REVIEW
Vaginal discharge
Alexandra Rice
Mohamed ElWerdany
Essam Hadoura
Tahir Mahmood
Abstract
Vaginal discharge is a common presenting symptom at gynaecology
and sexual health clinics and in general practice. It is usually physio-
logical and is subject to hormonal variations in consistency and quan-
tity. With this in mind, appropriate diagnosis and treatment of
abnormal vaginal discharge can be challenging. Concurrent pregnancy
can also complicate the situation. Some pathological conditions may
contribute to vaginal discharge, including cervicitis, aerobic vaginitis,
atrophic vaginitis and mucoid ectopy. We mainly focus on the three
most prevalent pathological causes namely; bacterial vaginosis, vulvo-
vaginal candidiasis and Trichomonas vaginalis and will also provide a
brief overview of atypical inflammatory vaginitis as well. Obtaining a
methodical and detailed history from the patient should give the major-
ity of the information required. Examination and analysis of discharge
with swabs are a useful adjunct to aid diagnosis. Once a diagnosis is
made, appropriate treatment must then be instigated and in some
cases partner notification and treatment may also be required.
Keywords bacterial vaginosis; candidiasis; desquamated inflam-
matory vaginitis (DIV); HIV; pregnancy; trichomonas; vaginal discharge
Introduction
Vaginal discharge is a common condition. Discharge is mainly
physiological. It is affected by hormonal variation throughout the
lifetime of females. Diagnosis of abnormal discharge is quiet
challenging. Conditions such as pregnancy and co-morbidities
like diabetes mellitus make the management really challenging.
Pathologies such as vaginitis, cervicitis or cervical atopy may
also contribute to vaginal discharge. The most common causes of
vaginal discharge are bacterial vaginosis, candidiasis and Tri-
chomonas vaginalis.
Alexandra Rice MRCOG is a Specialty Trainee in Obstetrics and
Gynaecology, South East of Scotland, Victoria Hospital, Kirkcaldy,
Fife, UK. Conflict of interest: none.
Mohamed ElWerdany MBBCh MSc is a Specialty Trainee in Obstetrics
and Gynaecology, South East of Scotland, Victoria Hospital,
Kirkcaldy, Fife, UK. Conflict of interest: none.
Essam Hadoura FRCOG is a Consultant Obstetrician and
Gynaecologist at Victoria Hospital, Kirkcaldy, Fife, and Honorary
Senior Lecturer, University of St. Andrews, St Andrews, UK. Conflict
of interest: none.
Tahir Mahmood MD FRCPI FACOG FRCPE FRCOG is a Consultant
Obstetrician and Gynaecologist at Victoria Hospital, Kirkcaldy, Fife,
UK. Conflict of interest: none.
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Please cite this article in press as: Rice A, et al., Vaginal discharge, Obstetrics, Gynaecology and Reproductive Medicine (2016), http://dx.doi.org/
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Causes of vaginal discharge include: physiological discharge,
bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), T.
vaginalis (TV), chlamydia, gonorrhoea, herpes simplex virus,
foreign body (e.g. retained tampon and condom), irritants (e.g.
perfumes or deodorants), atrophic vaginitis, fistulae and tumours
affecting the vulva, vagina and cervix.
History and examination
Vaginal discharge is a clinical feature not a diagnosis. History
and examination of the patient should be the first line in deciding
whether investigations and treatment are required. A routine
gynaecological history should be obtained including parity,
smear history, sexual history and current contraception. Sexual
history should dictate the need for discussion regarding full STI
screening. With regards to the vaginal discharge, its onset,
duration, timing related to menstrual cycle, odour, colour, con-
sistency and any exacerbating factors should be noted. Associ-
ated symptoms including itch, discomfort, pain, dysuria,
dyspareunia and irregular bleeding should be enquired.
A gynaecological examination consists of inspection,
bimanual examination and obtaining appropriate vaginal swabs.
The inspection part, includes both, a general external inspection
of the vulva and the perineal region, and an internal inspection of
the vagina and cervix with the aid of a speculum. Bimanual ex-
amination will give the gynaecologist an idea about the position,
size and mobility of the uterus as well as the presence of any
adnexal masses. Vaginal swab will help in the diagnosis of
pathogens that may be responsible for the abnormal discharge.
Who to swab?
Some patients can be given treatment without the need for full
investigations. A patient who complains with a first episode of
vaginal discharge with a clear clinical evidence of either vulvo-
vaginal candidiasis (VVC) or bacterial vaginosis (BV), and no
other risk factors, can be given empirical treatment without
further investigations. However, the following risk factors
require further investigations:

High STI risk (past history of STI, multiple sexual partners,
sharing needles and intravenous drug use)

Symptoms suggestive of an alternative cause (e.g. vaginal
bleeding and urinary or bowel symptoms)

Recent gynaecological procedure

BV associated with pregnancy
Indications to obtain a swab:

STI risk/requesting STI screening

Symptoms suggestive of upper genital tract infection

Postpartum, post-miscarriage, TOP or recent instrumenta-
tion of the uterus

Recurrent symptoms despite treatment

Abnormal symptoms of unknown cause

Cervicitis found on examination.
Taking appropriate swabs
There should be appropriate documentation sent with the swab
to aid proper testing in the lab. The site that was sampled should
be well documented. Symptoms, any recent treatments (e.g.
systemic antibiotics), pregnancy status and any recent
1 Ó 2016 Published by Elsevier Ltd.
 REVIEW
gynaecological procedures should be mentioned. Different labs
will have different capabilities with regards to the specific testing
they offer, therefore you should check your local laboratory prior
to sending samples.
A. High vaginal swab (HVS)
A swab taken from the lateral wall or posterior fornix of the
vagina under direct vision. The swab should then be placed in
Amies transport medium with charcoal. The high number of
commensal bacteria that reside in the vagina can often make
interpretation of results difficult and these should be interpreted
in the context of the clinical picture. It should only be obtained if
there is a clinical need for testing and not as a routine with
speculum examination. It should be obtained when symptoms do
not lead to a diagnosis. Abnormal discharge in pregnancy, post-
partum, post-termination and post instrumentation should al-
ways be swabbed. Similarly, if there is recurrence of symptoms
or possible treatment failure then a swab should be obtained.
B. Endocervical swab (ECS)
The cervical os should be cleaned with a disposable swab and
discarded. The ECS should then be inserted into the cervical os
and rotated firmly. The swab should then be placed in Amies
transport medium with charcoal. It is mainly used in the inves-
tigation of Chlamydia and gonorrhoea. The swab is sent for
NAAT (nucleic acid amplification testing). Some labs are now
analysing these samples for BV and TV.
C. pH testing
A swab from the lateral vaginal wall is placed on a narrow
spectrum litmus paper. BV and TV (T. vaginalis) will have pH
>4.5. There is good evidence that clinical features and mea-
surement of vaginal pH is a sensitive (but not specific) predictor.
If HVS and ECS are also obtained, there is an increased accuracy
of diagnosis. Therefore, a swab should be obtained if features are
not suggestive of BV/VVC.
D. Microscopy
Wet microscopy requires a certain level of expertize and tech-
nical skills for proper implementation. A small sample of the
discharge should be placed on two ends of a slide. Normal saline
is put on one end and potassium hydroxide on the other. A cover
slip is placed on the slide and these are visualized under a mi-
croscope. This test is of varying sensitivities depending on the
offending organism:

70% sensitivity for TV (TV swabs need to be processed
with wet microscopy within 6 hours).

Saline microscopy will show spores/pseudohyphae in 40
e60% of Candida

30e50% sensitivity for Gonorrhoea
E. Gram stain

Commonly used for the diagnosis and grading of BV

65e68% detection in symptomatic Candida
F. Culture

Candida grows best on Sabouraud agar (95% growth on
culture). Its growth can be classified as light, medium or
heavy. Culture was considered the gold standard for
detecting T. Vaginalis before NAAT (nucleic acid
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amplification testing) took its place. Culture should be
undertaken in patients with negative microscopy despite
symptoms and those with apparent recurrent disease.
G. NAAT (nucleic acid amplification tests)
Is effective in detecting Chlamydia and gonorrhoea. Reported
detection rates of 100% with BV although its use in the diagnosis
of BV is not widespread.
H. Intrauterine contraceptive devices (IUCDs)
The entire device should be sent to microbiology. The presence
of an IUCD may be associated with PID. Infections may be pol-
ymicrobial with the isolation of both Gram positive and Gram
negative aerobic and anaerobic organisms. Actinomyces species,
particularly Actinomyces israelii, may be significant isolates. We
recommend that IUCDs are only cultured where there are clinical
indications of PID or other inflammatory conditions.
Physiological discharge
Physiological vaginal discharge is a normal finding in all women
and most commonly described as an inoffensive discharge. The
fluctuating levels of oestrogen and progesterone during the
menstrual cycle greatly affects the consistency and composition
of the physiological discharge. Oestrogen makes the discharge
thin and clear for easy passage of sperm through the cervix at the
time of ovulation. Progesterone makes the discharge thick and
sticky after ovulation.
The vaginal environment maintains its stability by the action
of commensal organisms. Lactobacilli colonize the vagina since
puberty under the influence of oestrogen. These are responsible
for converting glycogen to lactic acid, maintaining a vaginal pH
of around 4.5. Other commensal organisms are streptococci,
enterococci and coagulase negative staphylococci. A few other
organisms which are part of the normal flora, but are associated
with vaginal infections, include, anaerobic Bacteroides, anaer-
obic cocci, Gardenella vaginalis, Candida, Ureaplasma ure-
alyticum and Mycoplasma species.
Bacterial vaginosis
Aetiology and transmission
Bacterial vaginosis is the commonest cause of vaginal discharge
in women; during their childbearing period. It has been found in
postmenopausal women and rarely prepubertal. It is more
common in black African and American women (45e55%).
Caucasian women have a prevalence of approximately 5e15%.
Previously, it was considered as a harmless finding, but we now
know it to be associated with many pathological conditions such
as puerperal endometritis, preterm labour, premature rupture of
membranes, PID and UTI.
The condition is associated with a prevalence of the anaerobic
species in preference to the normal Lactobacillus species. Or-
ganisms associated with bacterial vaginosis include the Prevotella
species, G. vaginalis, Mobiluncus species, Peptostreptococcus
species and Mycoplasma hominis. Some women experience the
change in the microorganism environment really abruptly, while
others take longer time interval to feel the change.
Bacterial vaginosis is experienced more in patients with
multiple sexual partners, no use of condoms or douching. Most
2 Ó 2016 Published by Elsevier Ltd.
 REVIEW
carriers are asymptomatic. Women who were never sexually
active are rarely affected.
Women with bacterial vaginosis are more likely to acquire
other sexually transmitted infections, pregnancy complications,
post-surgery complications and disease recurrence. However,
due to insufficient data, routine screening for these groups is not
recommended.
Diagnosis
Diagnosis of bacterial vaginosis is either clinical or by using the
gram stain. Gram stain is considered by many laboratories as the
golden standard for diagnosis. It is used to estimate the con-
centration of lactobacilli (Long gram positive rods) and the gram
negative anaerobes.
Nugent scoring system and Amsel’s clinical criteria are the
most common diagnostic systems used to diagnose bacterial
vaginosis. Nugents scoring system is considered the gold stan-
dard for diagnosis. However, it is costly, time consuming and
requires laboratory expertize, to implement. Physicians prefer
Amsel’s criteria as it is simpler and comparably as effective as
Nugent scoring system. Hay Ison criteria is recommended by the
Bacterial Special Interest group of BASHH to be implemented in
GUM clinics.
A. Clinical criteria (using Amsel) require three of the following
symptoms or signs:
1. Homogeneous, grey-white discharge;
2. Clue cells on wet microscopy;
3. pH of vaginal fluid >4.5;
4. Fishy odour with or without the addition of 10% KOH
(whiff test).
B. Nugent score:
This method estimates the relative proportions of bacterial
types on a Gram stained vaginal smear. A score between
0 and 10 is then assigned.
1. Score of <4 is normal,
2. Score of 4e6 is intermediate
3. Score of >6 is BV.
C. Hay Ison criteria: based on findings on a Gram stained smear
and gives an idea about flora types.
1. Grade 0: Not related to BV, epithelial cells only, no
lactobacilli.
2. Grade 1: (Normal): Lactobacilli predominate
3. Grade 2: (Intermediate): Mixed flora with some Lac-
tobacilli, and Gardnerella or Mobiluncus also present
4. Grade 3 (BV): Few or absent Lactobacilli. Gardnerella
and/or Mobiluncus morphotypes, clue cells,
predominate.
5. Grade 4: Not related to BV, no lactobacilli, Gram þ ve
cocci only.
Some other tests such as OSOM BV Blue test, Affirm VP III test
and DNA hybridization probe test are comparable to the gram
stain in results. Card tests to detect elevated pH and the cervical
smear tests have low specificity and sensitivity and are not rec-
ommended. PCR as a diagnostic tool in BV is still under research.
G. Vaginalis culture is not specific and not recommended.
Treatment
Treatment is recommended for the following group of patients:

Patients with symptoms.
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Preoperative for vaginal surgery

Pregnant women, if further investigated with direct mi-
croscopy (due to persistent negative gram stain findings
and still symptomatic or failure of treatment) and found
positive.

Treatment individualized in patients with positive direct
microscopy without symptom.
Recommended regimens:

500 mg Metronidazole: oral tablets, twice daily for 7 days,
or

2 gm Metronidazole: Single oral dose, or

0.75% Metronidazole gel: one full applicator (5 g) intra-
vaginally, once daily for 5 days, or

2% Clindamycin cream: one full applicator (5 g) intra-
vaginally at bedtime for 7 days
Alcohol, sexual intercourse or vaginal douching may hinder
the effectiveness of treatment. Alcohol should not be consumed
during treatment up to 24 hours after completion of metronida-
zole course, as it may precipitate a disulfiram-like reaction.
Clindamycin cream may affect latex condoms and diaphragms
and reduce their effectiveness for up to 5 days after its use.
Vaginal douching increases the risk of recurrence and insufficient
data supports their use for treatment or symptom relief.
Some studies have further evaluated the effectiveness of
intravaginal lactobacillus formulations in the treatment of bac-
terial vaginosis. No improvement in the disease has been noticed
and their use requires further research.
Pregnancy
In the UK, a BV prevalence of 12% was found in women
attending antenatal care, and 30% in women opting for termi-
nation of pregnancy.
Treatment of bacterial vaginosis is recommended for all
symptomatic women. Metronidazole regimen (500 mg) is similar
to non-pregnant population. Using Amstel criteria to define cure,
Yudin MH et al., found that oral metronidazole was as effective
as metronidazole gel for treatment during pregnancy, with a cure
rate of 70%. Metronidazole use during pregnancy is not associ-
ated with an increase in congenital malformations. A study by
Ugwumadu A. et al. using gram stain criteria showed an 85%
cure in patients receiving clindamycin. Newer studies have
shown that vaginal clindamycin is safe to administer in preg-
nancy. Both oral and topical regimens are both as effective and
safe to be prescribed in pregnancy.
Mixed results have been noticed in preterm delivery rate in
patients treated. Harm, no harm and benefit have been found in
several studies. Another study showed a decrease in late
miscarriage and adverse neonatal outcome in the treated group.
However, treatment is recommended for all symptomatic women
with BV as benefits outweigh the risks.
Insufficient data is available for treating asymptomatic preg-
nant women for which bacterial vaginosis was incidentally
discovered. Therefore, routine screening for bacterial vaginosis
in pregnancy is not recommended.
Metronidazole is secreted in breast milk. Studies have
revealed metronidazole and its metabolites in the plasma of ba-
bies, but this level was insignificant a lot lower than the levels
used by the mother to treat the infection. However, some ob-
stetricians recommend deferring breastfeeding for at least 24e48
3 Ó 2016 Published by Elsevier Ltd.
 REVIEW
hours after completion of treatment. Treatment in breastfeeding
should be with metronidazole twice daily for 5e7 days rather
than a one off dose. Although metronidazole treatment produces
parasitologic cure, certain trials have shown no significant dif-
ference in perinatal morbidity following metronidazole
treatment.
Management of partner
Routine screening and treatment is not recommended because
studies have shown that treatment of the male partner does not
affect recurrence or relief for women with bacterial vaginosis.
Follow up
It has been found that symptom recurrence occurs within 3e12
months of any regimen used for treatment. Recurrence rate has
been found at 15e30%. No follow up appointments are recom-
mended if symptoms resolve. Patients are advised to contact
their healthcare professional if symptoms persist or recur.
There is limited data for management of persistent or recur-
ring bacterial vaginosis. Using the same regimen or changing the
regimen are both acceptable management plans to treat such
conditions.
Women with recurrent infection may benefit from using
0.75% Metronidazole gel twice weekly for 4e6 months. A study
by Mcclelland and Richardson has found that administering a
monthly dose of 2 g oral metronidazole together with 150 mg
fluconazole is effective in reducing recurrence, although its
suppression is not long term once treatment is discontinued.
Vulvovaginal candidiasis (VVC)
Aetiology and classification
Yeast is often found as a commensal organism in the vagina. 10
e20% of women in their reproductive age are colonized by
candida. 75% of women experience symptomatic infection at
least once in their life. Vaginal candidiasis is a condition which
occurs if an alteration in the vaginal environment lead to pro-
liferation of yeast. Hyper-oestrogenic states may lead to vaginal
candidiasis. Some of the hyper-oestrogenic states associated with
candidiasis are pregnancy, diabetes mellitus, obesity, immuno-
suppression, use of oral contraception and after antibiotic treat-
ment. Tampons, sanitary towels or panty liners are not
associated with VVC when they are used appropriately.
Candida albicans species accounts for about 85% of vaginal
candidiasis. The remaining 15% of vaginal candidiasis is
accounted by Candida krusei, Candida kefyr, Candida tropicalis
and Candida glabrata.
White discharge, pruritus and dysuria are the common
symptoms. These symptoms are non-specific. 75% of patients
with these symptoms will have one episode of vaginal candidi-
asis. 45% will have two or more episodes.
Vaginal candidiasis is classified into either non-complicated
(85%) or complicated (15%). Below are the criteria used to
classify vaginal candidiasis:
A. Uncomplicated vaginal candidiasis:
1. Infrequent (3 episodes per year)
2. Mild-to-moderate
3. Likely to be Candida albicans
4. Non-immunocompromised women
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B. Complicated vaginal candidiasis is either:
1. Recurrent
2. Severe
3. Albicans/non-albicans candidiasis
4. During pregnancy
5. Immunocompromised conditions
Diagnosis
Clinical diagnosis is important to diagnose vaginal candidiasis.
Symptoms include white discharge, pruritus, burning, dysuria,
pain or redness. Signs include fissure, excoriation, vulval
oedema or thick white discharge. Patients who have some of the
above symptoms and signs can have the following tests to di-
agnose vulvo-vaginal candidiasis:

Gram stain or a wet preparation (saline, 10% KOH) of
vaginal discharge will show hyphae, or pseudohyphae or
budding yeasts. 10% KOH will improve visualization and
sensitivity of the test.

Culture of vaginal discharge will show positive for one of
the yeast species. A culture is indicated if results come
back negative for the Gram or wet stain with persistent
symptoms. Candida isolated from culture with no clinical
symptoms or signs should not be treated, as about 15% of
women harbour candida in their vagina as a commensal.
PCR is not recommended to diagnose candida; culture re-
mains the gold standard for diagnosis.
Treatment
General advice given to patients:

Avoid synthetic tight fitting clothes, and avoid washing
underwear in biological washing powder.

Avoid perfumed local products such as toiletries, antisep-
tics, douches and wipes.

Use soap substitutes (e.g. amole root, soap plant root,
soap root bulb, guaiac leaves, papaya leaves and quillaia
bark) and skin conditioners. These products should not be
used more than once per day to clean the vulval area
externally.

Emollients and skin conditioners may be used several
times per day.
Recommended regimens:
A. Over-the-counter products:
a) Intravaginal creams:
1. Clotrimazole 1% 5 g daily for 7e14 days
2. Clotrimazole 2% 5 g daily for 3 days
3. Miconazole 2% 5 g daily for 7 days
4. Miconazole 4% 5 g daily for 3 days
b) Vaginal suppositories:
1. Miconazole 100 mg daily for 7 days
2. Miconazole 200 mg for 3 days
3. Miconazole 1200 mg one single dose
c) Intravaginal ointment:
1. Tioconazole 6.5%, 5 g single vaginal
application
B. Agents which require a prescription:
a) Intravaginal creams:
1. Butoconazole 2%, 5 g in a single application
2. Terconazole 0.4%, 5 g daily for 7 days
3. Terconazole 0.8%, 5 g daily for 3 days
4 Ó 2016 Published by Elsevier Ltd.
 REVIEW
b) Vaginal suppositories:
1. Terconazole 80 mg, daily for 3 days
C. Oral agent:
1. Fluconazole 150 mg, single oral dose
All oral azoles and nystatin give about 80% cure rate. If
itching is a major problem, hydrocortisone containing topical
preparations may be of benefit. Creams, suppositories and oint-
ments in the above preparations may weaken latex condoms and
diaphragms. Condom product information should be reviewed.
Pregnancy
Vulvovaginal candidiasis is common among pregnant women.
Up to 40% of carriers will have symptoms during pregnancy.
Only topical azole therapy is recommended for symptomatic
pregnant women. Animal studies have found that Oral antifun-
gals triazoles (fluconazole and itraconazole) causes fetal abnor-
malities and should be avoided during pregnancy.
HIV
Vaginal Candida colonization rates among women with HIV
infection are higher than among seronegative women with
similar demographic and risk behaviour characteristics, and the
colonization rates correlate with increasing severity of immu-
nosuppression. Symptomatic VVC is also more frequent in
women with HIV infection and similarly correlates with severity
of immunodeficiency. In addition, among women with HIV
infection, systemic azole exposure is associated with the isola-
tion of non-albicans Candida species from the vagina.
On the basis of available data, therapy for uncomplicated and
complicated VVC in women with HIV infection should not differ
from that for seronegative women. Long-term prophylactic
therapy with fluconazole at a dose of 200 mg weekly has been
effective in reducing C. albicans colonization and symptomatic
VVC.
Management of partner
Asymptomatic partners do not require testing or treatment; as
vaginal candidiasis is not a sexually transmitted disease. How-
ever, few male partners may benefit from topical antifungal
agents if they experience balanitis (pruritus with erythema of the
penile glans).
Follow up
No follow-up is required for a single episode of vaginal candi-
diasis. However, if symptoms persist or recur within 2 months of
over-the-counter products, a medical evaluation and in-
vestigations are essential.
Recurrent vulvo-vaginal candidiasis
This is defined as four or more episodes of candidiasis within a
year. Prevalence within symptomatic women is expected to be
less than 5%. Non-albicans yeast species cause 10e20% of
recurrent disease. A comprehensive history and exclusion of risk
factors is mandatory for management. Treatment options are a
longer duration of use (7e14 days) of vaginal creams and sup-
positories, or using oral Fluconazole weekly for 6 months as
suppression and maintenance regimen. Most patients are disease
free during treatment and for around 6 months afterwards but
most do relapse within a year.
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T. vaginalis
Prevalence
Trichomoniasis is usually acquired through sexual contact. The
prevalence of the disease among black women is 13%, while it’s
prevalence among white is estimated at a rate of about 1.8%. It
affects about 11% of women aged more than 40 years. The
flagellate protozoan, T. vaginalis, is responsible for the disease.
Abnormal vaginal discharge, pruritus and dysuria are the main
symptoms. The characteristic feature of the infection is the
strawberry cervix. This appears as a friable, erythematous cervix
with punctate areas of exudate.
Urethral infection is present in 90% of cases. However,
isolating the protozoan from just the urethra is just below 5% of
cases.
Screening for T. vaginalis in asymptomatic women is not
recommended. Screening can be considered in asymptomatic
women who are at high risk for infection. These include patients
with multiple sexual partners, drug abusers and patients with a
history of STIs. However, there is insufficient data regarding
screening asymptomatic women without additional risk factors.
Diagnosis
About 70e85% of infected patients are asymptomatic. Increased
local polymorph nuclear leucocytes (PMNL) is the main host
response to infection.
Sites for sampling are either by high vaginal swabs from the
posterior fornix, self-taken vaginal swabs or urine samples.
Methods for detection of T. vaginalis include:

NAAT (nucleic acid amplification testing) is a highly sen-
sitive method for detection of T. Vaginalis. It can detect
three to five times more than wet preparations using direct
microscopy. It is now considered the gold standard for
detection of T. vaginalis. Specimens are usually retrieved
from the vagina, endocervix or urine. This method detects
the protozoal RNA with a high sensitivity of 95.3e100%
and a high specificity of 95.2e100%.

Direct microscopy: this is the method of choice for
screening. A wet preparation has a low sensitivity of 50
e70%. Vaginal discharge mixed with a drop of saline on a
glass slide can be used to detect T. vaginalis motility. T.
vaginalis lose their motility quickly, therefore the wet
preparation should be read within 10 minutes of collec-
tion. Microscopy with a magnification of 400 is used to
confirm the morphology and visualize the flagella. Acri-
dine orange when used as a stain for films was found
more sensitive than unstained wet preparations. This
method is more practical due to its lower cost compared
to NAAT.

Culture was considered in the past as the gold standard for
detection of the protozoan. It has a sensitivity of 75e96%
and a specificity of up to 100%. For culture, vaginal
discharge is preferred compared to a urine specimen, as
urine culture is less specific.

Immunomodulation: OSOM Trichomonas Rapid Test and
the Affirm VP III.

Cervical smear Pap tests can incidentally detect T. vagi-
nalis, but their false positive and false negative rates make
them unreliable as a diagnostic tool
5 Ó 2016 Published by Elsevier Ltd.
 REVIEW
Treatment
Indications for treatment:

Testing positive for T. vaginalis, regardless of symptoms

Treatment of sexual partners
Recommended regimen:

A single dose of 2 g metronidazole orally
OR

A single dose of 2 g tinidazole orally
Alternative regimen

Twice daily 500 mg metronidazole orally for 7 days
The only effective treatment against T. vaginalis are metro-
nidazole’s. The cure rate for metronidazole is 84e98%, while
that for tinidazole, a more expensive drug, is 92e100% Metro-
nidazole gel is less effective due to its low absorption rate and is
not recommended for treatment.
Alcohol, sexual intercourse or vaginal douching may hinder
the effectiveness of treatment. Alcohol should not be consumed
during treatment up to 24 hours after completion of a course of
metronidazole, or 72 hours after completion of a tinidazole
course, as it may precipitate a disulfiram-like reaction. Sexual
intercourse should be avoided during and at least for one week
after treatment. Douching is not recommended as it alters the
vaginal flora and increases the risk of infection.
Persistent or recurrent T. Vaginalis
Persistent or recurrent Trichomoniasis can be a result of re-
infection by the partner or antibiotic-resistant T. Vaginalis
strains. 4e10% of T. vaginalis are resistant to metronidazole and
1% are resistant to tinidazole. Avoid single dose therapy for
treatment of persistent or re-infection with T. Vaginalis.
If the single dose of 2 g metronidazole fails, a 500 mg
metronidazole twice daily oral dose for 7 days is recommended.
If this management fails, then 2 g metronidazole or 2 g tinidazole
for 7 days is advisable. Susceptibility to metronidazole or tini-
dazole should be tested if there is no cure after 1 week of treat-
ment. Intravaginal tinidazole, plus high dose 2e3 g daily oral
tinidazole, could be considered for highly resistant strains.
However, expert opinion should be sought.
Pregnancy
Screening in pregnancy for T. vaginalis in asymptomatic women
is not recommended. T. vaginalis is a risk factor for the vertical
transmission of HIV. Therefore, screening and treatment of T.
vaginalis is recommended for HIV positive pregnant women.
These individuals should have a repeat test 3 months after
treatment.
Infection in pregnancy is associated with a two-to-three-fold
increase in rates of preterm delivery and low birth weight. The
recommended treatment in pregnancy is 2 g oral metronidazole
as a single dose. Treatment may prevent genital or respiratory
infection in the new born.
Metronidazole can be prescribed at any gestational age, if
indicated. Although it crosses the placenta, no evidence of tera-
togenicity has been established.
Metronidazole is secreted in breast milk but only low plasma
levels are found in the breast fed babies of women using this
medication. However, some obstetricians recommend deferring
breastfeeding for at least 24e48 hours after completion of
treatment.
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Due to limited data regarding the safety of tinidazole use in
pregnancy, it is better avoided. Breastfeeding should be deferred
for at least 72 hours following the uptake of the 2 g tinidazole
dose.
HIV
There is increased transmission of both HIV and TV as a result of
increased shedding of the virus. Patients with HIV should be
given a 7-day course of metronidazole so as to ensure full
treatment of the infection. Retesting after 3 months may be
warranted in some cases.
Management of partner
Infection is readily transmitted between partners by the act of
unprotected sexual intercourse. Condom use is the main method
for prevention against infection. Uncircumcised men carry
greater risk of transmission to their partners than those who are
circumcised.
Treatment of the partner is recommended to prevent reinfec-
tion or transmission among partners. Abstaining from sexual
intercourse is imperative until both partners are treated. The
same regimen of treatment is advised for the partner. Treatment
should be commenced regardless of their test results.
Follow up
Peterman found a recurrence rate of 17% after treatment for T.
Vaginalis. A test of cure is recommended after 3 months of
completing the treatment course. Retesting by NAAT can be done
after 2 weeks of treatment. Limited data is available to guide
retesting the male partner.
Desquamated inflammatory vaginitis (DIV)
This is an uncommon form of chronic purulent vaginitis, which
mainly occurs in Caucasians with a peak occurrence in peri-
menopause. Its aetiology is unknown and it is a diagnosis of
exclusion. Its main symptoms are purulent discharge and
vestibular-vaginal irritation and dyspareunia. It has an estimated
incidence of 0.8e4.3% of women referred with persistent vaginal
discharge. The symptoms and signs are non-specific and exten-
sive investigation may be required.
Presentation
Most patients with DIV will have complaints for more than a
year. Most patients are typically symptomatic, although asymp-
tomatic DIV occasionally occurs. Purulent vaginal discharge
ranges from mild to profuse, associated with signs of inflam-
mation, such as focal petechiae (30e70%) or diffuse vaginal
erythema. Up to 27% of patients may have a similar lesion
involving the cervix and biopsy may show dense lymphocytic
infiltrates.
There is a marked increase in inflammatory cells, predomi-
nantly polymorphonuclear leukocytes, together with an increase
in immature squamous cells. Vaginal flora is abnormal with the
loss of lactobacillus morphotype and pH is always elevated
above 4.5.
The diagnosis of DIV is by exclusion of other conditions as
listed:

Infectious diseases: T. vaginalis, Group A Streptococcus,
Cervicitis
6 Ó 2016 Published by Elsevier Ltd.
 REVIEW

Immune/autoimmune induced inflammation: erosive
lichen planus, cutaneous vesiculobullous disorder

Hormonal conditions: oestrogen deficiency (atrophic
vaginitis)

Contact dermatitis: chemical vaginitis, allergy (latex,
sperm)

Miscellaneous: trauma, foreign body, urinary incontinence
including vesico-vaginal fistula, or cervical tumour,
Management
It has now been accepted that a trial of treatment with topical
oestrogens is a useful method to differentiate between DIV and
atrophic vaginitis. Menopausal women should continue to apply
vaginal oestrogens in addition to the anti-inflammatory treatment
for DIV as well. It is reasonable to send a vaginal culture in
search for Group A Streptococcus and if positive, be treated. Both
topical vaginal clindamycin and local vaginal corticosteroids are
useful and sometimes curative as both have anti-inflammatory
effects.
The recommended regimens are as follows:

Clindamycin:
 Insert 2% clindamycin (5 g) vaginally once a night for
three weeks, followed by a maintenance therapy twice a
week for two months
 Clindamycin 200 mg vaginally each night for three
weeks, followed by a maintenance therapy twice a week
for two months

Corticosteroids:
 Vaginal hydrocortisone 200e500 mg once a night for
three weeks, followed by a maintenance therapy twice a
week for two months
 Vaginal cortisone acetate suppository 25 mg twice a day
for three weeks, followed by polymorphonuclear leuko-
cytes maintenance therapy three times a week for two
months.
25% of patient will develop a symptomatic yeast infection. It
is recommended to add oral fluconazole to the treatment regimen
in patients prone to develop such an infection.
Women with DIV require long term follow up to assess
improvement and remission. The evaluation includes measure-
ment of inflammatory and parabasal cell numbers, vaginal pH
and the presence of normal healthy lactobacillus.
Conclusion
Management of vaginal discharge could never be accomplished
without a thorough medical history. pH strips are a simple
additional diagnostic test that is underutilized in gynaecological
clinics. Routine testing or screening of all gynaecological patients
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
Please cite this article in press as: Rice A, et al., Vaginal discharge, Obstetrics, Gynaecology and Reproductive Medicine (2016), http://dx.doi.org/
10.1016/j.ogrm.2016.08.002
is not recommended, except in special circumstances. DIV is an
uncommon severe form of vaginitis and should be considered
among women where symptoms have persisted for a long time
despite multiple pharmaceutical treatments. Examination, his-
tory and investigations are all complementary in the diagnosis
and the management process to prevent over treatment or under
diagnosis of susceptible women. A
FURTHER READING
British Association of Sexual Health and HIV Infection. UK national
guideline on the management of vulval conditions 2014.
Guidelines developed by the Clinical Effectiveness Unit (CEU) of the
Faculty of Sexual and Reproductive Health Care (FSRH) in
collaboration with the British Association for Sexual Health and HIV
(BASHH) [FSRH, 2012].
Gutman RE, Peipert JF, Weitzen S, Blume J. Evaluation of clinical
methods for diagnosing bacterial vaginosis. Obstet Gynecol 2005;
105: 551e6.
Larsson P-G. Treatment of bacterial vaginosis. Int J STD AIDS 1992; 3:
239e47.
National Institute for Health and Care Excellence Clinical Knowledge
Summary. Vaginal Discharge. May 2013.
Peterman TA, Tian LH, Metcalf CA, et al. High incidence of new
sexually transmitted infections in the year following a sexually
transmitted infection: a case for rescreening. Ann Intern Med 2006;
145: 564e72.
Reichman O, Sobel J. Desquamated inflammatory vaginitis (in) vul-
vovaginal disease-best practice & research. Clin Obstet Gynaecol
2014; 28: 1042e50. Elsevier, Newyork.
Sherrard J, Donders G, White D, Jensen JS. European (IUSTI/WHO)
guideline on the management of vaginal discharge. 2011, www.
isuti.org.
Yudin MH, Landers DV, Meyn L, et al. Clinical and cervical cytokine
response to treatment with oral or vaginal metronidazole for bac-
terial vaginosis during pregnancy: a randomized trial. ObstetGy-
necol 2003; 102: 527e34.
Practice points
C Vaginal discharge is a common complaint e not all vaginal
discharge is abnormal or requires treatment
C A thorough history should yield valuable information. pH testing
and swabs can be taken as necessary
C Extra caution must be exhibited when managing pregnant women
with pathological vaginal discharge
7 Ó 2016 Published by Elsevier Ltd.