What is Vaginal Discharge?
Vaginal discharge is a common reason for women to seek treatment from the general practitioner or gynaecologist. The women may be embarrassed to tell about her symptoms openly to the physician. Therefore, it is important for the health care provider to be sensitive when taking history. Sexual history is very important and should be frequently asked regardless of the marital status of the patient. The causes are numerous but the common aetiologies are as listed below in this article.
What is the Causes of Vaginal Discharge?
The causes can be divided into infective or non-infective causes. The common infective causes are Bacterial Vaginosis, Candida infection, Chlamydia trachomatis, Nesseria gonorrhoea and Trichomonas vaginalis infections. The latter three being sexually transmitted diseases. Common Non-infective causes are physiological, cervical ectropion cervical polyp, retained foreign bodies or allergy.
Bacterial Vaginosis (BV)
Is the commonest cause of vaginal discharge in women in their reproductive age. The prevalence is about 10-30% in the developed country but there are no local figures for Malaysia. . The women’s vagina consists of good bacteria (lactobacillus) which help to maintain the vagina acidity for vaginal protection. In BV, there is an overgrowth of bacteria species (Gardnerella vaginalis and genital mycoplasma) and reduction or absence of lactobacillus. Risks of BV in young women, include vaginal douching, the use of IUCD and increase in number of sexual partners.
50% of BV is asymptomatic, but when present, there is profuse, malodorous vaginal discharge which is offensive (due to amine production from bacteria) is often worse after sex or during menses. The discharge may be white, thin, homogenous and not associated with vulva or vagina inflammation.
Diagnosis of BV
A high vaginal swab is taken and diagnosis is made in one of two ways.
- The Amsel’s criteria : thin discharge on examination, vaginal pH>4.5 (alkaline) by pH paper, amine smell (fishy odour) when adding 10% KOH on a glass slide or identifying clue cells (bacteria covering epithelial cells) on the vaginal discharge added with saline under microscopic examination.
- Gram stained vaginal smear : Isolation of G. vaginalis on High Vaginal Swab put on a slide. However, it is a poor test for BV as 50% of women are asymptomatic carriers.
Treatment of BV
Metronidazoles 400mg taken orally twice daily for 5-7 days or 2g taken orally as a single dose are acceptable regime for treatment. All treatment show 80% cure rate after 4 weeks. Metronidazole can be used during pregnancy although it is not recommended in the first trimester. (Clinical experience showed that it is safe at any time in pregnancy)
Recurrent BV is defined as the condition where the patient has 3 or more proven episode in a year. The cause of recurrence is unknown but may be due to rise of vaginal pH (become more alkaline). Management of recurrent BV includes counselling to avoid all irritants. The IUCD should be removed and changed to other forms of contraception until the patient is symptom free. The patient must be reassured that BV is not a Sexually Transmitted Infection (STI). Treatment of recurrence has many regimes. One option is to give oral Metronidazole 400mg twice daily for 3 days at start and end of menses. Since BV is not a STI, the male partner need not be notified or treated.
Candida infection occurs in at least two thirds of women during their lifetime. Majority of the causative organism is Candida albican. Pruritis (vulva itching) is the commonest symptom and vaginal discharge occur in half of the patients. The discharge is curdy white (like yogurt), odourless and may be associated with superficial dyspareunia and vaginal soreness. Candida infection affects many healthy or immuno-compromised women and its risk factors are pregnancy, diabetes mellitus and patients on long term antibiotics.
Diagnosis of Candida
Diagnosis of Candida is based on clinical findings. Vaginal swabs are taken and smeared on a wet slide (with saline) and examined under the microscope. In half of the cases, the slide will show pseudohyphae or spores. However the most sensitive method of diagnosis is culture on Sabourands media.
Treatment of Vaginal Candida
Both vaginal and oral anti-fungal are effective in treating the condition. Intravaginal regimes are: Clotrimozole pessary 500mg as single dose or Miconazole pessary 100mg daily for 14 days. Vaginal Nystatin 100,000u can also be used for 10 to 14 days and is effective for non albican candida. Oral Fluconazole capsule 150 mg as a single dose or Itraconazole capsule 200mg twice a day for 1 day.
Recurrent candida is defined as the condition where the patient has symptoms with vaginally mycoplasma proven infection 4 times in a year. Incomplete eradication of vaginal candida or drug resistance may be the cause of recurrence. The patient should be given vaginal anti-fungal for longer period (6 months). It is important that irritant should be avoided and she is reassured that candida is not a STI. Male partner treatment and notification are therefore not necessary.
The prevalence of Chlamydia in Malaysia is unknown but in the UK it is 10-14% among patients of 25 years of age and above. The causative agent is Chlamydia trachomatis which is an obligatory intracellular organism (live in the cells like viruses). It infects the genital tract (cervix and urethra) and can also involve the conjunctiva and oropharynx. Chlamydia is a sexually transmitted disease therefore partner notification and treatment is compulsory.
Signs & Symptoms
The patient will have symptoms of purulent (pus) vaginal discharge. Other symptoms are lower abdominal pain, post-coital bleeding, intermenstrual bleeding and cervicitis (inflammation of the cervix). However, majority of women are without symptoms
Diagnosis is vaginal and urethra swab followed by cell culture which is expensive and difficult to perform, therefore not all laboratories perform this test. The method used is enzyme immunoassay (EIA). Recently, laboratories have switched from EIA to nucleic acid amplification test (NAAT) which is more sensitive and easier to collect.
Complication of Chlamydia
Ascending infection can cause endometritis, salpingitis or pelvic inflammatory disease which can cause chronic pelvic pain. It can damage the fallopian tubes which may lead to ectopic pregnancy and infertility.
Treatment regimes are Azithromycin 1gm orally as a single dose or Doxycycline 100 mg twice daily for 7 days.
N. gonorrhoea is sexually transmitted disease where the organism is a Gram negative diplococcus. The patient is usually asymptomatic but for those who are symptomatic will complain of purulent vaginal discharge, intermenstrual bleeding, postcoital bleeding or pelvic pain. Complications during pregnancy may cause premature labour and low birth weight babies.
The diagnosis is by vaginal swab and culture which is the gold standard test. More recently the NAAT is used for diagnosis but it is not readily available in the laboratories in Malaysia.
Complication is similar to Chlamydia which is ascending infection causing inflammation of the endometrium, fallopian tubes and cervix. It can also cause tubal damage and blockage leading to ectopic pregnancy or infertility.
The recommended treatment is with antibiotic Ceftrioxone 250mg intramuscular injection as a single dose or Cefixime 400mg orally as a single dose. Gonorrhoea needs partner notification and treatment of the sexual contacts.
Trichomonas Vaginalis (T.V.)
T. vaginalis is a common sexually transmitted disease in the developing country and affect up to 30% of sexually active women. The organism is a flagellated protozoa which is only present in the genital tract. Infection of T.V. can lead to vaginitis, vaginal discharge, cervicitis, urethiritis and PID. Women infected may be asymptomatic but they usually complain of vaginal discharge classically green and frothy (but can be of any colour) and malodorous. Other signs and symptoms include vulva and vagina itchiness. Classically, the cervix occasionally gives a ‘strawberry’ cervix on speculum examination. Symptoms are usually severe during menses or just after menses.
Diagnosis is by vaginal swab and smear on a wet slide (with saline) where the protozoa can be identified. The gold standard of diagnosis is culture of the T. vaginalis with incubation at 33-37°C. T.vaginalis may be detected during Pap smear but diagnosis still need to be confirmed by the vaginal swab. The recommended treatment is Metronidazole 2 gm orally as a single dose or 400mg orally twice a day for 5 days. The partner need to be notified and treated.
Generally, in addition to medication all patients with STI (gonorrhoea, Chlamydia and T. Vaginalis) need to abstain from sex until they and their partners have completed treatment and have received advice regarding safer sex practices
The question of ‘what is normal?’ is frequently asked by the patient and doctors when it comes to vaginal discharge. Many women accept that some discharge is normal. The quantity and consistency may differ between cycles which is maximum at the luteal phase and lesser at midcycle. The ‘normal’ colours of discharge are generally white or clear but some women would accept ‘yellow’ and ‘creamy’ as normal discharge. It is important for the physician to make a diagnosis not based solely on the discharge but a thorough history including sexual history should be taken. Examination and visualization of the cervix is important and exclude the common cause of discharge by diagnostic testing as discussed above. If there is no positive findings after this exhaustive process then it is likely that the discharge is ‘physiological’ in nature.
|Last Reviewed||:||26 April 2012|
|Writer||:||Dr. Mohamed Hatta Mohamed Tarmizi|
|Reviewer||:||Dr. Haris Njoo Suharjono|