1. CASE
Mrs Ford is a 29 years old lady who has been complaining of vaginal discharge for the past 3 days. Otherwise she is asymptomatic. Her PMH includes bronchial asthma. Her cycles are normally regular with no issues. She has been with her current partner for few months. ON examination there was no significant findings.
What do you want to know more?
What is your differential?
What investigations would you like to do, if any?
What are the treatment options?
What is your plan if this is a recurrent problem?
Can you suggest any preventive measures?

2. Causes Foreign bodies, e.g. retained tampon Vulval dermatitis
Non-infective:
Physiological
Cervical polyps and ectopy
Foreign bodies, e.g. retained tampon
Vulval dermatitis
Erosive lichen planus
Genital tract malignancy
Fistulae
Non-sexually transmitted infection:
Bacterial vaginosis
Candida
Sexually transmitted infection:
Chlamydia trachomatis
Neisseria gonorrhoeae
Trichomonas vaginalis

3. Assessment A full clinical and sexual history
Nature of the discharge: odour, onset, duration, colour.
Associated symptoms: itch, dyspareunia, dysuria, abdominal pain, abnormal bleeding, pyrexia.
Medications: antibiotics, steroids
PMH: DM, immunocompromised state.
Investigations: Triple swaps, vaginal pH testing (Candida and bacterial vaginosis can be diagnosed clinically and treated without sampling)

4. Bacterial Vaginosis May be asymptomatic (in up to 50% of women)
Thin, profuse and fishy smelling discharge without itch or soreness
Associated with poor pregnancy outcomes, endometritis after miscarriage, and pelvic inflammatory disease
Asymptomatic bacterial vaginosis in non-pregnant women does not require treatment.
Routine: oral metronidazole for 5-7 days or stat 2gm dose. Alternatively topical metronidazole or oral clindamycin or topical clindamycin.
70-80 % cure rate but commonly recurs

5. Candidiasis
Thick, white, non-offensive discharge which is associated with vulval itch and soreness.
May cause mild dyspareunia and external dysuria
Examination may be normal or there may be erythema, oedema and fissuring
pH is less than 4.5
Asymptomatic vulvovaginal candidiasis does not need treatment.
Vaginal imidazole: clotrimazole, econazole, miconazole or fluconazole 150 mg orally (avoid in pregnancy)
80-95 % cure rate.

6. Infective (STD) vaginal discharge
Can present with vaginal discharge but may also be asymptomatic.
Associated with an increased risk of HIV transmission.
May be complicated by PID.
Trichomonas vaginalis:
Offensive yellow vaginal discharge, which is often profuse and frothy, with vulval itch and soreness, dysuria, abdominal pain and superficial dyspareunia
Is associated with preterm delivery
Chlamydia trachomatis:
Copious purulent vaginal discharge, but it is asymptomatic in 80% of women
Diagnosis is confirmed on swabbing
Neisseria gonorrhoeae:
Purulent vaginal discharge but is asymptomatic in up to 50% of women
Mild symptoms include slight discharge, dysuria, intermenstrual bleeding

7. Treatment (infective STD discharge)
Refer to the GUM clinic (unless your practice has the appropriate expertise).
Chlamydia trachomatis; doxycyclin or azithromycin
Gonorrhoea; cefixime or ceftriaxone
Trichomonas vaginalis; metronidazole
Patients will be fully screened for concurrent STDs and treated as appropriate.
Partners will need to be identified, screened and treated too.

8. Recurrent discharge
Ensure pathology hasn't been missed (e.g. an STD in the case of a patient being treated for bacterial vaginosis).
Explore personal hygiene (douches, perfumed products and tight synthetic clothing)
If the patient has coil in situ, consider alternative.
Think of diabetes, immunosuppression or antibiotic administration.
Consider the 'silent' complaint: depression, anxiety or psychosexual dysfunction.
Post-menopausal atrophic changes may predispose women to recurrent vaginitis.