Management of Leukorrhoea Without Vaginitis
When leukorrhoea (white vaginal discharge) occurs without signs of vaginitis (no inflammation, normal pH, no pathogens on microscopy), no antimicrobial treatment is indicated—this represents physiologic discharge or noninfectious irritation that requires reassurance and identification of potential irritants rather than antibiotics. 1
Diagnostic Confirmation
Before concluding that leukorrhoea is non-pathologic, you must systematically exclude infectious causes:
Essential Testing
- Vaginal pH measurement: Normal vaginal pH is 3.8-4.5; pH >4.5 suggests bacterial vaginosis or trichomoniasis 1, 2
- Wet mount microscopy with saline: Look for motile trichomonads or clue cells (their absence doesn't completely exclude infection) 1
- KOH preparation: Identifies yeast/pseudohyphae of Candida species 1
- Whiff test: Fishy amine odor with KOH application indicates bacterial vaginosis 1
Key Clinical Finding
The presence of objective signs of vulvar inflammation in the absence of vaginal pathogens, along with minimal discharge, suggests mechanical, chemical, allergic, or other noninfectious irritation rather than infection. 1
When Leukorrhoea Alone May Be Significant
Cervicitis Consideration
- Leukorrhoea (>10 WBCs per high-power field on vaginal fluid microscopy) can indicate cervical inflammation even without vaginitis 1
- If cervicitis is suspected (mucopurulent endocervical discharge, easily induced endocervical bleeding), test for Chlamydia trachomatis and Neisseria gonorrhoeae using nucleic acid amplification testing (NAAT) 1
- Also evaluate for bacterial vaginosis and trichomoniasis in this context 1
Physiologic Discharge
- Normal vaginal discharge varies with menstrual cycle, sexual arousal, and pregnancy 3, 4
- The normal vaginal environment is dominated by H₂O₂-producing Lactobacillus species maintaining pH 3.8-4.2 2
Management Approach
For Confirmed Non-Infectious Leukorrhoea
Primary intervention is identification and elimination of irritants:
- Discontinue douching (associated with bacterial vaginosis risk) 5
- Avoid scented soaps, bubble baths, feminine hygiene sprays 3
- Switch to hypoallergenic laundry detergents 3
- Consider latex allergy if symptoms correlate with condom use 3
When Testing Fails to Identify a Cause
- Laboratory testing fails to identify the cause of vaginitis in a substantial minority of women 1
- In these cases, empiric antimicrobial therapy is inappropriate and may lead to more frequent return visits 6
- A study of 290 symptomatic women found that 34% without infectious vaginitis were inappropriately prescribed antibiotics/antifungals, and those treated empirically had significantly more recurrent visits within 90 days (P=0.02) 6
Critical Pitfalls to Avoid
Do Not Treat Empirically
- 42% of women with vaginitis symptoms in community practice received inappropriate treatment 6
- Women without infections who received empiric treatment were more likely to have recurrent visits within 90 days 6
- Unnecessary antibiotic use disrupts normal vaginal flora and may precipitate actual infections 3, 4
Do Not Assume All Discharge Is Pathologic
- Up to 50% of women meeting clinical criteria for bacterial vaginosis are asymptomatic 1, 5
- Physiologic discharge is common and requires no treatment 3, 4
Consider Atrophic Vaginitis in Appropriate Populations
- Postmenopausal women or those with estrogen deficiency may have vaginal dryness, irritation, and discharge 3, 7
- This requires hormonal (systemic or topical estrogen) or nonhormonal therapies, not antimicrobials 3, 7
Special Considerations
If Symptoms Persist Despite Negative Testing
- Re-evaluate for noninfectious inflammatory vaginitis (may respond to topical clindamycin and steroids) 3
- Consider referral to gynecology for further evaluation 3
- Microbiological culture may be warranted if clinical suspicion remains high despite negative microscopy 2