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:
- Patient’s partner is symptomatic (i.e. partner has a urethral discharge)
- Patient is less than 21 years old
- Patient is single
- Patient has more than one sexual partner
- 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.