STI-related Vaginal Discharge

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While a vaginal discharge is a notable clinical feature of an STI, not all forms of vaginal discharge are abnormal or indicative of an STI. A vaginal discharge may be associated with a physiological state such as menses or pregnancy, or with the presence or use of foreign substances and chemicals in the vagina.

A careful risk assessment (See note below) of women with a vaginal discharge may help identify STIs and non-STIs and selection of appropriate treatment regimens based on the most likely aetiology of the vaginal discharge. Other considerations for selecting treatment include pregnancy status and patient discomfort.

Cause

  • Neisseria gonorrhoea
  • Chlamydia trachomatis
  • Trichomonas vaginalis  (green or yellow, smelly, bubbly or frothy discharge associated with itching)
  • Herpes simplex virus (following first episode of infection)

Symptoms

  • Vaginal discharge - change in colour, odour, consistency or amount
  • Vulval swelling
  • Pain on urination
  • Lower abdominal or back pain

Signs

  • Vaginal discharge
  • Vulval swelling
  • Vulval erythema
  • Lower abdominal tenderness
  • Cervical excitation tenderness
  • Cervical mucopus or erosions (on speculum examination)

Investigations

  • High vaginal swab for microscopy, culture and sensitivity (if available)

TreatmentTreatment Objectives

  • To identify and treat non-STI vaginitis (especially candidiasis, which is frequently diagnosed in women being evaluated for STIs)
  • To assess STI risk and treat STI-related infections appropriately
  • To prevent complications and sequelae
  • To treat both partners simultaneously as much as possible

Non-pharmacological treatment

  • None for STI-related discharge 

Pharmacological Treatment

Evidence Rating: [C]

Risk Assessment: 

Parameters used in the risk assessment for cervicitis are:

  1. Patient’s partner is symptomatic (i.e. partner has a urethral discharge)
  2. Patient is less than 21 years old
  3. Patient is single
  4. Patient has more than one sexual partner
  5. Patient has had a new sexual partner in the last 3 months

The risk assessment is said to be positive and treatment for cervicitis is recommended if: 

  • The answer to (i) is yes or
  • The answer to any 2 of items (ii) - (v) is yes.

If a woman has a vaginal discharge with no positive risk factor, treat for vaginitis alone. If she has a vaginal discharge, and a positive risk factor, treat for both vaginitis and cervicitis

A. Treatment for trichomoniasis and bacterial vaginosis

  • Metronidazole, oral, 2 g stat. (contraindicated during the 1st trimester of pregnancy)

Or 

  • Metronidazole, oral, 400 mg 8 hourly for 5 days  (contraindicated during the 1st trimester of pregnancy)

Or

  • Secnidazole, oral, 2 g stat. (contraindicated during the 1st trimester of pregnancy)

Or

  • Tinidazole, oral, 2 g stat. (contraindicated during the 1st trimester of pregnancy) 

Or

  • Clindamycin cream (2%), topical (preferred in pregnancy)

And 

B. Treatment for candidiasis

  • Miconazole vaginal tablets, 200 mg inserted into vagina at night for 3 days

Or

  • Clotrimazole, vaginal tablets, 200 mg inserted into vagina at night for 3 days

And

  • Clotrimazole cream, apply 12 hourly (for vulval irritation)

C. Treatment for gonorrhoea

  • Ceftriaxone, IM, 250 mg stat.

Or

  • Cefixime, oral, 400 mg stat

Or

  • Ciprofloxacin, oral, 500mg stat (avoid  in  pregnant  and  lactating mothers)

And 

D. Treatment for chlamydia

  • Doxycycline, oral, 100 mg 12 hourly for 7 days (avoid in pregnant and lactating mothers)

Or

  • Tetracycline, oral, 500 mg 6 hourly for 7 days (avoid in pregnant and lactating mothers)

Or

  • Erythromycin, oral, 500 mg 6 hourly for 7 days

Or

  • Azithromycin, oral, 2 g stat.

Referral Criteria

  • Refer all cases of recurrent vaginal discharge and/or treatment failures to a health facility where speculum examination can be carried out and microbiological culture and antimicrobial sensitivity tests can be done on the vaginal discharge.