What is the management approach for vaginal discharge in women?

Management of Vaginal Discharge in Women

The management of vaginal discharge requires immediate diagnostic evaluation with vaginal pH measurement and microscopic examination to differentiate between the three most common causes—bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis—followed by targeted antimicrobial therapy based on specific diagnostic findings. 1

Diagnostic Algorithm

Step 1: Measure Vaginal pH

• pH >4.5 indicates bacterial vaginosis or trichomoniasis, while pH ≤4.5 suggests vulvovaginal candidiasis 2, 1
• Use narrow-range pH paper applied directly to vaginal secretions 2

Step 2: Perform Microscopic Examination

• Saline wet mount: Mix discharge with 1-2 drops of 0.9% normal saline to identify motile trichomonads (trichomoniasis) or clue cells (bacterial vaginosis) 2, 1
• KOH preparation: Mix discharge with 10% KOH to identify yeast or pseudohyphae (candidiasis) and perform the whiff test 2, 1
• Positive whiff test (fishy odor immediately after KOH application) confirms bacterial vaginosis or trichomoniasis 2

Step 3: Apply Clinical Criteria

For Bacterial Vaginosis (Amsel Criteria—need 3 of 4):

• Homogeneous white discharge adhering to vaginal walls 2, 1
• Clue cells on microscopy 2, 1
• Vaginal pH >4.5 2, 1
• Positive whiff test 2, 1

For Vulvovaginal Candidiasis:

• Vulvar itching, irritation, burning, and white discharge 1
• Identification of yeast or pseudohyphae on KOH preparation 2, 1

For Trichomoniasis:

• Yellow-green discharge with malodor 1
• Motile trichomonads on saline wet mount 2, 1

Treatment Protocols

Bacterial Vaginosis

• Metronidazole 500 mg orally twice daily for 7 days is the preferred regimen 1, 3
• Alternative: Metronidazole single-dose regimen (though 7-day achieves 95% cure rate vs. 84% for single-dose) 4
• Do not treat male partners—this does not prevent recurrence or alter clinical course 2, 5
• Critical warning: Patients must avoid alcohol during treatment and for 24 hours after completion due to disulfiram-like reaction 4

Vulvovaginal Candidiasis

• Fluconazole 150 mg orally as a single dose is the standard treatment, achieving 55% therapeutic cure rate 6
• Alternative: Intravaginal agents (clotrimazole, miconazole, terconazole, butoconazole, or tioconazole) for 7 days 1
• For recurrent cases (≥4 episodes/year): Initial 7-14 day course followed by fluconazole 150 mg weekly for 6 months maintenance therapy 5
• Do not treat asymptomatic Candida colonization—10-20% of women have vaginal Candida without symptoms and require no treatment 1, 5

Trichomoniasis

• Metronidazole single 2-gram dose is the standard treatment 1, 7
• Mandatory partner treatment to prevent reinfection—this is a sexually transmitted infection 1, 3, 7
• Treat asymptomatic male partners even with negative cultures, as organism isolation from males is difficult 3

Special Populations

Pregnant Women

• Use only 7-day topical treatments for bacterial vaginosis and candidiasis 5
• Avoid oral fluconazole—use birth control during treatment and for 1 week after if pregnancy is possible 6

HIV-Infected Women

• Treat with the same regimens as non-HIV-infected women 5

Post-Abortion or Post-Procedure

• Treat bacterial vaginosis immediately with metronidazole 500 mg twice daily for 7 days, even without confirmed diagnosis, as BV significantly increases risk of endometritis, PID, and vaginal cuff cellulitis 4
• BV bacteria have been recovered from endometrium and fallopian tubes of women with PID following uterine procedures 2, 4

Critical Pitfalls to Avoid

• Never recommend vaginal douching—this disrupts normal lactobacilli flora and increases infection risk 1, 5
• Do not allow self-medication except for women previously diagnosed with candidiasis experiencing identical symptoms 1, 5
• Do not treat based on symptoms alone—pH and microscopy are essential as symptoms overlap significantly between conditions 2, 1
• Do not treat asymptomatic bacterial vaginosis in non-pregnant women unless undergoing invasive uterine procedures 2
• Do not culture for Gardnerella vaginalis—it is present in 50% of normal women and is not specific 2

When Diagnosis Remains Unclear

• Culture for Trichomonas vaginalis is more sensitive than microscopy when clinical suspicion is high 2
• Culture for Candida species is more sensitive than microscopy but less specific for diagnosing symptomatic vaginitis 2
• Consider cervicitis from Chlamydia trachomatis or Neisseria gonorrhoeae if mucopurulent cervical discharge is present 2
• Laboratory testing fails to identify a cause in a substantial minority of women—consider mechanical, chemical, or allergic vulvar irritation if objective vulvar inflammation exists without vaginal pathogens 2

Follow-Up

• Return only if symptoms persist or recur within 2 months 1, 5
• Routine test-of-cure is not necessary if symptoms resolve 4
• Recurrence of bacterial vaginosis is common (50-80% within one year) but does not change initial management 4