Vaginal discharge
Exam Tips
- In OSCEs, start by separating physiological from pathological discharge using cycle timing, odour, itch, pain, and bleeding history.
- Vaginal pH is high-yield: <4.5 suggests candidiasis; >=4.5 suggests BV or trichomoniasis (cannot reliably distinguish those two on pH alone).
- Fishy odour with thin homogeneous discharge and minimal inflammation points to BV; curdy non-offensive discharge with vulval itch/erythema points to candidiasis.
- Any discharge plus deep dyspareunia, pelvic pain, fever, or abnormal bleeding should trigger PID/cervicitis assessment and early empiric management.
- Remember STI risk factors (age <25, new/multiple partners, condomless sex, prior STI) and include HIV/syphilis testing and partner notification.
- Red flags for urgent referral: post-coital/intermenstrual bleeding, persistent unexplained symptoms, visible lesion/mass, or suspected malignancy.
Definition
Vaginal discharge is a common presentation in which secretions may be physiological (normal cyclical cervical-vaginal mucus) or pathological due to infection, inflammation, atrophy, foreign material, or malignancy. Pathological discharge is suggested by a new change in colour, odour, volume, or consistency, especially when accompanied by itch, soreness, dysuria, pelvic pain, dyspareunia, or abnormal bleeding.
Pathophysiology
Normal discharge reflects oestrogen-driven cervical mucus production, vaginal transudate, and lactobacillus-dominant flora that maintain an acidic pH (<4.5 in reproductive-age women). Abnormal discharge occurs when this ecosystem is disrupted (for example anaerobic overgrowth in bacterial vaginosis), when mucosal infection causes cervicitis/vaginitis (Candida, Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae), or when non-infective pathology causes inflammation/erosion (irritant vaginitis, desquamative inflammatory vaginitis, erosive lichen planus, malignancy, genitourinary syndrome of menopause). Ascending infection from cervix to upper genital tract can produce PID, where epithelial damage and inflammation of endometrium, tubes, and adnexa drive pain, fever, and long-term subfertility risk.
Risk Factors
- Age under 25 years with recent sexual activity
- Condomless sex with new or casual partners
- More than one partner or a new partner in the last 12 months
- Previous STI history
- Recent vaginal products/irritants (douching, perfumed washes, latex/spermicides)
- Retained foreign body (tampon, condom, vaginal sponge)
- Pregnancy, postpartum or post-procedural state (for atypical/recurrent infection risk)
- Perimenopause/menopause causing hypo-oestrogenic atrophic change
Clinical Features
Symptoms
- Change in discharge colour, amount, consistency, or smell
- Vulval itch, soreness, burning, or irritation
- Dysuria or superficial dyspareunia
- Deep dyspareunia, lower abdominal/pelvic pain, fever (suggesting upper tract involvement)
- Post-coital, intermenstrual, or heavy bleeding
- Offensive fishy odour (classically BV)
- Curdy non-offensive discharge with itch (classically vulvovaginal candidiasis)
- Frothy yellow-green or malodorous discharge (possible trichomoniasis)
Signs
- Thin homogeneous grey-white coating discharge in BV with little vulval inflammation
- Vulval erythema/oedema, fissuring, excoriations, satellite lesions in candidiasis
- Mucopurulent cervicitis and contact bleeding in chlamydia/gonorrhoea
- Vulvitis/vaginitis; occasional strawberry cervix in trichomoniasis (see speculum image in STI atlases)
- Cervical motion, uterine, or adnexal tenderness in PID
- Visible foreign body, ulceration, erosive lesions, or suspicious cervical/vaginal mass on examination
Investigations
Management
Lifestyle Modifications
- Avoid vaginal douching, deodorants, and perfumed products; use gentle non-irritant vulval care
- Improve menstrual and genital hygiene; wipe front-to-back
- Advise condom use and sexual abstinence until treatment completion in STI-related disease
- Arrange partner notification and treatment for confirmed STIs (especially trichomoniasis, chlamydia, gonorrhoea)
- Safety-net urgently for fever, severe pelvic pain, pregnancy, post-coital/intermenstrual bleeding, or suspected malignancy
- Remove retained foreign body promptly and reassess symptoms
Pharmacological Treatment
Bacterial vaginosis (nitroimidazole/lincosamide)
- Metronidazole 400 mg orally twice daily for 5-7 days
- Metronidazole 0.75% vaginal gel 5 g nocte for 5 days
- Clindamycin 2% vaginal cream 5 g nocte for 7 days
Avoid alcohol with metronidazole and for 48 hours after last dose. Check interactions with warfarin (raised INR risk). Clindamycin cream can weaken latex condoms/diaphragms during treatment and for several days after use.
Vulvovaginal candidiasis (azole antifungals)
- Clotrimazole pessary 500 mg intravaginal single dose (or 200 mg nightly for 3 nights)
- Clotrimazole 10% external cream applied 2-3 times daily until symptoms settle
- Fluconazole 150 mg orally single dose (non-pregnant adults)
In pregnancy, use topical azole regimens and avoid oral fluconazole unless specialist advice. Recurrent disease (>=4/year) needs confirmation of species and longer regimens.
Trichomoniasis
- Metronidazole 400 mg orally twice daily for 5-7 days
Treat sexual partners concurrently and advise no sex until all parties complete treatment and symptoms resolve. Avoid alcohol with metronidazole.
Chlamydia cervicitis
- Doxycycline 100 mg orally twice daily for 7 days
- Azithromycin 1 g orally single dose (alternative in selected cases, including pregnancy per specialist/local protocol)
Doxycycline is contraindicated in pregnancy and generally avoided during breastfeeding. Ensure retesting and partner notification.
Gonorrhoea cervicitis
- Ceftriaxone 1 g intramuscular single dose (with local anaesthetic diluent per local protocol)
Take culture/NAAT and follow resistance guidance; manage with sexual health services. Check serious beta-lactam allergy history before cephalosporin use.
Suspected mild-moderate PID (empiric outpatient regimen)
- Ceftriaxone 1 g intramuscular single dose plus
- Doxycycline 100 mg orally twice daily for 14 days plus
- Metronidazole 400 mg orally twice daily for 14 days
Use low threshold for empiric treatment to reduce infertility/ectopic risk. Urgent specialist review if severe illness, pregnancy, tubo-ovarian abscess, or diagnostic uncertainty.
Genitourinary syndrome of menopause
- Estradiol vaginal tablet 10 micrograms daily for 2 weeks then twice weekly
- Estriol 0.01% vaginal cream 0.5 mg daily until improvement then twice weekly maintenance
Use after excluding infection and concerning bleeding pathology. Counsel on local oestrogen risks/benefits and review persistent bleeding urgently.
Surgical / Interventional
- Removal of retained vaginal foreign body under direct visualization
- Biopsy/colposcopic assessment for suspicious cervical or vaginal lesions
- Operative management of complications such as tubo-ovarian abscess drainage or fistula repair when indicated
Complications
- Pelvic inflammatory disease with chronic pelvic pain
- Tubal-factor infertility and increased ectopic pregnancy risk after PID
- Recurrent vulvovaginal symptoms and reduced quality of life
- Adverse pregnancy outcomes in some infections (for example preterm birth risk associations)
- Persistent infection and onward STI transmission if partners untreated
- Delayed diagnosis of gynaecological malignancy if red flags are missed
Prognosis
Most causes resolve with accurate diagnosis and targeted therapy, but recurrence is common in BV and candidiasis unless predisposing factors are addressed. Prognosis worsens when STI-related disease is untreated or PID treatment is delayed, because long-term reproductive sequelae become more likely.
Sources & References
🏥BMJ Best Practice(1)
✅NICE Guidelines(1)
- Vaginal discharge[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1703, 1704)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1703, 1704)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1580, 1581)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1703)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1580)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1587)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1586)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 267, 268)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 311)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 306, 307)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 9, 10)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 308, 309)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 110)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 83, 84)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 309, 310)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 1044)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 367)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 345)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 344, 345)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 309)[context]