Vaginal discharge

Increased vaginal secretions may be physiological-secretions or pathological-discharge. Psychological issues can also lead women to believe their vaginal secretions are abnormal. Vaginal secretions alter during the menstrual cycle and typically become heavier during pregnancy. Many women notice a difference after starting or stopping hormonal methods of contraception. Some causes of a pathological vaginal discharge are shown below-the commonest causes in each category are in bold.

The history is helpful in the differential diagnosis of increased vaginal
discharge. Note should be made of the following:

• The duration of the symptoms.
• The colour, amount and odour (if any) of the discharge.
• Associated symptoms such as pruritus vulvae, vulval pain, and
  deep dyspareunia (as may occur in pelvic inflammatory disease).
• Any variation with the menstrual cycle (physiological discharge tends to
  be more thin and watery at the time of ovulation and thicker mid cycle.
• A sexual history is essential.

Clinical examination is not essential in a woman who complains of a short history of increased vaginal discharge. If there is a good history of candida or BV a NAAT test should be sent and it is reasonable to offer empirical treatment while awaiting these results.

In women returning to BSH with a prolonged vaginal discharge which has not responded to empirical treatment a vaginal examination should be carried out.

Please see the vaginal discharge management pathway.

• Check NAAT swab results for chlamydia and gonorrhoea –this will
  have been performed a month earlier at Triage.
• Foreign bodies, such as a retained tampon, warts and neoplasms will be identified when the vagina is examined using a speculum. If there is a definite history of a foreign body but none is seen, do a digital vaginal examination as the offending item may be tucked into the posterior fornix.

On examination in:

• Bacterial vaginosis, there may be a pool of homogeneous white
  discharge at the introitus and on the walls of the vagina. When the discharge is wiped away with cotton wool, the vaginal mucosa appears normal, or, at most, mildly oedematous. The pH of the vaginal secretions is typically >4.5. Take care when checking the pH to sample from the lateral vaginal walls, thus avoiding the cervical secretions which are naturally alkaline.
• The typical appearance of trichomonal vaginitis is red vaginal mucosa with a frothy yellow discharge in the posterior fornix and an inflamed endocervix (“strawberry cervix”). They may also have vulvitis. This appearance, however, is not pathognomic of trichomoniasis, and it should be noted that many women with this infection have few abnormal signs. There will be no abnormalities at all on examination in up to 15% of women with TV.
• The typical appearance of candidal vaginitis is an inflamed mucosa with a thick “curdy” white discharge and adherent white plaques. There may also be vulval erythema and fissuring.
• Mucopus is seen exuding from the endocervical canal in some
  women with gonococcal and/or chlamydial cervicitis.
• Microscopy – take slides (or if microscopy unavailable, a HVS for
  microscopy in the laboratory) if you feel that they would aid the
  diagnosis. Remember some women will have had a low vaginal swab performed in Triage. If this is the case check the result which includes microscopy. Microscopy can be useful for diagnosing BV, candidiasis and trichomonas and should definitely be performed if the discharge is recurrent. Collect a sample of material from the posterior fornix using a cotton-wool tipped applicator and prepare a smear on a microscope slide for Gram-staining, and then suspend some of the material in a drop of isotonic saline on another slide.

The diagnosis is based on:

• A homogenous white vaginal discharge and characteristic odour
• Vaginal pH>4.5
• +/- microscopy - clue cells on wet prep, gram stain showing mixed flora (grade 2 - intermediate) or predominantly Gardnerella and/or Mobiluncus with few or absent lactobacilli (grade 3 – BV)

Treatment of non-pregnant women is given only if the woman is symptomatic. Large studies have shown that 30% of healthy women will have BV diagnosed on a HVS, but a minority of these women (<20%) will be symptomatic.

Treatment of sexual partners is not indicated.

Bacterial vaginosis in pregnancy:
BV may increase the risk of mid-trimester miscarriage. There is insufficient evidence for routinely screening pregnant women but it is reasonable to treat even asymptomatic pregnant women especially if they are under 20 weeks gestation and have other risk factors for preterm delivery. There is no evidence for teratogenicity with metronidazole but it is recommended that the 2g stat dose should be avoided and pregnant women should be treated with 400mg BD for 7 days or intravaginal therapies.

Breast-feeding – avoid high dose metronidazole as it enters the breast milk and affects the taste.

Patient Information:
BV is not an infection it is an imbalance of bacteria which live normally in the vagina. BV symptoms occur when there is an overgrowth of these anaerobic organisms which are normally found in the vagina in low numbers. This can occur when there is a reduction in the number of vaginal lactobacilli. Lactobacilli produce lactic acid which lowers the pH. BV can occur:

• After sex - seminal fluid has a high pH.
• When there is blood in the vagina as this increases pH.
• Washing practices can reduce lactobacilli numbers- see washing advice leaflet-resulting in an increase in pH.
• Smoking.
• Lesbian women have a higher incidence of BV as do women
  with multiple partners.
• ‘Keto crotch’ not described in scientific literature but noted in
  women on high protein diets. Presumably occurs due to a change in the gut and vaginal microbiome secondary to a high protein diet resulting in an offensive vaginal discharge.
• Although the condition is sexually associated it is not sexually
  transmitted- but using condoms may protect the vaginal pH and
  microflora and reduce the incidence of recurrence.
• There is no need to treat partner(s).
• Avoid soaps, bubble baths, douching and switch to a soap
  substitute for washing-see genital washing advice leaflet.
• Studies have shown that vaginal application of probiotics was
  effective at reducing recurrence rates of BV over a 6 month period. Relactagel has been shown to be as effective at
  reducing recurrences as metronidazole gel.

Follow up:

No follow-up required

Management of recurrent bacterial vaginosis

Most patients with BV will have a recurrence in the next 3-12 months whatever antibiotic treatment is used-oral or topical. For this reason looking at changing washing practices, behaviours and considering measures to improve the vaginal pH and the microbiome are important.

Recurrent BV is defined as three or more confirmed episodes in a 12 month period. It is important to confirm that recurrences are due to BV. It may be due to persistence of BV associated bacteria following treatment as occurs due to microfilm formation within the vagina, or failure to re-establish lactobacilli following therapy and hence a normal low pH. With a rise in pH, proliferation of the colonising anaerobes and Gardnerella vaginalis occurs. This explains why BV can recur after menstruation, douching and sex. The use of an IUD has been associated with recurrent BV, so in women with recurrent infection another form of contraception could be used. As semen raises the vaginal pH, condoms can help reduce recurrences.

Discussing diet and the link between high protein diets and change in the vaginal microbiome may be beneficial for some women.

The diagnosis of vaginal candidiasis is made by finding hyphae or pseudohyphae or spores in wet or Gram-stained film of vaginal secretions. However, a clinical diagnosis can be made without microscopy if the history and examination are in keeping with the diagnosis.

Treatment of vaginal candidiasis is given only if symptomatic-10-20% of women are asymptomatic carriers increasing to 40% in pregnancy (although in this situation treatment can be given with an antifungal to women who are very prone to antibiotic-induced thrush if treating another infection).

With respect to efficacy, there is little difference between the various drugs and their route of administration. In the selection of antifungal agent, however, several factors should be taken into consideration: 

• Patient choice between a topical or oral preparation.
• Pregnancy, or the possibility of pregnancy at the time of treatment.
• In the case of topical preparations, the possibility of damage
  to latex condoms or contraceptive diaphragms.
• In the case of oral antifungal drugs, the possibility of drug
  interactions, although the risk is small with single-dose therapy.

Fluconazole given in a single oral dose of 150mg is as effective as clotrimazole pessaries in the treatment of candidiasis, but is considerable less expensive. This agent should therefore be the treatment of choice when pregnancy is not likely. Check on BNF app for any possible drug-drug interaction.

Oral antifungal agents for the treatment of acute vulvovaginal candidiasis.

(CONTRAINDICATED IN PREGNANCY)

*REMEMBER COST. Itraconazole is much more expensive than fluconazole.

Topical agent for use in acute vulvovaginal candidiasis.

Patient Information:

• Candidiasis is not a sexually transmitted infection.
• The problem is caused by an overgrowth of Candida spp. which are a bowel commensal.
• There is no need to treat the partner.
• The condition may recur.
• The use of bubble baths, douching, tight clothing, nylon underwear, antibiotics, the pre-menstrual period and pregnancy may predispose.
• There is no evidence that diet has any effect on candidiasis.
• The use of the low oestrogen combined pill does not predispose to candidiasis.
• The infection is not eradicated by systemic treatment.

The management of recalcitrant or frequently recurring vulvovaginal candidiasis

Recurrent vulvovaginal candidiasis (RVVC) may be defined as four episodes of mycologically-proven candidiasis within 12 months and affects fewer than 5% of women.

• The diagnosis should always be confirmed by microscopy.
• Vaginal secretions should be sent for culture, to determine the species of Candida and its sensitivity to antifungal drugs. A blue-topped HVS swab should be sent and candida culture specifically requested on the request sent to the lab. The clinical response of C. glabrata, the second most common isolate from women with recurrent vulvovaginal candidiasis, to topical or oral antifungal agents is uncertain. The MICs of the available azoles are generally higher for C. glabrata than for C. albicans, and in many cases, there is frank resistance to fluconazole. Itraconazole has moderate activity against C. glabrata, but the MIC for the isolate does not always predict therapeutic success. Other treatments for candida glabrata include Nystatin pessaries used nightly for 14- 21 days or Flucytosine+/- Amphoteracin made up as a vaginal pessary, or Boric acid 600mg made up as a vaginal pessary for 14-21 days. Please discuss with Consultant as these preparations are expensive and require to be ordered via pharmacy taking several weeks to arrive.
• If there are other symptoms suggesting diabetes check a glycosylated haemoglobin.
• Treatment of the acute episode with any of the antifungal preparations noted above should be initiated. When vaginal pessaries or intravaginal cream are used, cream should also be applied to the vulval skin.)
• Maintenance treatment is initiated immediately after resolution of
  symptoms.
• This may be with:

The length of treatment must be tailored to the individual patient, but is unlikely to be less than 6 months. At the end of this period it is worth discontinuing therapy to assess outcome. Further therapy may be necessary.

It is important to discuss washing practices with the patient. Suggest switching to a soap substitute-essential to wash entire body with soap substitute as any soap product used above the waist will wash onto genital skin. Avoid perfumed bath products including washing hair in the bath, fabric softeners and wet wipes. Individual patients have reported a reduction in frequency of their ‘thrush’ symptoms when taking oral/vaginal probiotics. These need to be self sourced by the patient as they are not available on prescription. There is no evidence that treatment of the sexual partner influences recurrence.

Some women will have persisting vulvitis despite apparent mycological cure. In these women, the pathogenesis is probably hypersensitivity to candidal antigens. A combined steroid/antifungal cream-Daktocort often controls symptoms.

Candidiasis in pregnancy:

Asymptomatic and symptomatic candidiasis are both more prevalent during pregnancy but are not associated with any adverse pregnancy outcomes. Oral antifungal agents are contraindicated in pregnancy so topical antifungals should be used and longer (7 day) courses give higher cure rates.

The diagnosis is made by the detection of Trichomonas vaginalis in a saline mount preparation of material obtained from the posterior vaginal fornix. The protozoan may also be found in a high vaginal specimen sent to the laboratory in transport medium and occasionally Trichomonas-like organisms may be reported on cervical smear results. Trichomonas is an uncommon infection in Scotland but it may increase the risk of HIV transmission via increased genital shedding of the virus.

Treatment:

The cure rate is up to 95%.

Patient Information

• Trichomoniasis is a sexually transmitted infection
• Most men are symptomless.
• Male sexual partners should be treated.

Follow up:

The woman should be reviewed two weeks after treatment. A test of cure is only recommended if the patient remains symptomatic. It is also important to ensure that the appropriate contact tracing has been completed.

Recurrent or relapsing trichomoniasis

Treatment failure is usually due to non-adherence or re-infection. Occasional metronidazole resistance does occur. All cases should be discussed with a consultant. High dose oral and intravaginal metronidazole may have a higher efficacy. Other useful therapies are ampicillin or erythromycin in conjunction with metronidazole, or tinidazole 2G orally stat. Systemic treatment is recommended because T vaginalis infects the urethra and Skene's (paraurethral) glands as well as vagina.

See BASHH Guideline for further information.

Trichomoniasis in pregnancy:

There is some evidence that infection with Trichomonas is associated with adverse pregnancy outcomes including preterm delivery. Metronidazole is not contraindicated in pregnancy and is therefore the treatment of choice. A regime of 400mg BD for 7 days is recommended. A Test of Cure should be performed.

• Guidelines for BV, candidasis and trichomonas available on the
  BASHH website www.BASHH.org
• Joint BASHH/FSRH guidelines on vaginal discharge available on the
  FSRH website www.FSRH.org
• European (IUSTI/WHO) guideline on the management of
  vaginal discharge, 2018 J Sherrard