What questions should I ask a female patient with recurrent vaginal discharge?

Essential Questions for Recurrent Vaginal Discharge

For a patient with recurrent vaginal discharge, you must systematically assess symptom characteristics, sexual history, hygiene practices, medical conditions, and medication use to differentiate between bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis—the three most common infectious causes. 1

Symptom Characterization

Discharge Characteristics

• Color and consistency: White, thick, cottage cheese-like discharge suggests candidiasis; thin, homogeneous white discharge indicates bacterial vaginosis; yellow-green, frothy discharge points to trichomoniasis 2, 1
• Odor: A fishy or amine odor strongly suggests bacterial vaginosis or trichomoniasis, while candidiasis typically has minimal odor 2, 1
• Volume: Profuse discharge is significantly associated with infectious causes, particularly trichomoniasis 3

Associated Symptoms

• Vulvar itching: Highly suggestive of vulvovaginal candidiasis but can occur with any infection 2, 3
• Burning with urination (external dysuria): Common with candidiasis due to vulvar inflammation 2
• Dyspareunia (painful intercourse): Significantly associated with infectious vaginal discharge 3
• Lower abdominal pain: May indicate ascending infection or concurrent cervicitis from chlamydia or gonorrhea 3, 4

Recurrence Pattern Assessment

Frequency and Timing

• Number of episodes in past 12 months: Three or more symptomatic episodes defines recurrent vulvovaginal candidiasis (RVVC), which affects up to 9% of women 5
• Relationship to menstrual cycle: Candidiasis often worsens premenstrually 2
• Timing relative to sexual activity: Important for assessing trichomoniasis risk 2
• Response to previous treatments: Partial or temporary relief suggests incorrect diagnosis, resistant organisms, or reinfection 6, 5

Sexual and Partner History

Sexual Practices

• Number of sexual partners: Multiple partners increases risk of bacterial vaginosis and trichomoniasis 2, 6
• New sexual partner: Relevant for sexually transmitted infections including trichomoniasis 2
• Partner symptoms: Male partners with trichomoniasis may be asymptomatic but require treatment 2, 1
• Condom use: Inconsistent use increases STI risk 2

Critical caveat: While bacterial vaginosis is associated with sexual activity, treating male partners does not prevent recurrence and is not recommended 6

Medical History and Risk Factors

Underlying Conditions

• Diabetes mellitus status and control: Uncontrolled diabetes significantly increases susceptibility to recurrent candidiasis 5
• HIV status or immunosuppression: Major risk factor for RVVC, though treatment regimens remain the same 5
• Pregnancy status: Increases risk of vulvovaginal candidiasis 5

Medication History

• Recent antibiotic use: Frequently triggers candidiasis by disrupting normal vaginal flora 2
• Corticosteroid use: Risk factor for recurrent candidiasis 5
• Oral contraceptive use: May increase yeast infection frequency 7
• Immunosuppressive medications: Increase RVVC risk 5

Hygiene and Behavioral Practices

Practices That Alter Vaginal Flora

• Douching frequency: Associated with bacterial vaginosis and disrupts protective lactobacilli 2, 6
• Use of scented products: Soaps, bubble baths, or feminine hygiene sprays can cause irritation mimicking infection 4
• Type of underwear and clothing: Tight, non-breathable fabrics may contribute to candidiasis 7

Previous Diagnostic Testing

Prior Evaluations

• What specific tests were performed: pH testing, wet mount, culture, or only clinical diagnosis 1, 8
• Were cultures obtained: Essential for recurrent cases to identify non-albicans Candida species or confirm diagnosis 5
• Results of previous testing: Helps determine if empiric treatment was appropriate 6

Important pitfall: Many women with recurrent symptoms receive repeated empiric treatment without confirmatory testing, leading to misdiagnosis and inappropriate therapy 5, 9

Red Flag Symptoms Requiring Further Investigation

Concerning Features

• Postcoital or intermenstrual bleeding: May indicate cervicitis from chlamydia/gonorrhea or, rarely, cervical malignancy 4, 10
• Pelvic pain: Suggests possible pelvic inflammatory disease requiring different management 3
• Persistent discharge despite multiple treatments: Consider non-infectious causes including atrophic vaginitis, desquamative inflammatory vaginitis, or rarely cervical adenocarcinoma 4, 10
• Systemic symptoms: Fever or constitutional symptoms suggest ascending infection 2

Treatment Failure Assessment

For Recurrent Cases

• Compliance with previous regimens: Single-dose metronidazole has lower cure rates (84%) than 7-day treatment (95%) for bacterial vaginosis 6
• Alcohol consumption during metronidazole: Can cause severe reactions and should be avoided during treatment and 24 hours after 1, 6
• Partner treatment for trichomoniasis: Simultaneous partner treatment is essential to prevent reinfection 1

Key distinction: Bacterial vaginosis recurrence does not require partner treatment, while trichomoniasis absolutely does 6, 1