The management of chronic vaginal discharge, owing to physiological, infective and non-infective causes, in the reproductive-aged woman.

Vaginal discharge varies between individuals in volume and consistency. The causes of increased or altered vaginal discharge can be organised into three groups based on the age group affected: pre-pubertal; reproductive; and post-menopausal. This article addresses the management of chronic vaginal discharge in the reproductive-aged woman and is further divided into physiological, infective (sexually and non-sexually transmitted infections [STI and NSTIs]) and non-infective categories.

Physiological

During the menstrual cycle, cervical mucous production varies with levels of oestrogen and progesterone. This mucous, in combination with sloughed epithelial cells and transudate from the vaginal squamous epithelium, makes up physiological discharge.

Mucous production steadily increases with oestrogen levels during the follicular phase, to a peak at ovulation. Consistency also changes throughout the cycle, from thick and sticky during the non-fertile phase to clearer, stretchy and slippery towards ovulation. During the luteal phase, secretion decreases and again becomes thick and sticky in consistency, owing to reducing levels of oestrogen and increasing levels of progesterone.

There are a range of commensal bacteria in the vagina of reproductive women, of which the most abundant is lactobacilli. Lactobacilli produce lactic acid via glycogen metabolism thereby maintaining vaginal pH <4.5 and thus protecting against ascending infections. The absence of lactobacilli is a well-recognised risk factor for genital infections and complications of pregnancy.¹

Infective

Bacterial vaginosis – NSTI

Bacterial vaginosis (BV) is the most prevalent cause of infective vaginal discharge.² It results from a reduction in normal hydrogen peroxide-producing Lactobacillus species in the vagina that allows overgrowth of anaerobic and other fastidious bacteria. Organisms: Gardenerella vaginalis (40 per cent), others include species of Prevotella, Mycoplasma, Mobiluncus and Peptostreptococcus.¹ Signs and symptoms include:

• thin white or grey discharge with offensive or fishy odour, worse after intercourse; and
• discharge coating the vagina.

However, 50 per cent cases are asymptomatic.²
Risk factors are as follows:

• early age at first intercourse; and
• risky sexual behaviour.

It is more common in smokers and those using intrauterine contraceptive devices.

Associations:

• Higher risk of acquiring STIs.
• Associated with adverse pregnancy outcome, pelvic inflammatory disease (PID), chorioamnionitis and endometritis.³

The Amsel Criteria² can be used for diagnosis (three of four criteria is diagnostic):

1. grey, white or yellow homogenous discharge;
2. vaginal pH >4.5;
3. fishy odour (after application of ten per cent potassium
   hydroxide); and
4. presence of at least 20 per cent clue cells (bacteria-coated
   vaginal epithelial cells).

The Nugent score is a gram stain scoring system from one to ten, based on the number of lactobacilli, gram-negative to gramvariable bacilli and gram negative curved bacilli. A score of seven or above indicates BV.³

The BV Blue test is a point-of-care test detecting the presence of sialidase activity. It provides presumptive diagnostic information to women with BV when used in conjunction with clinical information.⁴

Management⁵:

• • Advise against douching and using feminine hygiene products, strong soaps and shower gel.
  • Metronidazole 400mg orally twice a day for seven days or 0.75 per cent vaginal gel, one applicator-full intravaginally for five nights or clindamycin 300mg orally twice a day for seven days or two per cent vaginal cream, one applicator-full intravaginally, for seven nights.
  • The cure rate is 70–80 per cent.
  • Clindamycin is more effective against resistant anaerobes and is preferred in pregnancy.
  • Success rates are similar between oral and vaginal application, but vaginal preparation has fewer systemic side effects.
  • Infection may resolve spontaneously in 30 per cent of cases, however, treatment may reduce the risk acquiring STIs¹ or pregnancy complications

Candida (NSTI)

Candida is the second most common cause of infective vaginal discharge and is caused by overgrowth of vaginal yeasts. More than 75 per cent women suffer from vulvovaginitis during their lifetime², and approximately 20 per cent of cases are asymptomatic.⁵ The organisms involved are: Candida albicans (80 per cent), C. glabrata, C. tropicalis and C. krusei.¹

Signs of candida include vulval erythema, oedema, fissuring or satellite lesions (small white plaques) while the symptoms are:

• • • non-offensive thick and white discharge (‘curdy’);
    • pruritus;
    • superficial dyspareunia; and
    • external dysuria.

The risk factors are pregnancy and being aged between 20 and 30 years.² Precipitating factors include: antibiotic treatment, steroid use, synthetic underwear, diabetes mellitus and pregnancy. Diagnosis is largely based on clinical symptoms. Swab microscopy reveals spores and pseudohyphae. Sensitivity is 50–80 per cent, however, primary culture is rarely indicated.⁴

Management⁵:

Vaginal imidazole (for example, clotrimazole ten per cent vaginal cream, one applicator-full intravaginally, as single dose at night or use two per cent vaginal cream for three nights or one per cent vaginal cream for six nights); or

• Nystatin 100 000 units/5g vaginal cream one applicator-full intravaginally twice a day for seven nights.
• Fluconazole 150mg orally as single dose if non-pregnant, intolerant to topical therapy or as personal preference.
• Local treatment is effective in at least 80 per cent women (to be avoided during menses).
• Nystatin, although less effective, is generally better tolerated.

If symptoms recur despite therapy then other causes should be sought, for example diabetes mellitus, C. glabrata infection (resistance to imidazoles frequent) or immunodeficiency¹.

Trichomonas vaginalis (STI)

Trichomonas vaginalis (TV) is a pathogenic flagellate, and is the most common STI worldwide, with an annual incidence of over 170 million cases.⁶

Signs:

• Blisters develop in a third of cases.¹
• ‘Strawberry’ cervix: punctate haemorrhagic lesions.
• A pH of >4.5, (often exceeds 6.0).

Symptoms:

• 50–75 per cent infections are asymptomatic¹;
• classic discharge is profuse, yellowish-green and frothy;
• strong-smelling fishy odour;
• pruritus;
• dyspareunia; and
• dysuria.

Co-infection with other STIs is common.⁶ Some studies indicate an association with premature rupture of membranes, preterm delivery and low birthweight.¹

The gold standard for diagnosis is high vaginal swab culture. Microscopy of vaginal wet mount has sensitivity of 60–70 per cent. Flagellates are seen with pear shaped morphology and whip-like processes (visible in 80 per cent).¹

Management⁵:

• Metronidazole 2g orally, as single dose or metronidazole 400mg orally twice a day for five days for cases that relapse after single-dose treatment. This has a 90 per cent cure rate; or
• Tinidazole 2g orally, as single dose.
• Patients and partners should be treated regardless of symptoms.

Chlamydia trachomatis (STI)

The signs of chlamydia infection are vaginal discharge (owing to cervicitis) and abnormal bleeding (postcoital or intermenstrual). Studies show 50 per cent of infected women¹ are asymptomatic. Symptoms can include lower abdominal pain, dyspareunia or urethral infection causing dysuria.

The risk factors for chlamydia are <25 years of age and having had a new sexual partner or multiple sexual partners in a year. Infection is associated with the following:

• Recurrent infections associated with PID, infertility and chronic pelvic pain.
• Ophthalmia neonatorum: neonatal conjunctivitis from infection at birth.

Diagnosis is by endocervical swab for culture or enzyme-linked immunosorbent assay (ELISA) and nucleic acid amplification tests (NAAT) on first-catch urine.⁶

Management (for patient and partners)⁵:

• Azithromycin 1g orally, as a single dose; or
• Doxycycline 100mg orally twice a day for seven days.
• Abstinence from intercourse recommended during treatment.

Neisseria gonorrhoeae (STI)

The key sign of Neisseria gonorrhoeae is vaginal discharge in up to 50 per cent of cases (owing to cervicitis, rather than vaginitis).⁷ However, up to 80 per cent of cases are asymptomatic.⁸ Symptoms can include:

• dysuria;
• intermenstrual or postcoital bleeding;
• lower abdominal pain; and
• pruritus or burning sensation.

Infection is associated with co-existance with other infections as well as ophthalmia neonatorum. Recurrence is associated with PID, infertility and chronic pelvic pain.

The gold standard method of diagnosis is culture using chocolate agar from endocervical swabs. NAAT from mid-catch urine or cervical swab and ELISA of fluid sample from affected area.

Management⁵, in urban areas where penicillin resistance is common:

• Ceftriaxone 500mg in 2ml of one per cent lignocaine IM, or 500mg IV, as single dose.
• If chlamydia infection has not been ruled out, also prescribe: azithromycin 1g orally, as single dose or doxycycline 100mg orally, twice a day for seven days.

Where penicillin resistance is less common (remote areas) prescribe:

• Amoxicillin 3g orally and Probenecid 1g orally, as single doses.

Non-infective

Foreign bodies can be associated with persistent, foul-smelling vaginal discharge, bleeding and/or pelvic pressure. They are most commonly seen in children and in these cases abuse must be considered.⁹ Forgotten tampons or condom pieces are common culprits in reproductive-aged women. Speculum examination and/or examination under anaesthesia may be required for visualisation and removal. Chronic sequelae can include embedding of objects in the vaginal wall, dysparunia or development of fistulae between the bladder, rectum or peritoneal cavity.²

Fistulae can result in chronic, foul or faeculent vaginal discharge and are usually managed surgically. There is often a history of trauma or previous surgery and recurrent urinary tract infections if the bladder is involved.

Cervical polyps occur in approximately four per cent women of reproductive age, most commonly in multiparous women aged 40–50 and in pregnancy.² Polyps (usually benign) may cause increased vaginal discharge, post coital or intermenstural bleeding or menorrhagia. They can be removed manually or through ablative methods (liquid nitrogen or electrocautery), once a biopsy has been taken to rule out malignancy, to prevent regrowth.

Genital tract malignancy can cause blood-stained discharge. More advanced cancers may have a secondary infection leading to frank bloody, purulent and foul-smelling discharge and can be associated with pelvic pain. Visual inspection, cytologic smears and colposcopy are usually adequate for diagnosis of cervical lesions, however, pelvic ultrasound and/or tissue samples from hysteroscopy or diagnostic laparoscopy may be needed to help identify lesions higher in the pelvis (uterus, fallopian tubes and ovaries). Genital tract malignancies usually require excision and/or chemotherapy/radiotherapy.

Allergic reaction is most commonly secondary to synthetic products (condoms, tampons, douches and so forth) and, rarely, can be owing to proteins within semen. Symptoms include discharge, pruritus and burning of the vagina and these can be relieved by antihistamines or topical steroids. Removing the causative agent is curative.

Psychosocial distress, such as abuse, has been shown to cause an increase in vaginal discharge. Appropriate counselling and support are required for these women.¹⁰