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1202 Murtagh's General Practice
106 Vaginal discharge
In all cases of abnormal vaginal discharge consider the possibility of the sexually transmitted infections,
gonorrhoea and non-specific urethritis.
Dr Stella Heley, Victorian Cytology Service, 
Vaginal discharge is one of the commonest
complaints seen by family physicians yet it is one
of the most difficult to solve, especially if it is
recurrent or persistent. It is present if the woman’s
underclothes are consistently stained or a pad is
required. It is important to make a proper diagnosis,
to differentiate between abnormal (physiological)
and pathological discharge and to be aware of the
considerable variation in secretion of vaginal fluid.
This variation extends to different age groups,
from prepubertal girls where dermatoses and
Streptococcus sp. infections occur to the elderly with
postmenopausal dermatoses and atrophic vaginitis.
The differential diagnoses should include
consideration of normal discharge, vaginitis, either
infective or chemical, STIs, and urinary tract infection.
Key facts and checkpoints
• A survey of a large family planning clinic found
that 17% of women complained of vaginal
discharge.1
• Vaginal discharge may present at any age but is
very common in the reproductive years.
• Vaginal discharge is a common presentation of
those STIs responsible for PID.
• The first step in diagnosis is to determine if the
discharge is cervical or vaginal in origin.
• One of the simplest methods of making a proper
diagnosis is a wet film examination.
A diagnostic approach
A summary of the diagnostic strategy model is
presented in TABLE 106.1.
Probability diagnosis
The two most common causes of vaginal discharge
are physiological discharge and infective vaginitis.
Physiological discharge
Normal physiological discharge is usually milky-white
or clear mucoid and originates from a combination of
the following sources:
• cervical mucus (secretions from cervical glands)
• vaginal secretion (transudate through vaginal
mucosa)
• vaginal squamous epithelial cells (desquamation)
• cervical columnar epithelial cells
• resident commensal bacteria
The predominant bacterial flora are lactobacilli,
which produce lactic acid from glucose derived from
the epithelial cells. The lactic acid keeps the vaginal
pH acidic (<4.7). Other commensal bacteria include
staphylococci, diphtheroids and streptococci.
With physiological discharge there is usually no
odour or pruritus.
In addition, the egg-white discharge accompanying
ovulation may be noted. The discharge may be
aggravated by the use of the pill. The normal discharge
usually shows on underclothing by the end of the day.
Clear or white, it oxidises to a yellow or brown on
contact with air. It is increased by sexual stimulation.
Management is largely based on reassurance and
explanation.
Infective vaginitis
The commonest cause of infective vaginitis is
bacterial vaginosis (formerly bacterial vaginitis,
Gardnerella vaginalis or Haemophilus vaginalis) which
accounts for 40–50% of cases of vaginitis.2,3 Candida
albicans is the causative agent in 20–30% of cases
while Trichomonas vaginalis causes about 20% of cases
in Australia. The comparable features are outlined
in TABLE  106.2. Human papilloma virus infection of
vaginal epithelium may cause excess discharge.
Serious disorders not to be missed
The ‘not to be missed’ group includes cancer of
the vagina, cervix or uterus and STIs, including
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Vaginal discharge 1155

Table Vaginal discharge: diagnostic strategy Pitfalls

106.1 model It is common to overlook the problem caused by
hygienic preparations. Apart from the vaginal
Q. Probability diagnosis tampon, which may be retained (knowingly or
A. Normal physiological discharge
otherwise), there is a variety of preparations that
Vaginitis:3
can induce a sensitivity reaction. These include
• bacterial vaginosis 40–50%
deodorant soaps and sprays and contraceptive agents,
• candidiasis 20–30%
especially spermicidal creams. Ironically, the various
• Trichomonas 10–20%
preparations used to treat the vaginitis may cause a
Q. Serious disorders not to be missed chemical reaction.
A. Neoplasia: Endometriosis of the cervix or vaginal vault may
• cancer cause a bloody or brownish discharge.
• fistulas
STIs/PID (i.e. cervicitis): Seven masquerades checklist
• gonorrhoea Of this group, diabetes mellitus leading to recurrent
• Chlamydia ‘thrush’, drugs causing a local sensitivity, and urinary
• herpes simplex—types 1 and 2 tract infection have to be considered (see TABLE 106.1).
Sexual abuse, esp. children
Tampon toxic shock syndrome (staphylococcal infection) Psychogenic considerations
Streptococcal vaginosis (in pregnancy) This question needs to be answered, especially if the
Q. Pitfalls (often missed) discharge is normal. The problem could be related to
A. Chemical vaginitis (e.g. perfumes) sexual dysfunction or it may reflect a problematic
Retained foreign objects (e.g. tampons, IUCD) relationship, and the issue may need to be explored
Endometriosis (brownish discharge) diplomatically. Vaginal discharge is an embarrassing
Ectopic pregnancy (‘prune juice’ discharge) problem for the patient and any discussion needs to
Poor toilet hygiene be handled thoroughly and sensitively. A relevant
Latex allergy sexual history may satisfactorily solve the problem.
Genital herpes (possible) 106
Atrophic vaginitis
Threadworms
The clinical approach
Q. Seven masquerades checklist History
A. Diabetes The history is important and should include:
Drugs
UTI (association) • nature of discharge: colour, odour, quantity,
relation to menstrual cycle, associated symptoms
Q. Is the patient trying to tell me something? • exact nature and location of irritation
A. Needs careful consideration; possible sexual • sexual history: arousal, previous STIs, number
dysfunction.
of partners and any presence of irritation or
discharge in them
• use of chemicals, such as soaps, deodorants,
PIDs caused by Chlamydia trachomatis and Neisseria pessaries and douches
gonorrhoeae. Vaginal discharge is the most common • pregnancy possibility
presenting symptom of both of these serious STIs. • drug therapy
Occasionally, infections of the endometrium and • associated medical conditions (e.g. diabetes)
endosalpinx will produce a discharge that gravitates
to the vagina.1 Benign and malignant neoplasia Examination
anywhere in the genital tract may produce a Optimal facilities for the physical examination
discharge. Usually it is watery and pink or blood- include an appropriate couch and good light, bivalve
stained. Sims specula, sterile swabs (preferably with transport
Inspection should include vigilance for fistulas that media), normal saline, 10% potassium hydroxide
may be associated with malignancy, inflammation or (KOH), slides and cover slips and microscope.
post-irradiation. Inspection in good light includes viewing the vulva,
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1204 Murtagh's General Practice

1156 PART SIX • Women’s health

Table 106.2 Characteristics of discharge for important causes of abnormal vaginal discharge2

Infective pH (normal Associated

organism Colour Consistency Odour 4–4.7) symptoms
Candida White Thick (cream cheese), None <4.5 Itch, soreness,
albicans lumpy redness
Trichomonas Yellow–green Bubbly, profuse Malodorous, fishy 5–6 Soreness
vaginalis (mucopurulent)
Bacterial Grey Watery, profuse, Malodorous, fishy 5–6 Irritation
vaginosis bubbly, homogenous (sometimes)
Cervicitis Yellow–green (coming Thick (mucopurulent) Variable—usually 4–4.7 Signs of PID
from cervix) malodorous
Source: After Weisberg2

introitus, urethra, vagina and cervix. Look for the
discharge and specific problems such as polyps, warts,
prolapses or fistulas. To differentiate between vaginal
and cervical discharge, wipe the cervix clear with a
cotton ball and observe the cervix. A mucopurulent
discharge appearing from the endocervix may be the
clue to an STI such as Chlamydia and gonorrhoea.
Perform a pH test and a wet film.
Pitfalls to keep in mind include:
• The patient may have had a bath or a ‘good wash’
beforehand and may need to return when the
discharge is obvious.
106 • A retained tampon may be missed in the
posterior fornix, so the speculum should slide
directly along the posterior wall of the vagina.
• Candida infection may not show the characteristic
curds, ‘the strawberry vagina’ of Trichomonas is
uncommon and bubbles may not be seen.
Acetic acid 2% is useful in removing the discharge
and mucus to enable a clearer view of the cervix and
vaginal walls.
Investigations
• pH test with paper of range 4 to 6
• Amine or ‘whiff’ test: add a drop of 10% KOH to
vaginal secretions smeared on glass slide
• Wet film microscopy of a drop of vaginal secretions
A full STI work-up
• First-pass urine and ThinPrep samples—for
Chlamydia and gonorrhoea NAAT (PCR)
• Swabs from the cervix for Chlamydia,
N. gonorrhoeae:
— swab mucus from cervix first
— swab endocervix
— place in transport media
• Pap test
• Viral culture (herpes simplex):
— scrape base of ulcer or, ideally, deroof a
vesicle
— immediately immerse in culture medium
— transport rapidly to laboratory
• Group B Streptococcus:
— swabs from endocervix, urethra, rectum
Preparation of a wet film
To make a wet film preparation2 (see FIG. 106.1), place
one drop of normal saline (preferably warm) on one
end of an ordinary slide and one drop of 10% KOH on
the other half of the slide. A sample of the discharge
needs to be taken with a swab stick, either directly
from the posterior fornix of the vagina or from
discharge that has collected on the posterior blade of
the speculum during the vaginal examination. A high
vaginal swab is required for C. albicans. A small amount
of the discharge is mixed with both the normal saline
drop and the KOH drop. A cover slip is placed over each
preparation. The slide is examined under low power
to get an overall impression, and under high power to
determine the presence of lactobacilli, polymorphs,
trichomonads, spores, clue cells and hyphae. A
summary of various findings on wet film examination
is presented in TABLE 106.3. Lactobacilli are long, thin
Gram-positive rods; clue cells are vaginal epithelial
cells that have bacteria attached so that the cytoplasm
appears granular and often the entire border is
obscured. They are a feature of bacterial vaginosis.
Trichomonads are about the same size as polymorphs;
to distinguish between the two, one needs to see the
movement of the trichomonad and the beating of its
flagella under high power of the microscope. Warming
the slide will often precipitate movement.
Refer to FIGURE 106.2.
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trichomonad

10% KOH normal saline

+ discharge + discharge

Examine for:
leucocyte
1 epithelial cell 4 tricomonads
2 polymorph 5 clue cells
3 lactobacilli
clue cell vaginal squamous cell
FIGURE 106.1 Wet film method

FIGURE 106.2 Relative sizes of various cells or organisms

Vaginal discharge in children
Most newborn girls have some mucoid white vaginal
discharge. This is normal and usually disappears by
3 months of age. From 3 months of age to puberty,
vaginal discharge is usually minimal.4 Staining on a
child’s underclothes may be due to excess physiological
discharge, especially in the year before the menarche.1
Vulvovaginitis is the most common gynaecological
disorder of childhood, the most common cause being
a non-specific bacterial infection.
Vaginal discharge in the elderly
Vaginal discharge can occur in the elderly from
a variety of causes, including infective vaginitis,
atrophic vaginitis, foreign bodies, poor hygiene and
neoplasia. It is important to exclude malignancy of
the uterus, cervix and vagina in the older patient.
Atrophic vaginitis
In the absence of oestrogen stimulation the vaginal
and vulval tissues begin to shrink and become thin
and dry. This renders the vagina more susceptible
to bacterial attack because of the loss of vaginal
acidity. Rarely, a severe attack can occur with a very
haemorrhagic vagina and heavy discharge:
• yellowish, non-offensive discharge
• tenderness and dyspareunia
as seen in a wet smear
• spotting or bleeding with coitus
• the vagina may be reddened with superficial
haemorrhagic areas
Treatment
local oestrogen cream or tablet (e.g. Vagifem).
The tablet is preferred as it is less messy
or
zinc and castor oil soothing cream
Note: perform a careful speculum examination.
Vaginal candidiasis 106
Infection with the fungus Candida albicans is a
common and important problem with a tendency
to recurrence. However, with the widespread use
of over-the-counter antifungals, resistant non-
albicans species, such as C. glabrata (in particular),
C. parapsilosis and C. tropicalis are becoming more
common.5 Microbiological investigation may clarify
diagnosis and is essential in recurrent or refractory
cases.
Clinical features
• Intense vaginal and vulval pruritus
• Vulval soreness

Table 106.3 Wet film examination

Lactobacilli Polymorphs Epithelial cells Clue cells Other

Normal + None or occasional + -
Candidiasis + None or occasional + - Spores/hyphae
Trichomoniasis Absent or scant Numerous + - Trichomonads
Bacterial vaginosis Absent or scant Numerous + 2–50%
Source: After Weisberg2