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Sunday, August 17, 2025

Vaginal discharge


Introduction

Vaginal discharge is a common gynecological symptom that can be either physiological (normal) or pathological (abnormal). It refers to fluid secreted from the vagina, cervix, or endometrium and plays an important role in maintaining vaginal health by providing lubrication, removing dead cells, and preventing infections.

The normal vaginal discharge is usually clear to white, non-offensive, and varies with age, menstrual cycle, hormonal status, and sexual activity. Abnormal discharge, however, may be excessive, foul-smelling, discolored, or associated with itching, pain, or systemic symptoms, and often indicates infection or other pathology.

Causes of Vaginal Discharge

1. Physiological Causes

  • Ovulation: Clear, stretchy mucus around mid-cycle.

  • Pregnancy: Increased discharge due to high estrogen and progesterone.

  • Sexual arousal: Increased transudation and glandular secretions.

2. Infectious Causes (Most Common)

a) Bacterial Vaginosis (BV)

  • Caused by imbalance of normal vaginal flora, with overgrowth of anaerobes (Gardnerella vaginalis).

  • Discharge: Thin, gray-white, fishy odor (positive “whiff test”).

  • Vaginal pH >4.5.

b) Vulvovaginal Candidiasis (Thrush)

  • Caused by Candida albicans.

  • Discharge: Thick, white, “cottage cheese-like”, associated with itching, burning, and soreness.

  • Vaginal pH usually normal (<4.5).

c) Trichomoniasis

  • Caused by Trichomonas vaginalis (sexually transmitted).

  • Discharge: Frothy, yellow-green, malodorous.

  • Associated with vulvar irritation, dysuria, and strawberry cervix on exam.

d) Sexually Transmitted Infections (STIs)

  • Neisseria gonorrhoeae and Chlamydia trachomatis: May cause purulent discharge, pelvic pain, dysuria.

  • Herpes simplex virus (HSV): Watery discharge with painful ulcers.

3. Non-Infectious Causes

  • Foreign body (e.g., retained tampon, condom): Causes foul-smelling discharge.

  • Allergic/irritant vaginitis: From soaps, douches, perfumed products.

  • Atrophic vaginitis: Post-menopausal estrogen deficiency → dryness, irritation, sometimes watery discharge.

  • Cervical causes: Cervical polyps, malignancy.

Clinical Presentation

  • Nature of discharge: Color, consistency, odor, volume.

  • Associated symptoms: Itching, burning, dyspareunia, dysuria, abdominal pain.

  • Systemic features: Fever, pelvic pain may suggest pelvic inflammatory disease (PID).

Diagnosis

1. History

  • Onset, duration, relation to cycle, sexual history, hygiene practices, use of contraceptives or antibiotics.

2. Examination

  • Inspection of vulva and vagina.

  • Speculum exam: Cervical appearance, discharge characteristics.

3. Investigations

  • Vaginal pH testing.

  • Microscopy: Saline wet mount for trichomonas, clue cells for BV, hyphae for Candida.

  • Whiff test (KOH): Fishy odor in BV.

  • Culture/PCR: For gonorrhea, chlamydia, candida, trichomonas.

  • Pap smear / colposcopy: If malignancy suspected.

Treatment

General Measures

  • Treat underlying cause.

  • Avoid douching and irritant products.

  • Safe sexual practices; treat partners if STI suspected.

1. Bacterial Vaginosis

  • Metronidazole 400 mg orally twice daily for 7 days OR

  • Metronidazole 2 g single oral dose OR

  • Clindamycin 2% vaginal cream once nightly for 7 days.

2. Candidiasis

  • Clotrimazole 500 mg pessary single dose OR

  • Fluconazole 150 mg orally single dose.

  • Recurrent: Fluconazole 150 mg every 72 hours for 3 doses, then weekly for 6 months.

3. Trichomoniasis

  • Metronidazole 2 g orally single dose OR

  • Tinidazole 2 g orally single dose.

  • Sexual partners must be treated simultaneously.

4. Gonorrhea and Chlamydia

  • Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg orally twice daily for 7 days.

5. Atrophic Vaginitis

  • Vaginal estrogen therapy: Estradiol 10 µg tablet twice weekly OR estradiol cream 0.5 g intravaginally twice weekly.

6. Foreign Body / Non-Infectious

  • Removal of foreign body.

  • Symptomatic relief with lubricants, avoidance of irritants.

Precautions

  • Antibiotics (especially Metronidazole) should be avoided with alcohol (risk of disulfiram-like reaction).

  • Fluconazole contraindicated in pregnancy; use topical azoles instead.

  • Estrogen therapy contraindicated in patients with hormone-dependent cancers without specialist supervision.

  • Always consider possibility of mixed infections (e.g., BV + Trichomonas).

Drug Interactions

  • Metronidazole + Warfarin: Increases anticoagulant effect.

  • Fluconazole + Statins or Warfarin: Increases risk of toxicity.

  • Clindamycin + Neuromuscular blockers: Enhanced effects.

  • Estrogens + CYP3A4 inducers (rifampicin, carbamazepine): Reduced efficacy.

Red-Flag Features Requiring Urgent Referral

  • Blood-stained discharge post-menopause (possible malignancy).

  • Persistent or recurrent discharge not responding to treatment.

  • Severe pelvic pain, fever, or systemic illness (possible PID or sepsis).

  • Suspicion of sexual abuse.




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