What are the guidelines for management of leukorrhea (white discharge)?

Guidelines for Management of White Discharge (Leukorrhea)

The management of white vaginal discharge should focus on identifying the specific cause through diagnostic testing and providing appropriate treatment based on the etiology, with bacterial vaginosis being the most common cause requiring metronidazole therapy. 1, 2

Diagnostic Approach

Clinical Evaluation

• White discharge should be evaluated using pH testing, microscopic examination, and amine odor testing to determine the specific cause 1
• Three common causes of white discharge include bacterial vaginosis (BV), vulvovaginal candidiasis, and trichomoniasis 2, 3

Laboratory Testing

• Perform pH testing using narrow-range pH paper (elevated pH >4.5 suggests BV or trichomoniasis) 1
• Prepare two microscopic slides:
  • Saline wet mount: Mix discharge with 1-2 drops of 0.9% normal saline to identify motile T. vaginalis or clue cells of BV 1
  • KOH preparation: Mix discharge with 10% potassium hydroxide to identify yeast or pseudohyphae of Candida species 1
• Perform "whiff test" by adding 10% KOH to discharge sample - a fishy amine odor suggests BV 1

Diagnostic Criteria for Bacterial Vaginosis

BV is diagnosed when three of the following clinical criteria are present:

• Homogeneous, white, non-inflammatory discharge coating vaginal walls 1
• Presence of clue cells on microscopic examination 1
• Vaginal fluid pH >4.5 1
• Fishy odor before or after addition of 10% KOH (positive whiff test) 1

Alternatively, Gram stain with Nugent scoring is an acceptable laboratory method for diagnosing BV 1

Treatment Guidelines

Bacterial Vaginosis Treatment

For symptomatic BV, the recommended regimen is:

• Metronidazole 500 mg orally twice daily for 7 days 1

Alternative regimens include:

• Metronidazole 2 g orally in a single dose 1
• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1
• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, twice daily for 5 days 1
• Clindamycin 300 mg orally twice daily for 7 days 1

Important precaution: Patients should avoid alcohol during metronidazole treatment and for 24 hours afterward 1

Special Considerations

• Only women with symptomatic BV require treatment 1
• Treatment of male partners is not recommended as it has not been shown to prevent recurrence 1
• Consider treating asymptomatic BV before surgical abortion procedures to reduce risk of post-abortion PID 1
• For pregnant women at high risk for preterm delivery who have BV, treatment may reduce the risk of prematurity 1

Management of Other Common Causes of White Discharge

Vulvovaginal Candidiasis

• Characterized by pruritus and cottage cheese-like discharge 2
• Diagnosis confirmed by identification of yeast or pseudohyphae in KOH preparation 1
• Caution against self-diagnosis and over-the-counter treatment which may lead to increasing resistance of Candida species to imidazoles 4

Trichomoniasis

• Presents with copious yellow/green frothy discharge 2
• Diagnosis confirmed by identification of motile T. vaginalis in saline wet mount or by culture 1
• Culture for T. vaginalis is more sensitive than microscopic examination 1

Common Pitfalls to Avoid

• Relying solely on clinical symptoms without laboratory confirmation can lead to misdiagnosis 2, 5
• Self-diagnosis and inappropriate use of over-the-counter antifungal medications may delay diagnosis of other conditions like BV or STIs 4
• Not all vaginal discharge is pathological; physiological discharge accounts for approximately 9.5% of cases 3
• Failure to identify the specific cause may result in inappropriate treatment and persistent symptoms 2, 6
• Culture of G. vaginalis is not recommended for BV diagnosis as it is not specific (can be isolated from vaginal cultures in about half of normal women) 1