Female Vaginal Discharge

exp date isn't null, but text field is

Questions to be asked

  • duration?
  • colour?
  • smell?
  • itchy/sore/painful?
  • intermenstrual bleeding? (IMB)
  • itchy/sore/painful?
  • dyspareunia
  • abnormal vaginal bleeding

Examination

  • note colour + consistency of discharge
  • signs of soreness, rash or fissures?
  • test vaginal ph
  • be prepared, speculum, lubricant, swabs, light source

NB: Chlamydia is the most common curable Sexually Transmitted Infection (STI )

  • asymptomatic in approx 80%
  • post-coital or intermenstrual bleeding (IMB)
  • lower abdominal pain
  • purulent discharge
  • mucopurulent cervicitis and/or contact bleeding
  • dysuria

For treatment suggestions, see chlamydia guidelines for:

  • Complicated Chlamydia Infection (symptomatic)
  • Uncomplicated Chlamydia Infection (asymptomatic)
Physiological discharge Candida Albicans Bacterial Vaginosis Trichomonas Vaginalis Gonorrhoea
  • present > 6 months
  • smooth, creamy yellow
  • not itchy or smelly
  • itchy or sore
  • may have rash or fissures
  • ‘curd’ like discharge/lumpy
  • ph < 4.5
  • smooth, creamy yellow discharge
  • not associated with soreness/itching
  • smelly – ‘fishy’ odour
  • ph of vaginal fluid > 4.5
  • offensive, yellow, frothy discharge in 30% of cases
  • vaginal discharge, varying consistency
  • vulvitis & vaginitis
  • ‘strawberrycervix’ appearance to the naked eye
  • green or creamy discharge coming out of cervix
  • intermenstrual bleeding of menorrhagia
  • pelvic/ lower abdominal pain
  • dysuria

(commonly no abnormal findings are present on examination)

Action

There is now NO requirement to examine asymptomatic patients, unless you identify a clinical indication. For female patients, ask them to obtain a self obtained low vaginal swab (purple swab)

Offer routine resting for Chlamydia and bacterial infection, i.e purple swab and black charcoal swab if there is a clinical indication i.e unprotected sexual intercourse and risk of infection

Action

If Candida albicans is suspected, take a black charcoal transport swab from vaginal discharge and on the request form ask laboratory staff to make a Gram stain and to culture for Candida species

Action – swabs to be taken

If bacterial vaginosis is suspected, ask the laboratory to make a Gram slide for a Hay-Ison score. You may also wish to perform pH testing, amine testing etc, but the diagnosis of BV is clinical. Culture is not routine

Action – swabs to be taken

If Trichomonas vaginalis (TV) is suspected, take a black charcoal transport swab from vaginal discharge and on the request form ask laboratory staff to make a wet preparation for TV. Request culture on Finebergs medium if available

Action - Swabs To Be taken
If gonorrhoea is suspected, take a black charcoal transport swab from the endocervix, and make a microscope slide for the laboratories to Gram stain and read. Alternatively, you can ask Lab staff to prepare slide from your transport swab.

Reassure + Await Results

Suggest:

  • recommend use of vulval moisturiser as a soap substitute
  • avoid tight fitting synthetic clothing
  • avoid local irritants e.g. perfumed products
  • OFFER: clotrimazole pessary 500mg stat. and clotimazole cream. Effect on latex condoms and diaphragms not known With this treatment- please advise patient of this.
  • Alternatively - Oral therapy – Fluconazole Capsule 150mg stat Note -AVOID IN PREGNANCY

Suggest:

  • advice stop using perfumed soaps, vaginal douches etc
  • offer metronidazole 400mg-500mg B.D. course for 5-7days
  • or intravaginal clindamycin cream (2%) once daily for 7days

Suggest:
Recommended Regimes: metronidazole 2g orallyin a single dose
or
metronidazole 400-500mg twice daily for 5-7 days

Alternative Regimens
Tinidazole 2g orally in a single dose

  • sexual partner(s) should be treated simultaneously
  • avoid sexual intercourse including oral sex until they & their partner(s) have completed treatment and follow up
  • screening for coexistent sexually transmitted infections should be undertaken in both men and women
  • Discuss Partner Notification - Current partners and any partner(s) within the 4 weeks prior to presentation should be screened for the full range of STIs and treated for TV irrespective of the results of investigations or Refer to HSH using SCI Gateway – using referral option HSH/PARTNER NOTIFICATION (preferred method of referral) or use other means of referral
  • Email referral form or Telephone referral leaving all relevant information – Tel 01471 820340 (ansaphone facility)
  • f you do not have access to email facility send completed postal referral form to Broadford, Isle of Skye, IV49 9BL

Offer: Ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose - (as genital infection with Chlamydia trachomatis commonly accompanies genital gonococcal infection) * Ceftriaxone is supplied as a powder which needs to be reconstituted with lidocaine solution. It should be given by deep intramuscular injection.

Alternative regime :- Cefixime 400 mg oral as a single dose and azithromycin 1 g stat. Only advisable if an intramuscular injection is contraindicated or refused by the patient
IMPORTANT - A TEST OF CURE IS RECOMMENDED IN ALL +VE CASES OF G.C. THIS SHOULD BE PERFORMED TWO WEEKS AFTER COMPLETION OF ANTIBIOTIC THERAPY 

Suggest:

Patients should be advised to abstain from sexual intercourse until they and their partner(s) have completed treatment

Refer to Highland Sexual Health. Tel. 01463 888300 or by SCI Gateway – using referral option HSH/PARTNER NOTIFICATION (preferred method of referral) *Partner Notification should be pursued in all patients with gonococcal infection, preferrably by a trained Health Advisor in Genito-urinary Medicine

 

Editorial Information

Last reviewed: 31 August 2015

Next review: 31 August 2017

Author(s): Senior Nurse - Sexual Health

Version: 8

Approved By: high-uhb.tam@nhs.net

Reviewer Name(s): Lynn Chalmers