g logo ipb green

Management of vaginal discharge in non-genitourinary medicine settings

Causes of vaginal discharge

  • Health professionals should be aware that the most common causes of altered vaginal discharge are physiological, bacterial vaginosis (BV) and candida, but sexually transmitted infections (STIs) and non-infective causes must be considered

Management of vaginal discharge

  • A detailed history, including sexual history, is essential to identify the necessary investigations and treatment options
  • Women experiencing vaginal discharge who are at low risk of STI can be treated by syndromic or empirical management (See management algorithm)
  • All women with persistent vaginal discharge should be examined to exclude serious pathology
  • Women assessed as being at risk of STI, or who request testing should be offered appropriate tests for chlamydia, gonorrhoea, syphilis and HIV
  • A high vaginal swab (HVS) is of limited diagnostic value in the management of vaginal discharge except in cases of inconclusive assessment, recurrent symptoms, treatment failure, or in pregnancy, postpartum, post-abortion or post-instrumentation

Treatment of vaginal discharge

  • Metronidazole and clindamycin administered either orally or vaginally are effective in the treatment of BV
  • In the management of BV, testing and treatment of male sexual partners is not indicated but testing and treatment of female sexual partners can be considered
  • Vaginal and oral azole antifungals are equally effective in the treatment of vulvovaginal candidiasis (VVC)
  • Women with vulval symptoms of VVC may use topical antifungals (in addition to oral or vaginal treatment) until symptoms resolve
  • There is no need for routine screening or treatment of sexual partners in the management of candidiasis
  • Oral nitroimidazole drugs (e.g. metronidazole) are effective in treating trichomoniasis
  • Current sexual partners of women diagnosed with Trichomonas vaginalis (TV) should be offered a full sexual health screen and should be treated for TV irrespective of the results of their tests

Algorithm for the management of vaginal discharge in non-genitourinary medicine settings

Algorithm for the management of vaginal discharge in non-genitourinary medicine settings

Management of vaginal discharge in special circumstances

  • Women with BV who are pregnant or breastfeeding may use metronidazole 400 mg twice daily for 5–7 days or intravaginal therapies. A 2 g stat dose of metronidazole is not recommended in pregnancy or breastfeeding women
  • Women with VVC in pregnancy should avoid oral antifungals
  • Women with VVC in pregnancy can be treated with topical imidazoles. Single-dose treatment is less effective than longer regimens of up to 7 days
  • For HIV-positive women with TV, longer treatment regimens with oral metronidazole may be more effective than a single dose
  • For women with recurrent BV, suppressive treatment with metronidazole vaginal gel may be considered. Evidence to support other regimens is limited
  • Women using acidifying gels for recurrent BV can be advised to use them alternate evenings for 1 month or longer if required
  • For women with recurrent VVC, an induction and maintenance regimen may be used for 6 months
  • Recurrent TV is usually due to re-infection, but consideration should be given to the possibility of drug resistance

Contraception and vaginal discharge

  • Additional contraceptive precautions are not required when using antibiotics that do not induce liver enzymes
  • Women and male partners should be advised that latex contraceptives may be damaged by some vaginal/vulval antifungal treatments
  • Women using combined hormonal contraception who experience recurrent VVC may wish to consider switching to an alternative method of contraception
  • Women with a copper-bearing intrauterine device who experience recurrent BV may wish to consider switching to an alternative method of contraception

Personal hygiene and vaginal discharge

  • Women experiencing vaginal discharge can be advised to avoid douching and local irritants as part of general management

full guidelines available from…
www.fsrh.org/standards-and-guidance

Faculty of Sexual & Reproductive Healthcare. Management of vaginal discharge in non-genitourinary medicine settings. February 2012 (update due February 2017).
First included: October 2012.