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Editor-In-Chief: C. Michael Gibson, M.S., M.D. ; Associate Editor(s)-in-Chief: Shankar Kumar, M.B.B.S.  Samah Obaiah Rinky Agnes Botleroo, M.B.B.S.
Synonyms and keywords: Discharge from the vagina, Leukorrhea
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 changeVaginal 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.
- Atrophic vaginitis or senile vaginitis, it as a result of estrogen deficiency lead to vaginal dryness, itching, irritation, discharge, and dyspareunia
- Bacterial vaginosisis mostally happen during the reproductive age of women characterized by a shift in the vaginal flora from the dominant Lactobacillus to a polymicrobial flora
- Cervical cancer
- Chlamydia,sexually transmitted infections.
- Foreign body vaginitis
- Gonorrhea,sexually transmitted infections
- Trichomoniasis,a parasitic infection typically contracted and caused by having unprotected sex
- Vaginal cancer
- Vaginal yeast infection
- Drug side effect as antibiotic or steroid use as, Amoxicillin and Clavulanic Acid , Butoconazole Vaginal Cream , Clotrimazole , Combined oral contraceptive pill, Estradiol Topical , Estradiol Transdermal , Estrogen and Progestin (Oral Contraceptives) ,Estrogen Injection , Estrogen Vaginal , Etonogestrel and Ethinyl Estradiol Vaginal Ring , Glatiramer Injection ,Hormone replacement therapy (trans), Letrozole, Leuprolide , Medroxyprogesterone Injection , Metronidazole Topical ,Miconazole , Nafarelin , Natalizumab injection , Norelgestromin and ethinyl estradiol transdermal system , Ospemifene, Oxcarbazepine , Pramipexole, Progesterone, Tamoxifen , Terconazole Vaginal Cream, Vaginal Suppositories , Toremifene, Zoledronic Acid Injection
Normal vaginal discharge as in Neonatal, Pediatric, Puberty, Menstrual cycle, Pregnancy, and Menopause. -Abnormal vaginal discharge as
Initial tests include:
- Urine culture
- Gonorrhea culture
- Chlamydia culture
Other Diagnostic Studies
|Trich||>4.5||yellow-green, copious||present||motile, flagellated|
|A.V.||thin, gray, watery||none||few epithelial cells|
|Patient with history of Vaginal discharge|
|Take complete history|
❑ Respiratory rate
❑ Heart rate
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"?|
Check if they have the following complaints :
❑ 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
|Ask if the following factors are present|
❑ 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|
|Is the discharge greenish?|
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
|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|
|Is the discharge thin, homogenous, bubbly?|
|While it does not produce vaginal discharge itself, it causes cervicitis and vaginitis that are associated with severe leukorrhea|
❑ Vary in intensity during menstrual cycle, worse at mid-cycle and especially after intercourse
|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)|
|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
❑ Culture of endo-cervical specimen shows gram negative diplococci, Neisseria gonorrhoea
❑ First void urine and vaginal swabs are the recommended specimens for NAAT( Nucleic Acid Amplification Test) for diagnosis of Chlamydia trachomatis.
'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|
Over-the-Counter Intravaginal Agents
Prescription Intravaginal Agents:
Amoxicillin orally 3 gm single dose
Erythromycin 500 mg orally QID for 7 days
Tetracycline 500 mg orally QID for 7 days
Erythromycin base 500 mg orally QID for 7 days
Patient should be referred to a gynecologist if following are present. 
- Retained foreign bodies.
- Recent instrumentation or surgery of the genital tract such as hysterosalpingography, dilation and curettage, hysteroscopy, termination of pregnancy/evacuation of retained products of conception, laparoscopy and major gynaecological surgical procedure.
- Suspected tumor of the genital tract.
- Cervical ectopy or polyps.
- Recurrent vulvovaginal candida infections.
- Pregnant woman with abnormal vaginal discharge
- Symptoms of upper genital tract infections as fever, lower abdominal pain
Treatment in pregnancy:
- Vulvovaginal Candidiasis: It frequently occurs during pregnancy. Only topical azole therapies for 7 days are recommended for use among pregnant women.
- Trichomoniasis: Metronidazole 2 g orally single dose is recommended. Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.
- Bacterial vaginosis: Treatment is recommended for all symptomatic pregnant women. Metronidazole 250-mg regimen is effective. But, Metronidazole 500 mg twice daily can be used.
- Metronidazole single dose for 7 days
Candida and Chlamydia
- Oral ciprofloxacin or IM ceftriaxone.
- Metronidazole single dose for 7 days.
- Intravaginal clotrimazole if pregnant or unable to use Metronidazole.
- ↑ 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
- ↑ Hainer BL, Gibson MV (2011). "Vaginitis". Am Fam Physician. 83 (7): 807–15. PMID 21524046.
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ Meyer T (August 2016). "Diagnostic Procedures to Detect Chlamydia trachomatis Infections". Microorganisms. 4 (3). doi:10.3390/microorganisms4030025. PMC 5039585. PMID 27681919.
- ↑ 9.0 9.1 "Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines".
- ↑ 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.
- ↑ 11.0 11.1 11.2 11.3 11.4 "Trichomoniasis - 2015 STD Treatment Guidelines".
- ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 "Bacterial Vaginosis - 2015 STD Treatment Guidelines".
- ↑ 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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