Abnormal Vaginal Discharge: Diagnosis & Management (Bacterial Vaginosis (BV), Vulvovaginal Candidiasis (Candida albicans), Trichomoniasis, Chlamydial Cervicitis, Gonorrheal Cervicitis)

Management Sheet

Cause	Key Features	First-Line Treatment	Alternative / Notes	Partner Treatment
Bacterial Vaginosis (BV)	Thin gray-white discharge, fishy odor, pH >4.5, clue cells	✅ Metronidazole 500 mg PO bid × 7 days	Clindamycin 300 mg PO bid × 7 days	❌ Not required
Vulvovaginal Candidiasis (Candida albicans)	Thick white “cottage cheese” discharge, itching, pH ≤4.5	✅ Fluconazole 150 mg PO single dose	Topical azole (Clotrimazole 500 mg PV single dose)	❌ Not required
Trichomoniasis	Frothy yellow-green discharge, strawberry cervix, pH >4.5	✅ Metronidazole 2 g PO single dose	Tinidazole 2 g PO single dose	✅ Yes, treat all partners
Chlamydial Cervicitis	Mucopurulent discharge, postcoital bleeding, and asymptomatic often	✅ Doxycycline 100 mg PO bid × 7 days	Azithromycin 1 g PO single dose (pregnant)	✅ Yes
Gonorrheal Cervicitis	Purulent discharge, dysuria, pelvic pain	✅ Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg PO bid × 7 days	If resistant: Cefixime 800 mg PO single dose	✅ Yes
Mixed infection (PID suspected)	Discharge + lower abdominal pain + CMT/adnexal tenderness	✅ Ceftriaxone 500 mg IM ×1 + Doxycycline 100 mg PO bid × 14 days + Metronidazole 500 mg PO bid × 14 days	Inpatient if severe → IV regimen	✅ Yes

---

🔍 Introduction

Vaginal discharge is a common presenting complaint among women of reproductive age. It may be physiological (normal) or pathological (abnormal). Distinguishing between the two is crucial, as abnormal discharge often indicates infection or inflammation of the lower genital tract, which may ascend and cause pelvic inflammatory disease (PID) or infertility if untreated.

🌸 Normal Vaginal Discharge (Physiologic Leukorrhea)

Characteristic	Description
Color	Clear to whitish, non-purulent
Consistency	Thin or mucoid, changes with menstrual cycle
Odor	Odorless
pH	3.8–4.5 (acidic due to Lactobacillus production of lactic acid)
Associated symptoms	None — no itching, irritation, or pain

Increased physiological discharge can occur during:

• Ovulation (mid-cycle estrogen surge)

• Pregnancy (high estrogen and progesterone)

• Sexual arousal

• Use of estrogen-containing contraceptives
  

---

⚠️ Definition of Abnormal Vaginal Discharge

Abnormal vaginal discharge refers to any discharge that:

• Changes in color, consistency, amount, or odor, AND

• It is associated with itching, pain, irritation, dysuria, or dyspareunia
  

---

🧫 Common Causes of Abnormal Vaginal Discharge

Abnormal discharge can result from infectious or non-infectious causes. Below are the five major infectious causes that account for >90% of abnormal discharges.

1. Bacterial Vaginosis (BV)

Etiology: Polymicrobial imbalance — ↓ Lactobacillus → ↑ Gardnerella vaginalis, Mobiluncus, Prevotella

Pathophysiology: Loss of protective acidic pH → overgrowth of anaerobes → amine (fishy) odor production

Clinical Features:

• Thin, gray-white, homogenous discharge

• Fishy odor, especially after intercourse (amine test positive)

• Usually, there is no itching or pain

• pH > 4.5

Diagnosis (Amsel’s Criteria – need ≥3):

1. Homogeneous thin gray discharge

2. Vaginal pH > 4.5

3. Positive Whiff test (fishy odor after adding 10% KOH)

4. Clue cells on wet mount microscopy (epithelial cells with bacteria coating their borders)

Treatment:

• Metronidazole 500 mg PO bid × 7 days or

• Clindamycin 300 mg PO bid × 7 days

Partner treatment: ❌ Not required

2. Vulvovaginal Candidiasis (Candida Vaginitis)

Etiology: Candida albicans (yeast/fungal infection)Risk factors: Antibiotic use, pregnancy, diabetes, immunosuppression, OCPs

Clinical Features:

• Thick, white, “cottage cheese-like” discharge

• Intense itching, vulvar erythema, dysuria

• No odor

• pH normal (≤4.5)

Diagnosis:

• Wet mount (KOH prep): budding yeast, pseudohyphae

• Culture if recurrent or non-albicans species suspected

Treatment:

• Fluconazole 150 mg PO single dose or

• Topical azole (Clotrimazole 500 mg vaginal tablet single dose)

Partner treatment: ❌ Not required (unless recurrent or male has balanitis)

3. Trichomoniasis

Etiology: Trichomonas vaginalis (protozoan parasite)Transmission: ✅ Sexually transmitted

Clinical Features:

• Frothy, yellow-green, malodorous discharge

• Vaginal and vulvar itching, burning

• Strawberry cervix (punctate hemorrhages on cervix)

• pH > 4.5

Diagnosis:

• Wet mount: motile trichomonads (flagellated protozoa)

• NAAT (if available) – gold standard

Treatment:

• Metronidazole 2 g PO single dose (or 500 mg PO bid × 7 days)

• Treat the partner concurrently to prevent reinfection
  

4. Chlamydial Cervicitis

Etiology: Chlamydia trachomatis (obligate intracellular bacterium)Transmission: ✅ STI

Clinical Features:

• Often asymptomatic

• May have mucopurulent cervical discharge

• Dysuria, postcoital bleeding, pelvic pain

• May lead to PID

Diagnosis:

• NAAT (PCR) of cervical or urine sample — gold standard

• Wet mount: many WBCs, no organisms

Treatment:

• Doxycycline 100 mg PO bid × 7 days or

• Azithromycin 1 g PO single dose (alternative)

• Partner treatment mandatory
  

5. Gonococcal Cervicitis (Gonorrhea)

Etiology: Neisseria gonorrhoeae (Gram-negative diplococcus)Transmission: ✅ STI

Clinical Features:

• Purulent vaginal or cervical discharge

• Dysuria, intermenstrual bleeding

• May cause PID, infertility

Diagnosis:

• NAAT for N. gonorrhoeae

• Gram stain: intracellular Gram-negative diplococci

Treatment:

• Ceftriaxone 500 mg IM single dose PLUS

• Doxycycline 100 mg PO bid × 7 days (for possible Chlamydia coinfection)

Partner treatment: ✅ Required

---

🧠 Mnemonic: "Be Careful To Check Girls"

Letter	Disease	Organism	Notes
B	Bacterial Vaginosis	Gardnerella vaginalis	Fishy odor, clue cells
C	Candida Vaginitis	Candida albicans	Cottage cheese discharge
T	Trichomoniasis	Trichomonas vaginalis	Frothy yellow-green discharge
C	Chlamydia	Chlamydia trachomatis	Mucopurulent discharge
G	Gonorrhea	N. gonorrhoeae	Purulent discharge

---

🧪 Summary of Diagnostic Clues

Parameter	BV	Candida	Trichomonas	Chlamydia	Gonorrhea
pH	>4.5	≤4.5	>4.5	Variable	Variable
Odor	Fishy	None	Foul	None	None
Appearance	Thin, gray	Thick, curdy	Frothy, yellow-green	Mucopurulent	Purulent
Microscopy	Clue cells	Pseudohyphae	Motile trichomonads	↑WBCs	Gram-negative diplococci
Partner Tx	No	No	Yes	Yes	Yes

---

⚕️ Complications

• PID (from Chlamydia or Gonorrhea)

• Infertility due to tubal scarring

• Ectopic pregnancy

• Preterm labor / PROM in pregnancy

• Recurrent infections or chronic pelvic pain

---

💊 General Management Principles

1. Rule out pregnancy (urine hCG)

2. Pelvic examination

3. Perform microscopy and NAAT to identify causative organisms

4. Treat empirically if patient has discharge + lower abdominal tenderness (PID)

5. Educate about:

   • Condom use

   • Completing antibiotics

   • Partner treatment (for STIs)

   • Avoiding douching and irritants
     

---

🧘 Prevention & Counseling

• Promote safe sex practices (consistent condom use)

• Regular STI screening for sexually active women <25 years

• Avoid vaginal douching (disrupts normal flora)

• Maintain good genital hygiene (use mild soap, avoid perfumed products)

• Encourage partner notification and treatment for STIs

---

📋 Conclusion

Abnormal vaginal discharge is a symptom, not a diagnosis. The color, consistency, odor, and associated symptoms provide valuable diagnostic clues. A systematic evaluation — history, pelvic exam, microscopy, and targeted lab testing — is essential for accurate diagnosis and appropriate treatment. Early management prevents complications like PID, infertility, and ectopic pregnancy, improving reproductive health outcomes.