Treatment of Leucorrhoea
Leucorrhoea treatment must be guided by identifying the underlying cause through clinical examination and laboratory testing, with specific antimicrobial therapy directed at the identified pathogen rather than empiric treatment of discharge alone.
Diagnostic Approach
The key to effective treatment is accurate diagnosis. Examine the discharge characteristics and perform:
- Vaginal pH testing (normal <4.5 suggests candidiasis; >4.5 suggests bacterial vaginosis or trichomoniasis)
- Wet mount microscopy with saline and 10% KOH to identify yeasts, pseudohyphae, clue cells, or trichomonads
- Whiff test (fishy odor with KOH suggests bacterial vaginosis)
- Vaginal culture when microscopy is negative or for recurrent cases 1
Treatment by Etiology
Vulvovaginal Candidiasis (VVC)
For uncomplicated VVC (sporadic, mild-to-moderate, likely C. albicans):
- First-line options include either:
- Fluconazole 150 mg oral single dose, OR
- Short-course topical azoles (1-3 days): clotrimazole, miconazole, terconazole, or butoconazole intravaginally 1
These regimens achieve 80-90% cure rates 1. The oral option offers convenience, while topical agents avoid systemic side effects.
For complicated VVC:
Severe disease (extensive erythema, edema, excoriation, fissures): Use 7-14 days of topical azole OR fluconazole 150 mg repeated 72 hours later 1
Recurrent VVC (≥4 episodes/year): Obtain vaginal cultures to identify non-albicans species. Treat acute episode with longer therapy (7-14 days topical or fluconazole 150 mg repeated after 3 days), then initiate 6-month maintenance with fluconazole 100-150 mg weekly, clotrimazole 500 mg vaginal suppository weekly, or alternatives 1
Non-albicans VVC: Use 7-14 days of non-fluconazole azole. If recurrent, consider boric acid 600 mg vaginal capsules daily for 2 weeks (70% eradication rate) 1
Pregnancy: Only 7-day topical azole therapy is recommended 1
Immunocompromised/diabetes: Correct underlying conditions and use prolonged 7-14 day therapy 1
Bacterial Vaginosis
While not explicitly detailed in the provided guidelines, the evidence indicates Gardnerella vaginalis is the most common cause (47% of cases) with 100% treatment success rates when appropriately treated 2. Standard treatment follows CDC guidelines with metronidazole or clindamycin regimens.
Trichomoniasis
Recommended treatment:
- Metronidazole 2 g oral single dose achieves 90-95% cure rates 3
- Treat sexual partners concurrently to prevent reinfection
- Instruct patients to avoid sexual intercourse until both partners are cured 3
In pregnancy: Symptomatic women may be treated with metronidazole 2 g single dose to relieve symptoms, though data do not show this lessens adverse pregnancy outcomes 1
Chlamydia and Gonorrhea
When cervical infection is identified, treat according to CDC STD guidelines with appropriate antibiotics. Note that treatment failure rates are higher for C. trachomatis (57% in one study) 2, emphasizing the importance of test-of-cure.
Critical Management Points
Partner management:
- VVC does not require routine partner treatment unless recurrent infection occurs 1
- Trichomoniasis requires concurrent partner treatment 3
- STDs require partner notification and treatment
Follow-up:
- Return only if symptoms persist or recur within 2 months 1
- For recurrent VVC, obtain cultures to identify resistant or non-albicans species 1
Common pitfalls:
- Avoid treating asymptomatic Candida colonization (10-20% of women) 1
- Do not use short-course therapy for severe or complicated VVC 1
- Recognize that 30-40% of women with recurrent VVC relapse after stopping maintenance therapy 1
- Be aware of drug interactions with oral azoles (warfarin, calcium channel blockers, protease inhibitors, oral hypoglycemics) 1
HIV-infected patients should receive the same treatment regimens as HIV-negative patients for all causes of leucorrhoea 1, 3