Doctors Revision

HIV, STI & TB

Abnormal Vaginal Discharge Syndrome

Syndromic management approach for women presenting with abnormal vaginal discharge (change in quantity, color, odour), often associated with itching or pain. Covers common causes like Candidiasis, Trichomoniasis, Bacterial Vaginosis, Gonorrhoea, and Chlamydia.

Also known as: Vaginitis, Cervicitis, Vaginal Discharge

Open in the interactive guide
On this page

Referral and warning signs

When to refer

Refer immediately if cervical cancer suspected. Refer for specialist management if discharge persists >7 days despite appropriate treatment and partner management. Refer if PID suspected and requires inpatient care or diagnostic uncertainty.

Red flags

  • Suspicion of cervical cancer on speculum exam
  • Lower abdominal tenderness suggesting PID
  • Persistent discharge despite appropriate treatment and partner treatment

Signs and symptoms

  • Abnormal vaginal discharge (increased quantity, abnormal colour - white, yellow, green, grey; abnormal odour - fishy)
  • Vulval/vaginal itching (pruritus)
  • Lower abdominal pain (assess for PID)
  • Pain during sexual intercourse (dyspareunia)
  • Specific types:
  • - Candida: Thick/lumpy white discharge, intense itching, red/inflamed vulva.
  • - Trichomonas: Itchy greenish-yellow frothy discharge, offensive smell.
  • - Bacterial Vaginosis: Thin grey/white discharge, fishy odour.
  • - Gonorrhoea/Chlamydia (Cervicitis): Often asymptomatic or thin purulent/mucoid discharge, non-itchy.

Risk factors

  • Unprotected sexual intercourse (for STIs like Trichomonas, Gonorrhoea, Chlamydia)
  • Multiple sexual partners
  • Douching
  • Antibiotic use (risk factor for Candida)
  • Diabetes (risk factor for Candida)
  • Pregnancy (hormonal changes)
  • Intrauterine device (IUD) use (associated with Bacterial Vaginosis)
  • HIV infection (increased susceptibility)

Diagnosis

Clinical assessment

Based on history (nature of discharge, itching, pain, sexual history, risk factors) and examination. Speculum examination crucial to assess cervix (rule out cancer, assess discharge origin/character) and vaginal walls. Assess for lower abdominal tenderness (suggests PID).

Investigations

  • Speculum examination
  • Vaginal discharge swab: Microscopy (wet mount for Trichomonas, clue cells; KOH prep for Candida hyphae), Gram stain, Culture & Sensitivity (less common for syndromic approach)
  • Vaginal pH testing
  • Whiff test (KOH application releases fishy odour in BV)
  • Cervical swabs/urine NAAT (for Gonorrhoea/Chlamydia if cervicitis suspected/available)
  • Blood: Syphilis tests (RPR/VDRL), HIV testing.

Diagnostic criteria

Patient complaint of abnormal vaginal discharge, confirmed by clinical assessment and potentially simple lab tests (pH, whiff) or microscopy, managed syndromically based on risk assessment and discharge characteristics.

Management

Non-pharmacological management

  • Take history and examine (general, abdominal, speculum).
  • Assess risk for STIs.
  • Advise abstinence or consistent condom use during and after treatment.
  • Partner notification and treatment is essential if STI (Gonorrhoea, Chlamydia, Trichomonas) is treated.
  • Provide health education on STIs, hygiene, and risk reduction.
  • Offer HIV counseling and testing (HCT).

Pharmacological treatment

  • Follow UCG Flowchart (Figure 9):
  • 1. Rule out PID (lower abdominal tenderness) -> If present, treat as PID (STI003).
  • 2. Rule out Genital Ulcers -> If present, treat as GUD (STI004).
  • 3. Speculum exam: Rule out Cervical Cancer -> If suspected, refer immediately.
  • 4. Assess discharge type/signs:
  • a. If discharge is thick/lumpy + itching + erythema/excoriations (Likely Candida):
  • - Clotrimazole pessaries 100mg daily x 6 days (or 200mg daily x 3 days)
  • - OR Fluconazole 150-200 mg PO single dose (Avoid in pregnancy).
  • - Optional: Add Metronidazole 2 g PO single dose (covers potential co-existing BV/Trichomonas).
  • - If pregnant: Use Clotrimazole pessaries. Add Metronidazole only after 1st trimester.
  • b. If discharge is abundant/smelly/frothy OR bacterial vaginosis suspected:
  • - Metronidazole 2 g PO single dose.
  • c. If purulent discharge OR high STI risk OR previous treatment failed:
  • - Treat for Gonorrhoea + Chlamydia + Trichomonas/BV:
  • - Cefixime 400 mg PO single dose OR Ceftriaxone 1g IV/IM single dose.
  • - PLUS Doxycycline 100 mg PO every 12 hours for 7 days.
  • - PLUS Metronidazole 2 g PO single dose.
  • - If pregnant: Substitute Doxycycline with Erythromycin 500 mg PO every 6 hours for 7 days OR Azithromycin 1 g PO single dose. Give Metronidazole only after 1st trimester.
  • - Treat sexual partner(s) for Gonorrhoea/Chlamydia.
  • Persistence: If discharge persists >7 days despite treatment and partner treatment, refer for specialist management.

Monitoring

Assess for symptom resolution after treatment. Follow up if symptoms persist.

Complications

  • Pelvic Inflammatory Disease (PID) if cervicitis untreated
  • Infertility
  • Ectopic pregnancy
  • Chronic pelvic pain
  • Increased risk of HIV acquisition/transmission
  • Adverse pregnancy outcomes (preterm birth, low birth weight)

Prevention

  • Consistent and correct condom use
  • Mutual monogamy with an uninfected partner
  • Abstinence
  • Partner notification and treatment
  • Regular STI screening for high-risk individuals
  • Avoid douching
  • Good hygiene practices

Patient education

  • Explain the likely cause (based on syndrome) and treatment plan.
  • Importance of completing medication.
  • Necessity of partner treatment if STI is covered.
  • Advise abstinence or condom use.
  • Educate on prevention and hygiene.
  • Advise return if symptoms persist or worsen, or if lower abdominal pain develops.

Uganda-specific notes

Syndromic management is the primary approach. Speculum examination is key. Differentiate between likely Candida, BV/Trichomonas, and potential Cervicitis requiring broader coverage. Partner treatment essential for STIs.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 3, Section 3.2.2, Figure 9

Scroll to Top