Vaginal discharge ⚠️

• Vaginal discharge can be normal
• Abnormal when there is an increased amount or changed colour, smell, soreness, itch
• Caused by a range of infectious and non-infectious conditions such as gonorrhoea, chlamydia, trichomonas, candida (thrush), bacterial vaginosis, atrophic vaginitis
• Less common causes include mycoplasma genitalium, herpes simplex, cancer or foreign body (eg retained tampon) 
• STIs are common in women with risk factors
• If pregnant consider ruptured membranes, intrauterine infection

Ask

• Discharge — amount, colour, smell, duration (how long)
• Itchy, sore
• Pain on passing urine. Urinary symptoms can be caused by STIs or UTIs
• Pregnant
• Last menstrual period
• Lower abdominal pain, pain deep inside with sex. If present — see Pelvic inflammatory disease
• Other STI symptoms — swollen lymph nodes, genital lumps, ulcers, sore throat, rash, hair loss
• Sexual partner/s — male, female, other, and if any from geographical area with penicillin-resistant gonorrhoea — Table 5.5
• Foreign body (eg tampon, condom)

Check

• U/A , pregnancy test 

Do

• Full STI check
• pH test if available — before putting swab into transport medium, touch sample onto pH paper (test unreliable if woman post-menopausal, semen or blood present)
• If pH 4.5 or more (high) or pH test not done — treat for trichomonas and bacterial vaginosis straight away. Do not wait for test result
• Give metronidazole oral — adult 2g, single dose
• OR metronidazole oral — adult 400mg, twice a day (bd) for 7 days. Best for breastfeeding, take after baby fed
• Contact tracing — telling partners
• STI and safer sex education
• Consider talking about contraception
• Consider thrush
• If foreign body suspected — do speculum exam (if skilled)

Do — if high risk of STI

High risk of STI — women with abnormal vaginal discharge and under 35 years

• Treat for both gonorrhoea and chlamydia. Presentations very similar, syndromic management. Do not wait for laboratory or POC Test results if not immediately available
• If woman and all sexual partners in last 3 months from a geographical area with penicillin SENSITIVE gonorrhoea — Table 5.5
• Give azithromycin oral — adult 1g, single dose
• AND amoxicillin oral — adult 3g, single dose
• AND probenecid oral — adult 1g, single dose 
• If woman and/or any sexual partner in last 3 months from a geographical area with penicillin RESISTANT gonorrhoea — Table 5.5 OR partners unknown 
• Give azithromycin oral — adult 1g, single dose
• AND ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
  
• If allergy to penicillin or pregnant — medical/sexual health consult

Follow-up

• Review after 1 week — test results, response to treatment and further education
• If no improvement with treatment — medical/sexual health consult
• If STI results positive — see STI management
• Check HIV and syphilis serology done
• Any woman who has had an STI is at high risk of getting more STIs
• If positive test result, re-test in 3 months OR in 4 weeks if pregnant
• Standard STI check

Candidiasis (thrush)

• Usually caused by Candida albicans
• Not sexually transmitted and contact tracing not needed
• Often found in vagina without causing any problems (asymptomatic) 
  
• More common if pregnant, weakened immune system, diabetes, long course of broad-spectrum antibiotics
• Only treat if causing problems
• Thrush can cause
• Vulval itch or burning
• White, thick curd-like discharge that sticks to vaginal walls
• Very red inflamed vulva and vagina

Do

• Talk with woman about keeping genital area clean and dry, salt water washes and wearing cotton underwear
• Give clotrimazole vaginal pessary — 500mg, single dose
• OR miconazole 2% cream for 7 days
• If not better medical consult about fluconazole oral — adult 150mg, single dose.
• Do not give if pregnant or breastfeeding
• If woman has diabetes try to improve blood glucose control

Follow-up

• Some women get recurrent thrush even when well. If recurrent or persistent thrush — important to check for diabetes and weakened immune system
• BGL
• Offer HIV serology
• Medical consult about further tests. Consider Candida glabrata — arrange for MC&S

Woman with recurrent discharge caused by thrush needs management plan in file notes to stop repeated, unnecessary treatment for STIs

Bacterial vaginosis (BV)

• Due to change in vaginal bacteria and causes high pH
• Can cause abnormal vaginal discharge and unpleasant odour
• Not sexually transmitted and contact tracing not needed
• Often found in vagina without causing any problems (asymptomatic)

Do

If MC&S result shows 'clue cells' or other findings consistent with BV AND

• If symptomatic 
• Give metronidazole oral — adult 2g, single dose
• Make sure standard STI check done
• If asymptomatic AND not pregnant or pregnant with no history of preterm labour — Do not treat
• If pregnant with history of preterm labour — medical consult about management plan
• If still symptoms after initial single dose treatment 
• Give metronidazole oral — adult 400mg, twice a day (bd) for 7 days
• Advise women to avoid douching (cleaning inside vagina)
• No follow-up needed but if symptoms persist — medical consult