3. Some recommend that the partner apply some of the cream to his penis at the same time as the patient treats herself. The evidence is unclear
4. Advise thrush is not a sexually transmitted infection
5. Suggest simple measures – pelvic hygiene without douches, & wearing loose fitting underwear, & allowing the body to dry for some minutes, walking in a dressing gown or towel after showering or bathing, before putting clothes on. Other fungal infections: wash feet after genitalia
6. Candida glabrata & cerviciensis are not sensitive to the conventional anti fungals mentioned

FOREIGN BODY

Diagnosis

• This usually presents with a foul-smelling or blood-stained vaginal discharge
• More common in small children
• Adult women may forget tampons in the vagina
• A tampon or swab may be left behind following a surgical procedure, e.g. episiotomy, cone biopsy etc.
• Speculum examination will identify the offending object
• Examination under anaesthesia is required for a suspected vaginal foreign body in a child

Management

1. Carefully remove the foreign body completely
2. Use general anaesthesia if necessary (always in a small child)
3. Broad spectrum antibiotics if necessary, e.g. amoxicillin 500 mg orally 3 times daily, with metronidazole 400 mg orally 3 times daily
4. Vaginal oestrogen cream for a child less than 8 years old

VULVOVAGINAL TRICHOMONIASIS

Diagnosis

• This typically presents as a profuse offensive discharge, there can be dysuria, or vaginal itching, irritation, dyspareunia
• Sometimes there are no symptoms (e.g. if found on a Pap smear)
• The classical ‘strawberry cervix’ on speculum is rarely seen
• Frothy grayish discharge may/may not be seen with speculum
• On wet prep or Pap smears biflagellate protozoa may be seen

Management

1. Metronidazole 2 g orally as a single dose, or 400 mg orally twice daily for 7 days. In the first trimester of pregnancy the WHO recommends clotrimazole as for candidiasis
2. Recommend treatment of the partner
3. although the CDC permits metronidazole

BACTERIAL VAGINOSIS

This is not an infection. Rather, it represents overgrowth of the vagina with bacteria, other than the normally predominant lactobacillus, mainly anaerobic bacteria, many of them commensal in sexually active women.

Diagnosis

• The complaint may be of a fishy smelling vagina, especially after intercourse
• Diagnostic criteria (not always used) are the 4 Amsel criteria:
• The discharge - profuse or scanty, grey or off white
• Positive whiff test – fishy smell after adding potassium hydroxide
• ‘Clue cells’ (epithelial vaginal cells covered with bacteria) under the microscope on wet prep
• Vaginal pH greater than 4.5 (litmus or other test)

Management

1. Metronidazole as for trichomoniasis or clindamycin 300mg bd po for 7 days. Alternative: clindamycin ovules 100mg intravaginal for 3 nights - not usually available in the state
2. Recurrence is a problem. Monthly single dose metronidazole 1g & fluconazole 150mg has been successful
3. Advise that bacterial vaginosis is not a sexually transmitted infection
4. Place of probiotics remains uncertain
5. There is no need to treat the partner
6. Asymptomatic BV detected on a Pap (clue cells) does not need treatment out of pregnancy

MUCOPURULENT CERVICITIS & GONOCOCCAL CERVICITIS

Gonorrhoea or Chlamydia cause cervicitis in adults. In prepubertal girls, gonococcal vaginitis may occur, associated with sexual abuse. If a gonococcal discharge is found in a child, discuss with a consultant for specific treatment & intervention i.e. social worker referral.

Diagnosis

• This may or may not coexist with acute PID
• The discharge is yellowish & non-offensive
• On speculum examination, a mucopurulent discharge from the external cervical os
• In a child, there is vaginitis rather than cervicitis
• Pus swabbing using routine materials is unlikely to grow these organisms
• Gonococcal infection is classically associated with purulent discharge from paraurethral (Skene’s) glands when milking the urethra from the anterior vaginal wall

Management

1. Prescribe Ceftriaxone 750mg im as a single dose for gonorrhea plus either azithromycin 1G as a stat dose or doxycycline 100 mg orally twice daily for 10 days (which will also cover chlamydia)
2. Metronidazole 400 mg orally twice daily for 10 days may be added
3. Advise treatment of the partner

PELVIC INFLAMMATORY DISEASE

An offensive vaginal discharge may  be associated with acute PID, but if there is NO cervical motion tenderness & no adnexal tenderness, PID is unlikely. PID & treatment regimens for PID are discussed in Clinical Methods.

CERVICAL OR ENDOMETRIAL MALIGNANCY

A blood stained & foul-smelling discharge may be caused by malignancy. Speculum examination is always mandatory. Consider cervical biopsy, endometrial biopsy &/or transvaginal ultrasound for women over the age of 45 years. There is even a possibility of fallopian tube or even ovarian cancer (v rare causes). Malignant conditions are discussed in Cervical Cancer & Endometrial Cancer.

CERVICAL ECTROPION or ‘ectopy’ 

This has been called a ‘cervical erosion’ because of its appearance

Diagnosis

• The complaint is of a profuse inoffensive clear or cloudy discharge
• The cervix looks reddened at the centre since the mucus-producing epithelium of the endocervix is exposed at the external os
• There is no inflammation & no infection

Management

1. When doing a Pap smear, sample the true squamo-columnar junction & transformation zone (further out from the os than usual)
2. Colposcopy & biopsy essential to confirm normality; do not confuse with cancer
3. Diathermy or cryotherapy restores the normal position of the squamo-columnar junction. The discharge ceases
4. Discuss cases with a consultant to avoid missing a malignancy

PHYSIOLOGICAL VAGINAL DISCHARGE

Diagnosis

• The amount of normal discharge varies between individuals, within individuals, with the menstrual cycle, with pregnancy & with sexual arousal
• The discharge is whitish
• The discharge is not fishy or foul-smelling

Management

1. Reassure the patient that the discharge is normal. This may not be adequate
2. Advise use of panty-liners
3. Do not disregard symptoms if the patient insists the discharge is abnormal – consider follow-up of such patients
4. If in doubt about infection, prescribe doxycycline 100 mg orally twice daily & metronidazole 400 mg orally three times daily for 10 days. This may not be effective

OTHER VULVAL INFECTIONS & STIs

STREPTOCOCCAL INFECTION

Diagnosis

• This appears as a reddened vulva and may occur in young girls
• Treatment for candidiasis is unsuccessful
• There is no thickening of the skin to suggest dermatosis or dysplasia

Management

1. Amoxycillin 500 mg orally three times daily (lower doses for children)
2. Advise that this is not a sexually transmitted infection
3. In a child, reassure that this is not evidence of child abuse

WORM INFECTION

Diagnosis

• Pruritus ani or pruritis vulvae is the presenting symptom
• Other members of the family may be infected
• Worms may be identified in the anus or in the stools. Sticky tape applied to the perianal area may pick up the eggs or worms, for microscopic identification

Management

1. Prescribe mebendazole (Vermox) 100 mg orally twice daily for 3 days
2. For pregnant women, prescribe pyrantel (Combantrin) 600 mg orally as a single dose
3. Consider treating other family members & advise on general hygiene

SCABIES

Diagnosis

• Generalized itchy rash is typical, which may involve the vulva
• The head & neck are typically not involved
• Distinctive burrows are most easily seen webs of finger & toes

Management

1. Benzyl benzoate emulsion (Ascabiol) is applied in a thin layer over the whole body except for the head and neck, & wash off after 12-24 hours. This can be repeated in 7 days if necessary
2. Gamma-benzenehexachloride shampoo (Gambex) is used in the same way as benzyl benzoate, but is contraindicated in pregnancy & lactation
3. Consider treatment of the whole family, clothes and bedding

PUBIC LICE (‘CRABS’)

Diagnosis

• This presents as itching in hairy parts of the external genitalia
• Careful inspection will reveal the lice or their nits 

Management

1. Prescribe gamma-benzenehexachloride (Gambex) 30 mL, to be massaged & lathered into the affected area with a little water, avoiding contact with the vestibule, vagina & urethra. Rinse off thoroughly after 4 minutes. Nits can be removed by fine combing.
2. In pregnant & lactating women, use benzyl benzoate emulsion (Ascabiol), applied to the affected area and washed off after 24 hours
3. Suggest treatment of the partner  

HERPES SIMPLEX

Genital herpes is almost always HSV 2(cold sores HSV 1)

Diagnosis

• This appears as small blisters which erode & crust in the immune competent patient
• In HIV positive women, there may be large clearly defined ulcers, with a beefy red flat base(these resemble chancroid)
• Lymphadenopathy commonly coexists in primary or severe infections

Management

1. Give acyclovir (Zovirax) 400 mg tds po daily for 5-10 days in a primary infection, & 5 days in a recurrence.
2. Use topical acyclovir 3% ointment twice daily for mild cases
3. For HIV positive patients with chronic ulcers, give aciclovir 400 mg orally 5 times daily for 10 days
4. Recurrent herpes simplex can be suppressed with long-term aciclovir 400 mg orally twice daily; discuss with a consultant
5. Valaciclovir (1G bd), Famciclovir (400mg bd) are not available at most public hospitals

CHANCROID

Diagnosis

The causative organism is Haemophilus ducreyi. Rare in SA.

• Ulcers may single or multiple, & are typically dirty, soft-based, undermined & painful. Regional lymphadenopathy is common
• Syphilis serology & microscopy should be negative

Management

1. Specific treatment is erythromycin 500 mg orally 3 times daily for 7 days, or azithromicin 1G po x1, or ceftriaxone 250mg im x1, or ciprofloxacin 500mg bd po for 3days
2. Syndromic management of genital ulcer disease includes erythromycin
3. Advise treatment of the partner
4. Consider HIV testing

GRANULOMA INGUINALE (DONOVANOSIS)

Diagnosis

The causative organism is Klebsiella granulomatis (formerly Calymmatobacter granulomatis). Rare in SA.

• The condition is rare in Johannesburg – more common in the tropics
• Ulcers are painless, large, beefy, raised, single or multiple, with rolled edges. Chronic herpes simplex ulcers may look similar
• There may be ‘pseudolymphadenopathy’, & associated lymphatic stenosis or elephantiasis
• Diagnosis is difficult by culture. Donovan bodies on microscopy

Management

1. Give doxycycline 100 mg orally twice daily for 3 weeks or erythromycin in pregnant women) 500 mg orally 4 times daily for 3 weeks, or azithromycin 1g weekly for 3 weeks, or ciprofloxacin 750mg bd for 3 weeks
2. Advise treatment of the partner
3. Consider HIV testing 

LYMPHOGRANULOMA VENEREUM

Diagnosis

The causative organism is Chamydia trachomatis. Rare in SA.

• The most common presentation is lymphadenopathy, tender, often unilateral(at first). Glands may suppurate or become matted in a large mass with sinuses. Elephantiasis may follow in untreated patients
• Ulcers, often not seen, are small, single and painless
• Rectal involvement: pain, tenesmus, constipation, mucoid discharge which can lead to stricture, fistulae
• Swabs for immunofluorescence, serum testing not usually in our setting

Management

1. Prescribe doxycycline 100 mg bd po for 3 weeks or Erythromycin 500mg qds po 3 weeks
2. Advise treatment of the partner
3. Consider HIV testing

SYPHILIS

Diagnosis

The causative organism is Treponema pallidum

• A single firm painless ulcer (chancre) is typical in primary syphilis
• Secondary syphilis may present with condylomata lata – grey, flat, velvety painless lesions (unless secondarily infected), with associated rash, fever and adenopathy
• The RPR test is strongly positive in secondary syphilis, but may be negative in the early stages of primary syphilis. TPHA tests, though more specific for syphilis, remain positive for life (even if an infection was successfully treated for example 20 years ago)

Management

1. Both primary & secondary syphilis respond to benzathine penicillin 2.4 million units IM as a single dose
2. Secondary latent – 3 such injections (weekly)
3. Penicillin-sensitive patients may be offered penicillin desensitization or given doxycycline 100 mg orally twice daily or erythromycin 500 mg orally 4 times daily, for 15 days
4. Recommend treatment of the partner
5. Suggest HIV testing 

VULVAL WARTS

Diagnosis

• The causative organism is the human papillomavirus (HPV 6 & 11)
• The cauliflower appearance is typical
• Warts may be small but distressing to patient
• Large warts may be obstructive, painful, infected & foul-smelling
• Large warts are more frequent in teenagers, pregnant women & immunocompromised patients

Management of small warts

1. Prescribe podophyllin paint (25%) for the patient to bring to the clinic. Do NOT use unless you are sure pregnancy has been excluded. Aldara cream is an alternative (a Category C drug in pregnancy; safety unknown)
2. A doctor must apply the paint carefully to the warts
3. Use a cotton bud or bacteriology swab to apply the paint
4. Do not allow any contact with normal skin – it burns
5. Advise that the paint will burn even on the warts
6. The paint should be washed off thoroughly after 3-6 hours
7. Repeat the treatment weekly as necessary
8. Trichloroacetic acid 85% can be used as an alternative in the same way
9. Moderate warts, or not responding, treat with diathermy, cryotherapy

Management of large warts

1. Consider HIV testing (positivity is likely & probably known)
2. Give amoxicillin 500 mg orally 3 times daily & metronidazole 400 mg orally 3 times daily for 7 days if the warts are infected or foul smelling
3. In pregnancy, defer treatment until after delivery. Warts resolve significantly postpartum
4. Large warts may be burnt with diathermy or surgically removed, under general or regional anaesthesia. Burn the wart, not the surrounding skin
5. Radiotherapy has been recommended in HIV seropositive non-pregnant patients with very advanced warts. Discuss with a consultant. Such cases should be referred to the oncology group