CASE Mrs Ford is a 29 years old lady who has been complaining of vaginal discharge for the past 3 days. Otherwise she is asymptomatic. Her PMH includes bronchial asthma. Her cycles are normally regular with no issues. She has been with her current partner for few months. ON examination there was no significant findings. What do you want to know more? What is your differential? What investigations would you like to do, if any? What are the treatment options? What is your plan if this is a recurrent problem? Can you suggest any preventive measures?

Causes Foreign bodies, e.g. retained tampon Vulval dermatitis Non-infective: Physiological Cervical polyps and ectopy Foreign bodies, e.g. retained tampon Vulval dermatitis Erosive lichen planus Genital tract malignancy Fistulae Non-sexually transmitted infection: Bacterial vaginosis Candida Sexually transmitted infection: Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis

Assessment A full clinical and sexual history Nature of the discharge: odour, onset, duration, colour. Associated symptoms: itch, dyspareunia, dysuria, abdominal pain, abnormal bleeding, pyrexia. Medications: antibiotics, steroids PMH: DM, immunocompromised state. Investigations: Triple swaps, vaginal pH testing (Candida and bacterial vaginosis can be diagnosed clinically and treated without sampling)

Bacterial Vaginosis May be asymptomatic (in up to 50% of women) Thin, profuse and fishy smelling discharge without itch or soreness Associated with poor pregnancy outcomes, endometritis after miscarriage, and pelvic inflammatory disease Asymptomatic bacterial vaginosis in non-pregnant women does not require treatment. Routine: oral metronidazole for 5-7 days or stat 2gm dose. Alternatively topical metronidazole or oral clindamycin or topical clindamycin. 70-80 % cure rate but commonly recurs

Candidiasis Thick, white, non-offensive discharge which is associated with vulval itch and soreness. May cause mild dyspareunia and external dysuria Examination may be normal or there may be erythema, oedema and fissuring pH is less than 4.5 Asymptomatic vulvovaginal candidiasis does not need treatment. Vaginal imidazole: clotrimazole, econazole, miconazole or fluconazole 150 mg orally (avoid in pregnancy) 80-95 % cure rate.

Infective (STD) vaginal discharge Can present with vaginal discharge but may also be asymptomatic. Associated with an increased risk of HIV transmission. May be complicated by PID. Trichomonas vaginalis: Offensive yellow vaginal discharge, which is often profuse and frothy, with vulval itch and soreness, dysuria, abdominal pain and superficial dyspareunia Is associated with preterm delivery Chlamydia trachomatis: Copious purulent vaginal discharge, but it is asymptomatic in 80% of women Diagnosis is confirmed on swabbing Neisseria gonorrhoeae: Purulent vaginal discharge but is asymptomatic in up to 50% of women Mild symptoms include slight discharge, dysuria, intermenstrual bleeding

Treatment (infective STD discharge) Refer to the GUM clinic (unless your practice has the appropriate expertise). Chlamydia trachomatis; doxycyclin or azithromycin Gonorrhoea; cefixime or ceftriaxone Trichomonas vaginalis; metronidazole Patients will be fully screened for concurrent STDs and treated as appropriate. Partners will need to be identified, screened and treated too.

Recurrent discharge Ensure pathology hasn't been missed (e.g. an STD in the case of a patient being treated for bacterial vaginosis). Explore personal hygiene (douches, perfumed products and tight synthetic clothing) If the patient has coil in situ, consider alternative. Think of diabetes, immunosuppression or antibiotic administration. Consider the 'silent' complaint: depression, anxiety or psychosexual dysfunction. Post-menopausal atrophic changes may predispose women to recurrent vaginitis.