Synopsis
Distinguish physiological discharge from vaginal, cervical, upper-genital-tract and non-infective disease while recognising pregnancy complications, pelvic infection, safeguarding concerns and malignancy promptly.
- Normal discharge varies with ovulation, pregnancy, sexual arousal and exogenous hormones; it is usually clear or white and is not accompanied by itch, strong odour, bleeding or pelvic pain.
- Localise the syndrome before naming an organism: vulval itch and soreness suggest candidiasis or dermatosis, malodour suggests bacterial vaginosis or trichomoniasis, and mucopurulent contact bleeding suggests cervicitis.
- Bacterial vaginosis typically causes thin homogeneous discharge, a fishy odour and vaginal pH above 4.5 with little inflammation; symptoms alone do not prove the diagnosis.
- Vulvovaginal candidiasis more often causes itch, soreness, erythema, fissuring and non-offensive discharge with pH at or below 4.5; asymptomatic Candida colonisation does not require treatment.
- Take an exposure-sensitive sexual history and offer site-appropriate NAAT for chlamydia and gonorrhoea; add a validated trichomonas test when the phenotype or exposure makes it plausible.
- Pregnancy testing, consented examination and targeted microscopy, pH or swabs are selected according to symptoms; a normal external examination does not exclude cervical or upper-tract infection.
- Persistent or recurrent discharge after negative infection tests should trigger review for irritant dermatitis, a retained foreign body, genitourinary syndrome of menopause, fistula or neoplasia rather than repeated empirical antimicrobials.
Key red flags
A positive pregnancy test with unilateral pain, shoulder-tip pain, bleeding, syncope or peritoneal signs requires urgent assessment for ectopic pregnancy.
Fever, vomiting, marked lower abdominal pain, cervical excitation, adnexal tenderness or peritonism suggests pelvic inflammatory disease or a surgical emergency.
Hypotension, tachycardia, rash, confusion, severe myalgia or a retained tampon raises concern for toxic shock or sepsis and needs emergency care.
Postmenopausal, persistent blood-stained, offensive or watery discharge, especially with a visible lesion or pelvic mass, needs an expedited cancer pathway.
Severe vulval pain, necrosis, rapidly extending erythema, urinary retention or immunosuppression warrants same-day specialist examination.
Investigation priorities
Identify pregnancy before interpreting pain, bleeding or selecting medicines.
Management branches
Discharge is accompanied by pain, bleeding, fever, systemic symptoms or clinical deterioration.
- Record observations, assess abdomen and obtain hCG promptly when pregnancy is possible.
- Escalate haemodynamic compromise, peritonism, suspected ectopic pregnancy, sepsis or necrotising vulval infection immediately.
- When PID is clinically likely, collect appropriate microbiology but do not delay empirical treatment for laboratory confirmation.
The patient is stable and requires a focused diagnostic assessment.
- Separate physiological variation from vulval inflammation, vaginal dysbiosis, cervicitis, upper-tract disease and a non-infective structural cause.
- Offer consented external, speculum or bimanual examination only where findings will alter the pathway, with a chaperone and option to stop.
- Select pregnancy, pH, microscopy, culture and site-specific NAAT according to the resulting hypotheses rather than ordering an undifferentiated panel.