The three common vaginal causes
- Physiological discharge changes through the cycle and in pregnancy; reassurance after excluding the three is a diagnosis too.
- Cervicitis (chlamydia, gonorrhoea) is tested by NAAT on a vaginal or cervical swab or urine; contact tracing and retesting after treatment.
| Cause | Discharge | pH | Microscopy | Treatment |
|---|---|---|---|---|
| Bacterial vaginosis | Thin, grey, fishy (positive whiff test) | Over 4.5 | Clue cells | Metronidazole oral or vaginal, or clindamycin; not an STI but recurs |
| Candida | Thick, white, itchy, with erythema | Normal (4 to 4.5) | Hyphae and spores | Topical azole or oral fluconazole (topical in pregnancy) |
| Trichomonas | Frothy, yellow-green, malodorous, cervicitis | Over 4.5 | Motile trichomonads (NAAT is more sensitive) | Metronidazole; treat partners; an STI |
Pelvic inflammatory disease
- Ascending infection: chlamydia, gonorrhoea, Mycoplasma genitalium and anaerobes. Lower abdominal pain, discharge, fever, dyspareunia, intermenstrual bleeding.
- Diagnosis is clinical: cervical motion, uterine or adnexal tenderness in a sexually active woman with no other cause. The threshold to treat is deliberately low because the cost of missed disease is tubal infertility, ectopic pregnancy and chronic pain.
- Outpatient: ceftriaxone intramuscularly plus doxycycline and metronidazole for 14 days. Admit for severe illness, a tubo-ovarian abscess, pregnancy, inability to take oral treatment, or failure to improve within 72 hours.
- Tubo-ovarian abscess: intravenous antibiotics; drainage for large abscesses or failure to respond; rupture is a surgical emergency.
- Treat partners, retest, and remove an IUD only if there is no improvement after 48 to 72 hours.
Left hydrosalpinx
Transvaginal, left adnexa. An elongated, tubular, fluid-filled structure with incomplete septa (the folded tube).
Open in the Ultrasound LabOn the modelVaginaCervixFallopian tubes