Approach to vaginal discharge: Clinical sciences

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Introduction0:00–1:05

Vaginal discharge is one of the most common reasons for patients to present for gynecologic care. Normal physiologic discharge is generally asymptomatic, but abnormal vaginal discharge can cause significant discomfort and pain, can adversely affect daily activities, and has a considerable impact on sexual functioning and self-image.
Normal vaginal discharge is the result of a combination of endocervical and vaginal secretions, sloughing of vaginal epithelial cells, and the presence of normal vaginal flora.
A disruption of these components results in abnormal vaginal discharge, which is associated with vaginal or vulvar irritation, pain, or pruritus.
Common causes of abnormal vaginal discharge include a foreign body in the vagina; vaginal inflammation; and vaginal or cervical infection.Your first step in evaluating a patient who presents with vaginal discharge is a focused history and physical examination.

Focused H&P1:05–1:11

Let's start with an assessment for a foreign body. During history taking, the patient may describe an increase in vaginal discharge and possibly recent sexual activity or tampon use.

Assess for foreign body1:11–2:28

Patients may express concerns about a retained foreign body such as a tampon or condom. However, they may be unaware of the presence of a foreign object or unwilling to disclose the information.
Physical examination will reveal an abnormal, often purulent or even bloody, vaginal discharge and, if a foreign body is present on speculum examination, you have made your diagnosis.Here’s a clinical pearl.
Malodorous purulent vaginal discharge is often caused by retained hygiene products such as tampons, and in prepubertal female patients, fragments of toilet paper are a common culprit.
However, if the foreign body is an item that is unusual or unexpected, make sure to consider and screen for sexual abuse.
If there is no evidence of a foreign body, the next step is to assess for the presence of vaginal inflammation or infection, known as vaginitis, starting with these first three.
Let’s discuss the first possible scenario, physiologic discharge, where you’d actually be ruling out vaginitis. Patients will report a history of increased vaginal discharge without odor, as well as an absence of vaginal or vulvar irritation.

Physiologic discharge2:28–4:06

The physical exam will reveal a white or clear vaginal discharge. In this case, consider physiologic discharge, and obtain samples of the discharge from the vaginal walls and fornices.
Examine the discharge with saline microscopy and test the vaginal pH. If the saline microscopy reveals mature squamous cells and abundant lactobacilli, and the pH is 3.5 to 4.5, those are all normal findings, so you can rule out vaginitis and diagnose physiologic discharge.Here’s a clinical pearl to keep in mind!
Physiologic leukorrhea is a normal condition that typically precedes the onset of menses by 3 to 6 months, and is associated with an otherwise asymptomatic and odorless clear to white vaginal discharge.
A microscopic exam of a swab specimen will reveal an abundance of epithelial cells, which further supports the diagnosis.And another clinical pear!
Poor hygiene and long baths can cause vaginal discharge and irritation, particularly in young patients. Counsel regarding good hygiene practices, including wiping from front to back and wearing cotton underwear; as well as avoiding scented hygiene products and bubble baths.

Bacterial vaginosis4:06–5:28

Now let’s discuss bacterial vaginosis, which is the most common cause of abnormal vaginal discharge. Keep in mind this is not a true infection but a dysbiosis, meaning it’s an imbalance of the normal microorganisms in the vagina.
This happens when the normal hydrogen peroxide and lactic acid producing Lactobacillus species are replaced by an overgrowth of anaerobes.
If the patient reports a thin watery discharge with an unpleasant odor, and the physical exam is positive for a thin gray-white vaginal discharge with an amine or “fishy” odor, consider bacterial vaginosis.
Assess for bacterial vaginosis by sampling the vaginal discharge. Perform saline microscopy, looking for clue cells and lactobacilli.
Test the vaginal pH and perform a KOH whiff test. Next, assess for the Amsel criteria, which include thin gray-white vaginal discharge on physical exam; microscopy revealing more than 20% clue cells; vaginal fluid pH greater than 4.5; and a positive KOH whiff test.
If 3 out of the 4 criteria are met, you can diagnose bacterial vaginosis. Our next possible source of vaginitis is vulvovaginal candidiasis, which is the second most common form of vaginitis, after bacterial vaginosis.

Vulvovaginal candidiasis5:28–6:58

It is the result of inflammation of the vagina and vulva due to infection with yeast, most commonly by Candida albicans.
Patients typically report thick, white vaginal discharge and vaginal itching. They may also report associated symptoms of vulvar itching, pain, redness, or swelling.
The physical exam will reveal a thick, white, curd-like vaginal discharge. The vulva may appear erythematous, edematous, and there may be excoriations from scratching that may develop fissures.
With these findings, consider vulvovaginal candidiasis. Sample the vaginal discharge, perform microscopy with 10% KOH, and test the vaginal pH.
It is also possible to send the vaginal discharge for a culture or PCR testing for Candida species. If the KOH microscopy demonstrates pseudohyphae and spores, as well as the presence of many lactobacilli, and the vaginal pH is 3.5 to 4.5; or if the candida culture or PCR testing is positive; the diagnosis is vulvovaginal candidiasis.
Ok, let’s continue on to three other types of vaginitis. Now let’s consider another possibility, such as vaginal trichomoniasis.

Vaginal trichomoniasis6:58–8:47

Unlike bacterial vaginosis and candidiasis, this one is considered a sexually transmitted infection. It's caused by the protozoan parasite, Trichomonas vaginalis.
Many patients with trichomoniasis will be asymptomatic, but the most common history findings include vaginal discharge with odor, vulvar itching, irritation, and dysuria in a patient who has been sexually active.
The physical exam may reveal a yellow, frothy, vaginal discharge as well as vaginal or cervical erythema with petechiae, known as a strawberry cervix.
In this case, consider vaginal trichomoniasis. Again, obtain samples of the vaginal discharge from the vaginal walls and fornices.
Perform saline microscopy, test the vaginal pH, and consider a nucleic acid amplification test, NAAT, for Trichomonas vaginalis.
If the microscopy is positive for motile trichomonads and many polymorphonucleocytes, and the pH is greater than 4.5; or the NAAT is positive; the diagnosis is vaginal trichomoniasis.Here’s a clinical pearl!
The assessment of vaginal discharge is the same in pregnant and non-pregnant patients. However, there is an increase in normal vaginal discharge during pregnancy, commonly called leukorrhea.
And if a pregnant patient presents with a watery vaginal discharge, consider and assess for spontaneous rupture of membranes.

Desquamative inflammatory vaginitis8:47–10:09

In desquamative inflammatory vaginitis, a patient typically reports a yellow, brown vaginal discharge with vaginal and vulvar burning, and possible dyspareunia.
History may reveal a hypoestrogenic state, which can occur in peri- or postmenopausal patients as well as those who are breastfeeding or taking medications that suppress ovarian function.
The physical examination demonstrates vulvar and vaginal erythema and copious vaginal discharge. In this case, consider desquamative inflammatory vaginitis, or DIV.
To test for DIV, perform saline microscopy and test the vaginal pH. If the microscopy is positive for many parabasal cells, many white blood cells, and normal mixed vaginal flora, with a pH >4.5, the diagnosis is desquamative inflammatory vaginitis.Here’s another clinical pearl.
Parabasal cells are immature epithelial cells that are rounded and have a large nucleus to cytoplasm ratio. They are rare in normally estrogenized vaginal epithelium but are common when estrogen levels in the vagina are low and are a marker of a hypoestrogenic state.
Let’s move on to atrophic vaginitis. A patient will report a heavy yellow or watery vaginal discharge as well as symptoms of vaginal dryness, itching, burning, and dyspareunia.

Atrophic vaginitis10:09–11:03

Like DIV, these patients are experiencing a hypoestrogenic state. The exam reveals a yellow, watery, or blood-tinged discharge as well as atrophy of the vagina and vulva.
In this case, consider atrophic vaginitis. To support the diagnosis, perform saline microscopy and test the vaginal pH.
If the microscopy demonstrates parabasal cells, few white blood cells, and decreased mixed vaginal flora, and the pH is >4.5, this supports the diagnosis of atrophic vaginitis.After completing an assessment for vaginitis, assess for cervicitis.

Assess for cervicitis11:03–12:06

The patient may present with a history of a thick vaginal discharge, dysuria, non-menstrual or post-coital spotting, and possible pelvic pain as well as a history of recent sexual activity.
The physical exam may reveal mucopurulent cervical discharge, a friable cervix, and possible pelvic or cervical motion tenderness.
Consider a diagnosis of gonorrhea or chlamydia, and test for both with a NAAT. If the testing is positive for gonorrhea, diagnose gonococcal cervicitis.
If the testing is positive for chlamydia, diagnose chlamydial cervicitis. Generally, testing for gonorrhea and chlamydia is performed simultaneously and it is not unusual to have a positive test result for both; however, many patients may be infected with these pathogens yet still be asymptomatic.Finally, after assessing for common causes of vaginal discharge, consider and assess for alternative diagnoses such as physiologic discharge of pregnancy, vulvar dermatoses, vesicovaginal fistula, and rectovaginal fistula.Alright, as a quick recap… Vaginal discharge can be a normal finding, but when it is associated with pain, irritation, or pruritus, it is abnormal and warrants evaluation.

Assess for alternative diagnoses12:06–12:26

Review12:26–13:04

Common causes of vaginal discharge include a foreign body in the vagina or physiologic discharge. Problems such as bacterial vaginosis, vulvovaginal candidiasis, trichomonas vaginalis, desquamative inflammatory vaginitis, and atrophic vaginitis are also common causes of vaginal discharge, as is cervicitis caused by gonorrhea or chlamydia.