Vaginal discharge
Gynaecology
Clinic
The first question
Is it physiological, vaginal, or cervical?
- 01
Characterise
Colour, consistency, odour, itch, timing, partners, symptoms in a partner.
- 02
Examine
Vulva, speculum for the discharge and the cervix, pH, whiff test; bimanual if pain or fever.
- 03
Test
Microscopy where available; NAAT for chlamydia, gonorrhoea and trichomonas.
- 04
Treat and, if an STI, treat partners
And offer screening for the others.
Where it is
Each opens the structure on the 3D pelvis.
History that discriminates
- Discharge character and odour
- Itch, dysuria, dyspareunia
- Pelvic pain, fever (PID)
- Sexual history, new partners, condom use
- Contraception, pregnancy, recent antibiotics, diabetes, douching
- Intermenstrual or postcoital bleeding
Examination that discriminates
- Vulval erythema, fissures
- Speculum: discharge character, cervix (ectropion, cervicitis, contact bleeding), foreign body
- Vaginal pH
- Bimanual if pain or fever
Investigations
- Vaginal pH and whiff test
- Microscopy: clue cells, hyphae, trichomonads
- NAAT for chlamydia, gonorrhoea, trichomonas
- Cervical screening if due
- Pregnancy test if relevant
The differential
| Diagnosis | Favours | Against | Urgency |
|---|---|---|---|
| Physiological discharge | Clear or white, no odour or itch, cycle variation | Odour, itch, colour | routine |
| Bacterial vaginosis | Thin grey fishy discharge, pH over 4.5, clue cells | Itch, thick discharge | routine |
| Candidiasis | Thick white curdy discharge, itch, erythema, normal pH | Odour, raised pH | routine |
| Trichomoniasis | Frothy green-yellow discharge, odour, strawberry cervix | Normal pH | routine |
| Cervicitis (chlamydia, gonorrhoea) | Mucopurulent cervical discharge, contact bleeding, intermenstrual bleeding, risk factors | Normal cervix | urgent |
| Pelvic inflammatory disease | Pain, fever, cervical motion tenderness | No pain or fever | urgent |
| Foreign body (retained tampon) | Foul discharge, a tampon on speculum | Nothing found | routine |
| Atrophic vaginitis | Postmenopausal, dryness, thin discharge | Premenopausal | routine |
Pitfalls this pathway refuses
- Treating candida repeatedly without confirming it
- Missing cervicitis because the discharge looked like BV
- Not offering STI screening and partner treatment