What is the appropriate management for a patient with vaginal discharge and their sexual partner?

Management of Vaginal Discharge and Sexual Partners

Sexual partners of patients with vaginal discharge should be notified, examined, and treated for the specific sexually transmitted infection identified or suspected in the index patient. 1

Diagnostic Approach to Vaginal Discharge

Proper management begins with accurate diagnosis of the underlying cause:

1. Clinical assessment:

   • Evaluate characteristics of discharge (color, consistency, odor)
   • Check for associated symptoms (itching, burning, pain)
   • Assess risk factors for STIs

2. Laboratory evaluation:

   • Measure vaginal pH using narrow-range pH paper
     • pH >4.5 suggests bacterial vaginosis (BV) or trichomoniasis
     • pH ≤4.5 suggests candidiasis or normal flora 2
   • Microscopic examination:
     • Saline wet mount to identify clue cells (BV) or motile trichomonads
     • 10% KOH preparation to identify yeast or pseudohyphae 1
   • Whiff test: Fishy odor after adding 10% KOH suggests BV 2
   • Testing for Chlamydia and Gonorrhea in at-risk patients

Common Causes and Management

1. Bacterial Vaginosis (BV)

• Characteristics: Thin, homogeneous, white discharge with fishy odor, pH >4.5, clue cells on microscopy
• Treatment:
  • Metronidazole 500mg orally twice daily for 7 days (95% cure rate) 2
  • Alternative: Metronidazole gel 0.75% intravaginally once daily for 5 days
  • Alternative: Clindamycin cream 2% intravaginally at bedtime for 7 days

2. Vulvovaginal Candidiasis

• Characteristics: Thick, white "cottage cheese" discharge, normal pH (≤4.5), intense itching
• Treatment:
  • Topical azoles (clotrimazole 1% cream or miconazole 2% cream) OR
  • Fluconazole 150mg oral single dose 2
  • For recurrent cases (≥4 episodes in 12 months): Initial intensive therapy followed by maintenance

3. Trichomoniasis

• Characteristics: Yellow/green frothy discharge, pH >4.5, motile trichomonads on wet mount
• Treatment:
  • Metronidazole 500mg orally twice daily for 7 days 3
  • Partner treatment is essential to prevent reinfection 3

4. Chlamydia/Gonorrhea

• Characteristics: May present with mucopurulent cervical discharge
• Testing: Nucleic acid amplification tests
• Treatment: According to current guidelines for these specific infections
• Partner treatment is mandatory 1

Management of Sexual Partners

The approach to partner management depends on the identified pathogen:

1. For STIs (Trichomoniasis, Chlamydia, Gonorrhea):

   • All sexual partners must be notified, examined, and treated 1, 3
   • For trichomoniasis: Treat all partners, even if asymptomatic, to prevent reinfection 3
   • For Chlamydia/Gonorrhea: Partner notification and treatment is essential to prevent reinfection and complications 1

2. For Bacterial Vaginosis:

   • Routine treatment of male partners is not recommended by CDC guidelines
   • However, consistent condom use may help prevent recurrence 2

3. For Vulvovaginal Candidiasis:

   • Partner treatment is not recommended unless the partner has symptomatic balanitis/balanoposthitis 2

Follow-up Recommendations

• Patients should abstain from sexual intercourse until:

  • Treatment is completed (7 days after single-dose regimen or after completion of a 7-day regimen)
  • Both patient and partner(s) are symptom-free 1

• Follow-up visits generally not needed unless:

  • Symptoms persist or recur
  • Pregnancy is involved (follow-up one month after treatment completion) 2

Important Considerations

• Patients using metronidazole should avoid alcohol during treatment and for 24 hours after 2
• Clindamycin cream can weaken latex condoms and diaphragms 2
• Self-medication with over-the-counter preparations should only be advised for women previously diagnosed with vulvovaginal candidiasis who experience recurrence of the same symptoms 2

Pitfalls to Avoid

1. Failing to test and treat partners for STIs, which can lead to reinfection and persistent symptoms
2. Treating empirically without proper diagnosis, which may lead to inappropriate therapy
3. Not considering mixed infections, which are common and may require multiple treatments
4. Overlooking the possibility of pelvic inflammatory disease in women with upper genital tract symptoms

By following this structured approach to diagnosis and ensuring appropriate partner management, healthcare providers can effectively treat vaginal discharge and prevent recurrence or complications.