What is the approach to managing leucorrhea (vaginal discharge)?

Approach to Managing Leucorrhea (Vaginal Discharge)

Initial Diagnostic Evaluation

The cornerstone of managing leucorrhea is performing vaginal pH testing and wet mount microscopy to differentiate between the three most common causes: bacterial vaginosis (BV), trichomoniasis, and vulvovaginal candidiasis (VVC). 1

Key Diagnostic Steps

• Measure vaginal pH using narrow-range pH paper: elevated pH >4.5 indicates BV or trichomoniasis, while pH <4.5 suggests candidiasis 1, 2

• Perform wet mount microscopy by diluting vaginal discharge in 1-2 drops of 0.9% normal saline on one slide and 10% KOH on a second slide 1

• Apply the "whiff test": an amine (fishy) odor immediately after applying KOH suggests BV or trichomoniasis 1

• Examine saline preparation under microscope for motile Trichomonas vaginalis or clue cells characteristic of BV 1

• Examine KOH preparation for yeast or pseudohyphae of Candida species 1

• Check for leukorrhea (>10 WBCs per high-power field), which is associated with cervical infection from Chlamydia trachomatis or Neisseria gonorrhoeae and has high negative predictive value when absent 1, 3

Treatment Based on Diagnosis

Bacterial Vaginosis

• Metronidazole 500 mg orally twice daily for 7 days is the first-line treatment 2
• Alternative regimens include metronidazole gel or clindamycin preparations 2

Trichomoniasis

• Metronidazole 2 g orally as a single dose is the recommended treatment 1, 2
• Alternative: Tinidazole 2 g orally as a single dose 1
• Treat all sexual partners within the preceding 60 days to prevent reinfection 1, 2
• Advise abstinence from sexual intercourse until therapy is completed and both patient and partner are asymptomatic 1

Vulvovaginal Candidiasis (Uncomplicated)

For uncomplicated VVC, short-course topical azole therapy (1-3 days) or oral fluconazole 150 mg as a single dose are equally effective, achieving 80-90% cure rates. 1

Recommended regimens include:

• Fluconazole 150 mg oral tablet as a single dose (most convenient) 1
• Clotrimazole 500 mg vaginal tablet as a single application 1
• Miconazole 200 mg vaginal suppository for 3 days 1
• Multiple other intravaginal azole options available over-the-counter 1

Important caveat: Oil-based creams and suppositories may weaken latex condoms and diaphragms 1

Complicated VVC (Recurrent, Severe, or Non-albicans)

• Requires longer initial therapy (7-14 days of topical azole) 1
• Maintenance therapy with fluconazole 150 mg weekly for 6 months is recommended for recurrent VVC (≥4 episodes per year) 1, 2

Cervicitis (When Leukorrhea Present)

• If leukorrhea is detected (>10 WBCs per high-power field), consider cervical infection with C. trachomatis or N. gonorrhoeae 1, 3
• Test for gonorrhea and chlamydia using nucleic acid amplification tests 1
• Empiric treatment may be appropriate in high-risk patients with uncertain follow-up 3

Special Populations

Pregnancy

• Only 7-day topical azole therapies are recommended for VVC in pregnant women; avoid oral fluconazole 1
• Symptomatic trichomoniasis can be treated with metronidazole 2 g single dose (no teratogenic effects demonstrated) 1
• Pregnant women with suspected pelvic inflammatory disease require hospitalization and parenteral antibiotics 1

HIV-Infected Patients

• Treatment regimens for BV, trichomoniasis, and VVC are the same as for HIV-negative patients 1

Follow-Up Recommendations

• For BV and trichomoniasis: Follow-up unnecessary if symptoms resolve 2
• For VVC: Return only if symptoms persist or recur within 2 months 1, 2
• Persistent symptoms after appropriate treatment warrant re-evaluation for alternative diagnoses, treatment failure, or reinfection 1

Common Pitfalls to Avoid

• Never treat empirically without proper diagnosis using pH and microscopy 2
• Do not rely on symptoms alone—they overlap significantly between conditions 1
• Avoid treating asymptomatic Candida colonization (10-20% of women harbor Candida without symptoms) 1
• Mixed infections are common—treat all identified pathogens 2
• Self-medication with over-the-counter preparations should only be advised for women previously diagnosed with VVC who have recurrent identical symptoms 1
• In settings with uncertain follow-up, leukorrhea on wet mount strongly predicts cervical STDs and may warrant empiric antibiotic therapy 3
• Always test for concurrent STDs (syphilis, HIV) when sexually transmitted infections are diagnosed 1