Abnormal Vaginal Discharge (AVD)

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CLINICAL DESCRIPTION

  • While a vaginal discharge is a notable clinical feature of a Sexually Transmitted Infection (STI), not all forms of vaginal discharge are abnormal or indicative of an STI. Vaginal discharge may be associated with normal physiological changes such as the menstrual cycle or pregnancy. Increased discharge may also occur with the presence or use of foreign substances such as the Intra Uterine Contraceptive Device (IUCD).
  • Abnormal vaginal discharge due to STIs may result in serious pelvic inflammation with sequelae such as ectopic pregnancy and infertility. Careful risk assessment is therefore required (see note below) of women presenting with a vaginal discharge in order to identify the possible causes and provide appropriate treatment regimens based on the most likely aetiology of the vaginal discharge.

Causes

  • Vaginal infection
  • Cervical infection
  • Endometrial infection
  • Pelvic inflammatory disease (PID)

Common causes of infections vaginal

Common Causes of  cervical infections

Trichomonas vaginalis

Neisseria

candida albicans

gonorrhoea

bacterial vaginosis

chlamydia trachomatis

Note: Vaginal discharge is normal during and after sexual activity; at various points through-out the menstrual period; and during pregnancy and lactation.

It is mandatory to perform a pelvic examination which includes a speculum examination for all women presenting with abnormal vaginal discharge. 

CLINICAL FEATURES

SIGNS AND SYMPTOMS
  • Abnormal vaginal discharge - change in colour, odour, consistency or amount
  • Vulval itching and swelling
  • Pain on urination
  • Lower abdominal or back pain and tenderness
  • Cervical excitation tenderness
  • Cervical mucopus or erosions (on speculum examination)
INVESTIGATION
  • High vaginal swab for microscopy, culture and sensitivity  

 TREATMENT

NON-PHARMACOLOGICAL 
  • Do risk assessment to identify women at risk of cervical infection
  • Promote good peri-anal and genital hygiene
  • Encourage use of loose cotton underwear
  • Dry underwear out in the sun
  • Keep underwear dry
  • Avoid douching with herbal or chemical preparations
  • Avoid use of medicated soaps
PHARMACOLOGICAL
  • Treat all women with vaginal discharge and a positive risk assessment for gonococcus and Chlamydia infection, plus trichomoniasis and 
    • If the discharge is white and curd-like also treat for candidiasis.
  • Treat all women with vaginal discharge and a negative risk assessment for trichomoniasis and bacterial vaginosis, 
    • If the discharge is white and curd-like, also treat for candidiasis.

TREATMENT

  • If vaginal discharge is present and the risk assessment is positive:
    • Give Ceftriaxone 250mg IM STAT plus
    • Give Azithromycin 1g orally as single dose, plus
    • Give Metronidazole 2g orally single dose
  • If the discharge is white or curd-like add 1 Clotrimazole pessary 500mg inserted intra- vaginally stat
  • If vaginal discharge is present and risk assessment is negative:
    • Give Metronidazole 2g orally single dose stat ONLY
  • If no discharge is found and risk assessment is positive:
    • Give Ceftriaxone 250mg IM STAT plus  
    • Give Azithromycin 1g orally as a single dose.
  • If no discharge is found and risk assessment is negative:
  • Reassure client, counsel, educate and provide condoms.
  • Advise client to come back if symptoms persist.
  • Offer HIV testing after providing information and counselling
  • Offer cervical cancer screening

Note: Examination of GUS in women should never be omitted only for convenience of the health worker