Drug review Vaginitis Vaginal discharge: recommended management in general practice Helen Colver MRCP and Manoj Malu FRCP L P Vaginal discharge is usually S physiological or caused by infection, and most cases can be treated in primary care. Our Drug review considers the choice of treatments available followed by a review of prescription data. aginal discharge is one of the commonest gynae - of exclusion (see Table 2). It may cause slight staining Vcological complaints seen in general practice. of the underwear and the nature of the discharge may Physiological discharge and vaginal infection account vary according to the time in the woman’s menstrual for the majority of cases (see Table 1). 1 cycle. Ovulation, sexual arousal and cervical ectro - Although most patients with vaginal discharge can pion can all cause an increase in the volume of vaginal be satisfactorily managed in primary care, patients discharge. 1 with recurrent or recalcitrant symptoms may benefit Historically, treatment of cervical ectropion has from a review at a genitourinary medicine (GUM) been offered to reduce the volume of excessive dis - clinic. charge. However, there is no systematic review of the This review covers the management of physiolog - efficacy of techniques such as electrocautery, 2 and ical discharge, bacterial vaginosis (BV), vulvovaginal offering such treatment may reinforce the woman’s candidosis (VVC) and trichomoniasis (TV). belief that her discharge is abnormal. Once pathological causes have been excluded, Physiological discharge explanation and reassurance are usually all that Odourless and clear discharge without vaginal irrita - is required for women with physiological vaginal tion is most likely to be physiological; it is a diagnosis discharge. www.prescriber.co.uk Prescriber 5 March 2013 19 Vaginitis Bacterial vaginosis Infection BV is a complex alteration in the vaginal flora char - Nonsexual transmission – male partners do not need acterised by an overgrowth of anaerobic bacteria such treatment as Gardnerella vaginalis and a reduction in concentra - bacterial vaginosis tion of lactobacilli. The cause is unclear, although BV candidosis can sometimes be associated with various sexually transmitted infections (STIs). If no STIs are found, Sexual transmission – partners need evaluation and male partners do not need treatment. A high rate of treatment concordance for BV has been found in female part - Chlamydia trachomatis ners, although the benefit of simultaneously treating Neisseriae gonorrhoeae female partners of women with BV has not been trichomoniasis proven. cervical herpes infection cervical and vaginal warts Epidemiology BV is by far the commonest cause of abnormal vagi - Physiological nal discharge or malodour in women of childbearing pregnancy age. It is not considered an STI. Its prevalence varies ovulation from 5 to 50 per cent in various study populations. menstruation Risk factors include multiple sexual partners, change sexual stimulation of sexual partner, early age of first sexual inter - course, vaginal douching, use of an intrauterine Noninfective device, racial origin (more common in black women cervical ectropion than white), low social class and smoking. 3 Co-infec - cervical polyps tion with Chlamydia , gonorrhoea and trichomoniasis cervical cancer is common. 4 BV may remit and relapse, persist for several Miscellaneous months (usually remitting after repeated treatments) retained tampons and condoms or resolve spontaneously. 5 Oral contraceptive pills and foreign body condom usage are negatively associated with it. postabortion, postnatal (retained products) trauma Clinical features allergy (rare) Most women have an offensive, fishy-smelling vaginal discharge noticed by the patient or her partner. Atrophic (postmenopausal) vaginitis Odour increases after sexual intercourse. It is not asso - ciated with soreness, itching or irritation, and about Table 2. Important causes of vaginal discharge half of women have no symptoms. On examination a thin, discoloured, homogeneous discharge with BV is confirmed when three out of the following abnormal odour may be noticed coating the walls of four Amsel’s criteria 6 are met: the vagina and vestibule. • vaginal pH >4.5 • thin, grey-white, homogeneous discharge • a good history and examination of the genitalia are • a strong fishy odour on adding 10 per cent potas - essential in order to establish the correct diagnosis sium hydroxide (KOH) to a specimen on a glass slide • the intimate nature of vaginal examination requires (positive ‘whiff’ test) both informed consent and the offer of a chaperone • presence of ‘clue cells’ (vaginal epithelial cells heav - throughout the examination ily coated with bacteria) on microscopy. • vaginal fluid represents discharge not only from the However, in the primary-care setting many patients vagina but also from the cervix, vestibular glands can be diagnosed by observation of typical thin, grey- and endometrium white, homogeneous discharge in someone with • an itchy discharge is often due to candidosis, a non- appropriate history. The diagnosis is supported by the itchy discharge with a fishy smell to bacterial demonstration of a pH of greater that 4.5 on narrow- vaginosis range pH paper (see Figure 1). Growth of Gardnerella vaginalis on a high-vaginal Table 1. Points to consider when evaluating vaginal discharge swab (HVS) is not diagnostic of BV as this is present 20 Prescriber 5 March 2013 www.prescriber.co.uk Vaginitis in up to 50 per cent of women with normal dis - (if no testing is available, metronidazole 1g rectally at charge. the time of termination should be given) Although BV used to be regarded as a benign con - • pregnant with a history of ‘idiopathic’ preterm dition, it is associated with complications during delivery, who are at a high risk of recurrence of pre - pregnancy and following pelvic instrumentation (see mature birth. There is some evidence that screening Table 3). 7 and treatment of BV with oral metronidazole 400mg twice daily for five days early in the second trimester Management in these high-risk pregnant women may prevent Not all women with BV need treatment. In sympto - preterm birth. matic women with a low risk of complications, gen - Oral metronidazole (400mg twice daily for five to eral advice to avoid douching or scented bath seven days or 2g stat) is the recommended treatment products and to use condoms for sexual intercourse of symptomatic BV, but relapse may occur in up to 60 may reduce the frequency of recurrences. A full STI per cent of patients at three months. 5 Table 4 com - screen should be offered as BV may co-exist with or pares various regimens. mimic some STIs. Indications for treatment are Oral metronidazole is the most cost effective, women who are: and topical treatment should be reserved for • symptomatic women who cannot tolerate oral therapy. Although • undergoing termination of pregnancy, who should not widely used, another possible option is the use be routinely offered testing and treatment for BV 3,8 of a 1g dose of per rectal metronidazole (inserted www.prescriber.co.uk Prescriber 5 March 2013 23 Vaginitis Vaginal discharge If at risk of STIs refer to GUM or send Clinical and sexual history vaginal, endocervical swab or urine for Chlamydia and gonorrhoea Vaginal pH helps in diagnosis Use a swab to collect discharge from pH ≤4.5 pH >4.5 the lateral vaginal wall and rub it onto narrow-range pH paper. White curdy discharge No other symptoms Thin, grey/white Yellow, green frothy Discharge has other Other signs: vulval homogeneous discharge appearance itching or soreness, discharge coating the Fishy/offensive odour erythema/vaginitis, vaginal walls +/- pruritus, vaginitis, fissuring Fishy/offensive odour dysuria Not generally sore Candida No further investiga - Bacterial vaginosis Trichomoniasis Consider other causes: tions needed (most common) (less common) physiological, foreign body, STIs, strepto - coccal/staphylococcal infections Give empirical therapy Reassure that probably Give empirical therapy Refer to GUM Send HVS for culture Culture not needed physiological Microscopy and cul - Send HVS to lab for TV Also send: vaginal, unless recurrent ture not required and other STIs endocervical swab or urine for Chlamydia and gonorrhoea Figure 1. Diagnosis of vaginal discharge in patients >25 years using symptoms and signs after lubrication) for those who are unable to toler - mal approach. Suppressive therapy with metronida - ate the oral route. zole gel twice a week for four to six months, or with Topical clindamycin (Dalacin) can cause VVC and oral metronidazole 400mg twice a day for three damage latex condoms. days before and after menstruation, may improve Tinidazole (Fasigyn, 2g single dose orally) is occa - symptoms. 3 sionally used but has a similar side-effect profile to Routine follow-up is not necessary for uncompli - metronidazole. cated BV. GUM referral is indicated for the manage - Some women find over-the-counter topical vaginal ment of recurrent BV or if an STI is identified. preparations such as Balance Activ helpful for spo - radic or recurrent BV. At present there is insufficient Vulvovaginal candidosis evidence to support the efficacy of such products. Sexually active women have a 75 per cent lifetime risk The management of frequent recurrent episodes of developing symptomatic VVC. Predisposing factors of BV is challenging and there is no established opti - are listed in Table 5. Often both vulva and vagina are 24 Prescriber 5 March 2013 www.prescriber.co.uk