How should leucorrhoea be treated?

Treatment of Leucorrhoea (Vaginal Discharge)

Leucorrhoea requires identification of the underlying cause through clinical examination and testing, followed by targeted antimicrobial therapy for infectious etiologies or hormonal management for atrophic causes.

Initial Diagnostic Approach

The three most common infectious causes account for >90% of cases when a pathogen is identified 1, 2:

• Bacterial vaginosis (BV): 40-50% of cases 2
• Vulvovaginal candidiasis: 20-25% of cases 2
• Trichomoniasis: 15-20% of cases 2
• Noninfectious causes: 5-10% (atrophic, irritant, allergic, inflammatory) 2

Key Clinical Features to Assess

Vaginal pH measurement is essential for narrowing the differential 2, 3:

• pH 3.8-4.5: Suggests vulvovaginal candidiasis 1, 4
• pH >4.5: Suggests bacterial vaginosis or trichomoniasis 1, 3
• pH >5.4: More specific for trichomoniasis 4

Microscopic examination of vaginal discharge 2, 3:

• 10% KOH preparation: Reveals hyphae or budding yeast in 50-70% of candidiasis cases 1, 3
• Saline wet mount: Shows motile trichomonads (50-75% sensitivity), clue cells (BV), or inflammatory cells 1, 3

Whiff test (fishy odor with KOH application): Positive in BV and trichomoniasis 3, 4

Treatment by Specific Etiology

Bacterial Vaginosis

Diagnosis requires 3 of 4 Amsel criteria 5, 3:

• Homogenous noninflammatory discharge
• pH >4.5
• Clue cells (>20% of epithelial cells)
• Positive whiff test

First-line treatment 5, 2:

• Oral metronidazole 500 mg twice daily for 7 days (preferred) 5, 2
• Alternative: Intravaginal metronidazole gel or intravaginal/oral clindamycin 5, 2

For recurrent BV: Longer courses of therapy are recommended 5

Vulvovaginal Candidiasis

Uncomplicated candidiasis (90% of cases) 6:

• Topical azole therapy for 1-7 days OR oral fluconazole 150 mg single dose achieve >90% response rates 6, 7
• Both routes are equally effective 5, 3
• Clotrimazole options 8:
  • 1% vaginal cream for 7-14 days
  • 100 mg vaginal tablets for 7 days
  • 10 mg lozenges five times daily for 7-14 days (for oropharyngeal involvement)

Complicated candidiasis (10% of cases) requires >7 days of therapy 6, 5:

• Includes severe symptoms, non-albicans species, immunocompromised hosts, uncontrolled diabetes, pregnancy 6

Recurrent vulvovaginal candidiasis (≥4 episodes/year) 5, 1:

• Initial therapy followed by maintenance with oral fluconazole 150 mg weekly for up to 6 months 5
• Alternative: Fluconazole 150 mg weekly for up to 12 consecutive weeks 1

Candida glabrata infections (10-20% of recurrent cases) 9:

• First-line: Intravaginal boric acid 600 mg daily for 14 days (strong recommendation) 9
• Achieves 70-77% clinical and mycological cure 9
• Avoid fluconazole monotherapy due to intrinsic resistance 9
• Alternatives: Nystatin suppositories 100,000 IU daily for 14 days OR topical 17% flucytosine cream ± 3% amphotericin B cream for 14 days 9

Trichomoniasis

Diagnosis 6, 2:

• Nucleic acid amplification testing (NAAT) is recommended by CDC for symptomatic or high-risk women 2
• Clinical features: Foul, frothy discharge; pH >4.5; punctate cervical microhemorrhages (25%); motile trichomonads on wet mount (50-75% sensitivity) 1

Treatment 5, 2:

• Oral metronidazole 2 g single dose OR 500 mg twice daily for 7 days (equal 88% cure rates) 5
• Alternative: Oral tinidazole 2
• Partner treatment is mandatory even without screening to enhance cure rates 5, 2
• Test of cure is not recommended after standard therapy 5

Treatment-resistant cases: Higher-dose metronidazole therapy may be needed 5

In pregnancy: Treatment with oral metronidazole is warranted for prevention of preterm birth 5

Atrophic Vaginitis

Clinical presentation: Vaginal dryness, itching, irritation, discharge, dyspareunia due to estrogen deficiency 2, 4

Treatment: Both systemic and topical estrogen treatments are effective 4

Important Clinical Caveats

Partner treatment considerations 7:

• Not routinely recommended for candidiasis, as it does not alter clinical course or relapse rates 7
• Exception: Male partners with symptomatic balanitis may benefit from topical antifungal therapy 7
• Mandatory for trichomoniasis to prevent reinfection 5, 2

Pregnancy considerations 5, 3:

• Only topical azoles are recommended for candidiasis during pregnancy 2
• Oral metronidazole is safe and indicated for symptomatic trichomoniasis 5

Culture indications 2, 3:

• Recurrent or complicated vulvovaginal candidiasis to identify non-albicans species 2, 3
• Negative microscopy with persistent symptoms 9
• Suspected C. glabrata (does not form pseudohyphae/hyphae on microscopy) 9

Common pitfall: Approximately 10-20% of women harbor Candida species asymptomatically; colonization does not equal infection and does not require treatment 7