Vaginal Discharge – Causes, Symptoms, Treatment

Vaginal discharge is a white, nonhomogeneous, and viscous discharge that contains vaginal squamous epithelial cells in a serous transudate, and material from the sebaceous gland, sweat, and Bartholin’s glands, and abnormal secretions from the cervix. Changes that may signal a problem include an increase in the amount of discharge, a change in the color or smell of the discharge, and irritation, itchiness, and burning in or around your vagina area. A small number of polymorphonuclear leukocytes may be seen, probably coming from the cervix. The pH is below 4.5, usually between 3.8 and 4.2. The predominant organisms are lactobacilli, large gram-positive rods are found.

Types of Vaginal Discharge

There are several different types of vaginal discharge that are found. These types are categorized based on their color and consistency, and elasticity. Some types of discharge are normal. Others may indicate an abnormal underlying condition that requires treatment.

  • White – A great amount of white discharge, especially at the beginning or end of your menstrual cycle, is normal. However, if the discharge is accompanied by another itching that has a thick, cottage cheese-like consistency or appearance, it’s not normal and needs treatment. This type of discharge may be a symptom of a yeast infection.
  • Clear and watery – A clear and watery discharge is perfectly normal or abnormal. It can occur at any time of the month. It may be especially heavy after exercise.
  • Clear and stretchy – When the discharge is clear but stretchy, jelly-like, and mucous-like, rather than watery, it indicates that you are likely going to ovulate. This indicates a normal type of discharge.
  • Brown or bloody – Brown or bloody discharge is usually normal, or abnormal especially when it occurs during or right after your menstrual cycle. A late discharge at the end of your period or from starting can look brown instead of red. You may also experience a small amount of bloody discharge between periods. This is called in name spot.
  • Yellow or green – A yellow or green discharge, especially when it’s thick, or accompanied by an unpleasant smell, isn’t normal. This type of discharge may indicate a sign of the infection trichomoniasis. It is commonly spread through sexual intercourse.

Causes of Vaginal Discharge

Any change in the vagina’s balance, discharge of normal bacteria can affect the smell, color, or discharge texture. These are a few of the things that can upset you.

  • Antibiotic or steroid use
  • Bacterial vaginosis, a bacterial infection more common in pregnant women, who have multiple sexual partners
  • Birth control pills may causes
  • Cervical cancer
  • Chlamydia or gonorrhea (STDs), HIV or sexually transmitted infections
  • Diabetes Mellitus
  • Douches, bad brand scented soaps or lotions, bubble bath
  • Pelvic infection after surgery and pregnancy
  • Pelvic inflammatory disease (PID) also causes
  • Trichomoniasis, a parasitic infection typically caused by having unprotected sex
  • Vaginal atrophy, the thinning and drying out of the internal vagina of the vaginal walls during menopause
  • Vaginitis, irritation in, swelling, or around the vagina
  • Yeast infections most commonly

Other Causes

  • Atrophic Vaginitis (post-menopausal women)
  • Infectious Cervicitis
    • Neisseria gonorrhoeae
    • Chlamydia trachomatis
    • Herpes Simplex Virus
  • Vaginitis or Vulvitis
    • Scabies
    • Neurodermatitis
    • Vaginal or Vulvar Trauma
    • Lichen Planus
    • Vulvar Vestibulitis
    • Herpes Vulvitis (presents with severe pain, often before vesicular lesions appear)
    • Malignancy
    • Irritant Contact Vaginitis
    • Soaps
    • Tampons or sanitary napkins
    • Condoms
    • Spermicidal gel
    •  Diaphragm
    • Dyes
  • Physiologic discharge
    • Ovulation
    • Pregnancy

Vaginal Discharge

Symptoms of Vaginal Discharge

You should also be felt for symptoms of yeast infections, bacterial vaginosis, and trichomoniasis. These are 3 different infections that usually can cause changes in your vaginal discharge.

Signs of yeast infections

  • White, cottage cheese-like discharge substance
  • Swelling and pain around the vulva, and vagina
  • Intense itching
  • Painful sexual intercourse frequently

Signs of bacterial vaginosis

  • A white, gray, or yellowish color vaginal discharge
  • A fishy odor with an unpleasant odor that is strongest after sex or after washing with soap
  • Itching or burning
  • Slight redness and swelling of the vagina internal or vulva

Signs of trichomoniasis

  • A watery, yellowish, or greenish bubbly discharge may be found
  • An unpleasant odor is most common
  • Pain and itching when urinating or after urination
  • Most apparent after your period or abnormal period

Diagnosis of Vaginal Discharge

Normal Vaginal Secretions

  • Few vaginal discharges are expected in reproductive-age women. The secretions are white and flocculent and consist of the vaginal mucosa, vaginal epithelium transudate substance, mucous secretions from the cervix, endometrial gland secretions may be found, lactic acid, Bartholin gland secretions also appears, and sebaceous gland secretions from the vulva. There will be a wide spectrum of what is normal from patient to patient.

History

  • Symptoms may include patient reports of abnormal vaginal discharge, malodorous discharge, vaginal irritation, and dyspareunia. The differential diagnosis includes bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis, inflammatory vaginitis, atrophic vaginitis, allergic reaction, chemical irritation, cervicitis, and foreign bodies may be found.
  • The examination should begin with patient history and symptoms discharge, pruritus, pain, bleeding, swelling, pruritis, etc, and their timing. The patient should be questioned or ask about the previous times of similar symptoms. Good about the hygienic and healthy practice including the use of lubricants. Collect a sexual history and note previous sexually transmitted infections are present.  Finally, review the medical history looking for immune suppression drugs and recent steroid or antibiotic use.

Physical Exam

  • The gross examination is completed to characterize any discharge present or not. pH testing should be completed with the testing strip must be placed directly into the vaginal pool or along the sidewall. Cervical mucus, semen, and blood may all falsely elevate the pH.
  • A speculum examination should be performed with warm water. Lubricants can contain antibacterial agents that will affect the specimens. Make use of polyester-tipped swabs on plastic shafts, designated swabs from diagnostic test’s manufacturers. Cotton is toxic and the wood in the shafts of swabs can be toxic to Chlamydia trachomatis.

Diagnosis of Vaginitis

  • The Wet Prep – After specimen collection is completed during the exam, the swab substance is transferred to a tube containing 0.5 mL to 1 mL of physiologic saline. The swab should be to dislodge particulates. Three slides are prepared by placing a droplet utilizing a disposable transfer pipette and cottage. The three slides are a wet, a potassium hydroxide mount, and a slide for gram staining. The examination should proceed immediately after specimen collection. If this is not possible, the specimen should be kept at room is normal temperature and examined within 2 hours. Cooling may help limit the trichomonas motility.

The wet mount is examined immediately. The 10X objective is used to assess the types of epithelial cells present (mature, parabasal, basal, or clue cells) and to establish the presence of budding yeast or pseudohyphae. The 40X objective is used to count organisms and cells per the high-power field (HPF).

  • Squamous epithelial cells – are polygonal cells. The central nucleus is roughly the size of a red blood cell (RBC). There is a large amount of irregular cytoplasm that may found. The cells’ margins are distinct. They are present in large numbers in the vaginal secretions.
  • Clue cells – are an abnormal variation of the squamous epithelial cell. The cell is distinguished by coccobacillus bacteria which is attached in clusters to the cell surface. This makes the cells stippled and the borders indistinct. The cell is granular and irregular. Clue cells, when present in abundance, indicate Gardnerella vaginalis high growth.
  • White Blood Cells – will appear one-half to one-third the size of squamous epithelial cells. They exhibit a granular cytoplasm. The multi-lobed nucleus lends to the name white blood cells (PMN’s). In normal secretions, they are present in small numbers. Greater than 3% white blood cells (WBC) suggest vaginal candidiasis, atrophic vaginitis, or infections with trichomonas, chlamydia, gonorrhea, or HSV.
  • RBCs – are one-half the size of WBCs and are smooth, non-nucleated disks. RBCs can be confused with yeast, but KOH will lyse them while yeast cells remain on the mount.
  • Parabasal Cells – are larger than a WBC but smaller than squamous epithelial cells. They are round to oval-shaped with a nucleus level ratio of 1:1 or 1:2. The cytoplasm contains basophilic or amorphic basophilic structures. These are rarely seen in normal vaginal secretions unless women are menstruating or postmenopausal symptoms. Basal cells present with many WBCs indicate inflammatory vaginitis.
  • Basal Cells – are roughly the same size as WBCs but with a round nucleus. The nucleus-to-cytoplasm ratio is 1:2. These are not normally found in vaginal secretions. Their presence can indicate vaginal atrophy or in the presence of excessive WBCs,  inflammatory vaginitis.
  • Lactobacillus – species should predominate in the healthy reproductive age vagina. These will appear as large, nonmotile rods.
  • Trichomonas vaginalis – is a flagellated protozoan slightly larger on average than a WBC. There are four anterior flagella and an undulating membrane that extends half the body length. An axostyle bisects the trophozoite longitudinally and protrudes from the posterior end. This enables the organism to attach to the vaginal mucosa.
  • Yeast cells (blastospores) – are of similar size to RBCs. Pseudohyphae are multiple buds that instead of detaching, form chains. Yeast is best observed on the 10-fold objective.
  • Gram StainThe gram stain remains the one for identifying the causative agent for bacterial vaginosis but is only routinely used in the research setting. The gram stain slide must be heat-fixed. It is evaluated using the Nugent score. The Nugent score is calculated based on the observed quantities of Lactobacillus acidophilus, Gardnerella,  Bacteroides species, and Mobiluncus species.
  • Cultures – Cell culture has a limited role in the evaluation of vaginitis. It remains the gold standard for the detection of yeast. Unfortunately, the results are not timely. The culture is not useful as it is part of the normal flora in 50% of women. Trichomonas vaginalis can be cultured, but it requires a specific medium, Diamond’s medium, and is time-consuming and labor-intensive. Beyond recurrent yeast, culture is not clinically important to the evaluation of vaginitis.
  • DNA Technologies DNA hybridization probes are available for G. vaginalis, Candida species, Trichomonas vaginalis, chlamydia, and gonorrhea and are being used increasingly in the evaluation of abnormal vaginal discharge. The sensitivities are very high and turn around is quick.

Various point-of-care tests exist for Trichomonas vaginalis, and Gardnerella vaginalis are commercially available. Most require in-house equipment (exception, for trichomonas which has the lowest sensitivity), but the turn-around time is 15 to 60 minutes. Their sensitivities are 90% or better.

Treatment of Vaginal Discharge

Bacterial vaginosis

  • Metronidazole 2 g as a single oral dose, metronidazole 400-500 mg twice daily for five to seven days, intravaginal clindamycin cream (2%) once daily for seven days, or intravaginal metronidazole gel (0.75%) once daily for five days

Recommended Regimens per the Centers for Disease Control and Prevention (CDC):

  • Metronidazole 500 mg orally twice a day for 7 days

OR

  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days

OR

  • Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days

Alternative Regimens

  • Tinidazole 2 g orally once daily for 2 days

OR

  • Tinidazole 1 g orally once daily for 5 days

OR

  • Clindamycin 300 mg orally twice daily for 7 days

OR

  • Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days
  • Patients should be advised to abstain from alcohol for 24 hours after completion of the metronidazole course and 72 hours after the tinidazole course to avoid the disulfiram-like reaction. There is no evidence to support the use of Lactobacillus probiotics in BV treatment or the recurrence of symptoms.

Vulvovaginal candidiasis

  • Vaginal imidazole preparations (such as clotrimazole, econazole, miconazole—various preparations are available including single-dose ones), or fluconazole 150 mg orally

Uncomplicated

  • A short course (single dose; 1-day or 3-day course) of over-the-counter topical antifungals will result in cure rates of 80% to 90% for uncomplicated vulvovaginal candidiasis (clotrimazole, miconazole, tioconazole, butoconazole, itraconazole). A single dose by the mouth of fluconazole 150 mg by mouth is also effective. No follow-up is needed if the symptoms resolve.

Complicated Disease

  • Recurrent candidiasis – 7 to 14 days of topical therapy or a 100-mg, 150-mg, or 200-mg oral dose of fluconazole every third day for a total of 3 doses [day 1, 4, and 7) can be used. Oral fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for 6 months is the first line maintenance regimen. 30% to 50% of women will have recurrent disease after maintenance therapy is discontinued.
  • Severe candidiasis – 7 to 14 days of topical azole or 150 mg of fluconazole in two sequential oral doses 72 hours apart.
  • Nonalbicans candidiasis – 7 to 14 days of a non-fluconazole azole regimen (oral or topical) as first-line therapy. If recurrence occurs, 600 mg of boric acid in a gelatin capsule is recommended, administered vaginally once daily for 2 weeks.

Chlamydia trachomatis

  • Doxycycline 100 mg twice daily for seven days (contraindicated in pregnancy), azithromycin 1 g orally in a single dose (WHO recommends azithromycin in pregnancy but the British National Formulary advises against its use unless no alternatives are available)
  • A test of cure is not indicated
  • Partner notification required

Gonorrhea

  • Cefixime 400 mg as a single oral dose or ceftriaxone 250 mg intramuscularly as a single dose
  • Referral to a genitourinary medical unit is encouraged because of the existence of resistant strains of the organism
  • A test of cure is not routinely indicated if an appropriately sensitive antibiotic has been given, symptoms have resolved, and there is no risk of reinfection
  • Partner notification required

Trichomonas vaginalis

  • Metronidazole 2 g orally in a single dose or metronidazole 400-500 mg twice daily for five to seven days

Recommended Regimen per the CDC

  • Metronidazole 2 gm by mouth once or tinidazole 2 gm by mouth once.

Alternative Regimen

  • Metronidazole 500 mg by mouth two times per day for 7 days.
  • Partner notification required
  • Readers should refer to BASHH guidelines, the British National Formulary, and local policies for full treatment options, including treatment in pregnancy.

Complicated Disease

  • Recurrent candidiasis – 7 to 14 days of topical therapy or a 100-mg, 150-mg, or 200-mg oral dose of fluconazole every third day for a total of 3 doses [day 1, 4, and 7) can be used. Oral fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for 6 months is the first line maintenance regimen. 30% to 50% of women will have recurrent disease after maintenance therapy is discontinued.
  • Severe candidiasis – 7 to 14 days of topical azole or 150 mg of fluconazole in two sequential oral doses 72 hours apart.
  • Nonalbicans candidiasis – 7 to 14 days of a non-fluconazole azole regimen (oral or topical) as first-line therapy. If recurrence occurs, 600 mg of boric acid in a gelatin capsule is recommended, administered vaginally once daily for 2 weeks.

Can vaginal discharge be prevented or avoided?

There is no need to prevent normal vaginal discharge. However, abnormal vaginal discharge may be prevented by following these tips.

  • After using the toilet, always wipe from front to back. This may help prevent getting bacteria from your rectal area into your vagina.
  • Wear cotton underpants during the daytime. Cotton allows your genital area to breathe. Don’t wear underpants at night.
  • Avoid wearing tight pants, pantyhose, swimming suits, biking shorts, or leotards for long periods.
  • Change your laundry detergent or fabric softener if you think it may be irritating your genital area.
  • The latex in condoms and diaphragms and the sperm-killing gels that are used for birth control can be irritating for some women. If you think one of these things is a problem for you, talk to your doctor about other types of birth control.
  • Avoid hot tubs.
  • Bathe or shower daily and pat your genital area dry.
  • Don’t douche.
  • Avoid feminine hygiene sprays, colored or perfumed toilet paper, deodorant pads or tampons, and bubble baths.

References

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