Synopsis
Distinguish the common causes of vaginal discharge by symptoms, examination and point-of-care or laboratory testing, then use diagnosis-specific treatment, pregnancy precautions and partner management.
- Bacterial vaginosis typically causes thin homogeneous grey-white discharge and a fishy odour with little vulval inflammation.
- Vulvovaginal candidiasis usually causes intense itch, soreness, erythema and thick white discharge; vaginal pH generally remains normal.
- Trichomoniasis may cause offensive yellow-green or frothy discharge, vulval irritation and punctate cervical inflammation, but many infections are asymptomatic.
Key red flags
Pelvic pain, cervical motion tenderness or adnexal tenderness suggests pelvic inflammatory disease rather than isolated vaginitis.
Deep dyspareunia, intermenstrual bleeding, pelvic pain, fever or cervical excitation requires assessment for PID.
Investigation priorities
Differentiate normal-pH candidiasis from pH elevation in bacterial vaginosis or trichomoniasis.
Management branches
A patient presents with new vaginal discharge, odour, itch or vulval soreness.
- Ask onset, discharge, odour, itch, pain, bleeding, urinary symptoms, pregnancy possibility, antibiotics, diabetes, products and sexual exposures.
- Examine vulva and use speculum assessment when clinically appropriate, checking cervix, retained foreign body, ulcers and upper-tract tenderness.
Key medicines
Metronidazole for bacterial vaginosisGive 400 mg orally twice daily for five to seven days, or use the exact locally approved intravaginal alternative.
Clotrimazole for candidiasisGive a 500 mg intravaginal pessary once for uncomplicated disease; in pregnancy use a topical azole course for seven days.