Vaginal Discharge

Differential Diagnosis:      

  •  physiological – (neonate – sticky greyish d/c from mat. est.; thin whitish d/c 6-12 months before menarche; mid-cycle d/c with preg & OCP)
  • infectious (cervicitis – gonorrhea, chlamydia; vulvovaginitis – bacterial vaginosis, yeast, trich)
  • enterovaginal fistula
  • foreign body
  • neoplasm – vaginal SC Ca, cervical Ca, fallopian Ca

Bacterial vaginosis          

  • not sexually transmitted, but more common in very sexually active women
  • qual/quantitative shift in normal vaginal flora (increased anaerobes, decreased lactobacilli)
  • Symptoms:                         
    • many asymptomatic; dyspareunia
    • discharge: moderate amount, white/grey, homogenous/ coats vagina, fishy
    • bubbles in d/c due to anaerobes
    • no vulvar or vaginal inflammation
    • pH > 4.7, + amine test
    • saline microscopy – clue cells, coccobacilli
  • Criteria for diagnosis (need 3/4): 
    • 1) white homogeneous d/c
    • 2) vaginal pH> 4.7
    • 3) fishy amine odor (with addition of 10% KOH)
    • 4) clue cells
    • gram stain criteria
    • Not culture
  • Treatment: 
    • metronidazole 500 mg po bid x 7 days
    • metrogel 5 g pv x 6 days
    • dalacin 100 mg pv x 7 days (clindamycin)

Candidiasis       

  • associated with pregnancy, OCP, ABx, DM, immunosuppression
  • Symptoms     
    • vulvar pruritus, external dysuria, dyspareunia
    • discharge: scant – mod, white, cottage-cheese consistency, no bubbles
    • vulva/ vagina may have erythema, edema, whitish areas
  • Diagnosis:      
    • pH < 4.5, amine test -‘ve
    • saline microscopy – blastospores, pseudohyphae
    • wet prep (KOH) – buds/ hyphae
    • culture
  • Treatment:      
    • topical azole derivatives (eg monostat x 10-14 days, canesten x 1-7 days) or polyenes
    • single oral dose fluconazole  150 mg (or x 3 days) – GI SEs common

Trichomoniasis                

  • sexually transmitted protozoan
  • Symptoms:                      
    • men usually asymptomatic
    • vulvar pruritus, external dysuria (due to rawness around vulva), dyspareunia
    • discharge: profuse, yellow/green, homogenous, frothy, malodorous
    • vagina/ vulva – erythema, edema, “strawberry cervix”
    • Diagnosis:
      • pH 5-6, amine test occ +
      • saline microscopy  – ++ PMNs, motile trichomonads, no clue cells
      • wet prep (saline microscopy), culture, pap
    • Treatment:
      • metronidazole 2 g stat (95% cure, esp if Rx partner)
      • metronidazole 500 mg bid x 7 days (teratogenic so don’t use in pregnancy)

 Chlamydia & Gonorrhea  — See STI Notes

Leave a Comment