Guidelines International Journal of STD & AIDS 2018, Vol. 29(13) 1258–1272 2018 European (IUSTI/WHO) ! The Author(s) 2018 Article reuse guidelines: International Union against sexually sagepub.com/journals-permissions DOI: 10.1177/0956462418785451 transmitted infections (IUSTI) World journals.sagepub.com/home/std Health Organisation (WHO) guideline on the management of vaginal discharge Jackie Sherrard1 , Janet Wilson2, Gilbert Donders3, Werner Mendling4 and Jørgen S Jensen5 Abstract Four common pathological conditions are associated with vaginal discharge: bacterial vaginosis, aerobic vaginitis, can- didosis, and the sexually transmitted infection, trichomoniasis. Chlamydial or gonococcal cervical infection may result in vaginal discharge. Vaginal discharge may be caused by a range of other physiological and pathological conditions including atrophic vaginitis, desquamative inflammatory vaginitis, cervicitis, and mucoid ectopy. Psychosexual problems may pre- sent with recurrent episodes of vaginal discharge and vulval burning. These need to be considered if tests for specific infections are negative. Many of the symptoms and signs are non-specific and a number of women may have other conditions such as vulval dermatoses or allergic and irritant reactions. Keywords Trichomoniasis (Trichomonas vaginalis), women, diagnosis, bacterial vaginosis, candida, aerobic vaginitis, vaginal discharge Date received: 30 May 2018; accepted: 5 June 2018 Introduction Four common pathological conditions are associated with vaginal discharge: bacterial vaginosis (BV), aero- 1Department of Genitourinary Medicine, Sexual Health Department, bic vaginitis (AV), candidosis, and the sexually Buckinghamshire Healthcare NHS Trust, Amersham, UK transmitted infection, trichomoniasis. Chlamydial or 2Department of Genitourinary Medicine, Leeds Teaching Hospitals NHS gonococcal cervical infection may result in vaginal dis- Trust, Leeds, UK 3 charge. Vaginal discharge may be caused by a range of Department of Obstetrics and Gynecology, Regional Hospital H Hart Tienen, University Hospital Antwerp other physiological and pathological conditions includ- 4Infektionen in Gyn€akologie und Geburtshilfe, Wuppertal, Germany ing atrophic vaginitis, desquamative inflammatory 5Research Unit for Reproductive Microbiology, Statens Serum Institut, vaginitis (DIV), cervicitis, and mucoid ectopy. Copenhagen, Denmark Psychosexual problems may present with recurrent epi- Lead editor: Jørgen S Jensen sodes of vaginal discharge and vulval burning. These This guideline is an update of the European IUSTI vaginal discharge need to be considered if tests for specific infections are guideline 2011. negative. Many of the symptoms and signs are non-specific and a number of women may have other Corresponding author: Jackie Sherrard, Department of Genitourinary Medicine, Sexual Health conditions such as vulval dermatoses or allergic and Department, Buckinghamshire Healthcare NHS Trust, Amersham, UK. irritant reactions. Email: [email protected] Sherrard et al. 1259 Aetiology and transmission are frequent. It is not known whether AV has an infec- tious origin or whether it is an inflammatory process BV followed by a dysbiosis. It can cause long-term symp- toms with intermittent exacerbations, and recurrences BV is the commonest cause of abnormal vaginal dis- after treatment are common.8 Atrophic vaginitis in lac- charge in woman of childbearing age but may also be tating women is probably a variant of AV. More severe encountered in perimenopausal women.1,2 In forms of AV and DIV are probably the same condition. Caucasian women the prevalence is 5–15%; in Black women it is higher at 45–55%. Women who have sex with women (WSW) share similar lactobacillary types, Candidosis are more likely to have concordant vaginal microbiota More than 60% of healthy premenopausal women are (flora) patterns, and are at increased risk for BV.3 colonised with candida, with higher rates in pregnancy, BV is a dysbiosis of the vaginal microbiota. It is and lower rates in children and postmenopausal characterised by an overgrowth of predominantly women without hormonal replacement therapy.9,10 anaerobic organisms (e.g. Gardnerella vaginalis, An estimated 75% of women will experience at least Prevotella spp., Atopobium vaginae, Mycoplasma hom- one symptomatic episode during their lifetime and 6– inis, Mobiluncus spp.) in the vagina leading to a 9% will experience chronic recurrent vulvovaginal can- replacement of lactobacilli and an increase in vaginal didosis (at least four episodes per year). Vulvovaginal pH. Bacterial identification using PCR has demonstrat- candidosis results from an overgrowth of Candida albi- ed that there are many different, previously unculti- cans in 90% of women (remainder with other species, vated bacteria present in women with BV including e.g. Candida glabrata).11,12 Precipitating factors include BV-associated bacterium 1, 2, and 3, and Sneathia spe- antibiotic therapy, pregnancy, and endogenous or cies.4 Since these bacteria are difficult to culture, the exogenous immunosuppression (including diabetes antibiotic susceptibility of many is not known. mellitus and immunosuppressive medication). In some BV can arise and remit spontaneously and although women, symptoms may occur with a low burden of not strictly considered a sexually transmitted infection candida and it is thought this may be due to an allergic (STI) it is associated with sexual activity. The exact or inflammatory response to the yeast. aetiology of BV is still unclear but current evidence suggests that formation of a biofilm with G. vaginalis Trichomoniasis is important in the switch from normal vaginal flora Trichomonas vaginalis (TV) is a flagellated protozoon, to BV.5,6 which is a parasite of the genital tract. In adults, it is almost exclusively sexually transmitted. Due to site spe- AV/DIV cificity, infection only follows intravaginal or intraure- AV presents with a purulent discharge, some degree of thral inoculation of the organism. In women urethral atrophy, and vaginitis. Lactobacilli are decreased and infection is present in 90% of episodes, although the pH is elevated, but aerobic microorganisms, like urinary tract is the sole site of infection in <5% of Escherichia coli, group B streptococci, and cases. The most obvious host response to infection is Staphylococcus aureus predominate.7 Mixed infections a local increase in polymorphonuclear leucocytes. Table 1. Symptoms and signs. Bacterial vaginosis Aerobic vaginitis Candidosis Trichomoniasis Approximately 50% 10–20% asymptomatic Approx. 60% women colonised. 10–50% asymptomatic and asymptomatic Minority develop symptoms 5–15% no abnormal signs Thin white homogenous Purulent discharge Vaginal discharge may be curdy Offensive vaginal discharge in up discharge, coating walls (non-offensive) to 70% – frothy and yellow in of vagina and vestibule 10–30% Offensive fishy odour Vulval burning or stinging Vulval soreness/itching Vulval itching/irritation and erythema and erythema Absence of vaginitis Superficial dyspareunia Vulval fissuring Dysuria Vaginal erythema and Superficial dyspareunia Rarely low abdominal discomfort oedema Vaginal ulceration Satellite skin lesions Vaginitis Vulval oedema Approx. 2% ‘strawberry’ cervix visible to naked eye. 1260 International Journal of STD & AIDS 29(13) Clinical features Several studies in the last decade have shown a decrease in preterm birth, if vaginal candida colonisa- There are recognised symptoms and signs (Table 1). tion or infection had been treated with clotrimazole.39 The diagnosis of both BV and candidosis is syndromic, In a study by Holzer et al.40 women who were colonised i.e. based on clinical symptoms and signs supported by with candida spp. during the second trimester of preg- laboratory test findings, which in themselves vary in nancy had higher rates of preterm birth and lower neo- specificity and sensitivity. The classical features of TV 13,14 natal birthweight than those who were colonised are frequently absent or non-specific. during the first trimester of their pregnancy. According to old studies the vaginal treatment of an Complications asymptomatic candida colonisation during the last six Women with BV are at increased risk of acquiring weeks of pregnancy reduces the candida colonisation of STIs. They have a two-fold increased risk of HIV the newborn during vaginal delivery and thus reduces acquisition,15 1.5–2-fold risk of Chlamydia16 and gon- oral thrush and napkin dermatitis of the baby during 41 orrhoea,16 a nine-fold risk of TV,17 and a two-fold risk the first four weeks of life. Modern studies are urgent- of herpes simplex virus type 2 (HSV-2)18 compared to ly needed to confirm these findings. women without BV. HIV-positive women with BV have a three-fold risk of transmitting HIV.19 Monthly Diagnosis prophylaxis with metronidazole reduces the incidence 20 Women presenting with abnormal vulval or vaginal of STIs by almost 50%. The BV-associated bacteria symptoms should be tested to ensure that appropriate are probably also implicated in the aetiology of pelvic treatment is given.40,42–44 If this is not possible, then inflammatory disease (PID). A prospective study of examination and testing should definitely be performed women with clinically-suspected PID reported in the following situations: significant correlations between the presence of BV-associated bacteria and the presence of endometri- • Severe or recurrent symptoms 21 tis and recurrent PID. • Failure of vaginal discharge to respond to empiri- There