Vaginal Discharge - Gynaecology OPD Guide

Overview

Physiological vs Pathological

Causative Organisms

Vaginitis

Cervicitis

Clinical Features & Diagnosis

1. Bacterial Vaginosis (BV)

• Most common cause in reproductive-age women
• Discharge: homogeneous, low-viscosity, white/gray, uniformly coats vaginal walls
• Malodorous (fishy smell), especially after intercourse
• pH > 4.5
• No vulvar inflammation (distinguishes from candidiasis)
• KOH whiff test: positive (fishy amine odor)
• Microscopy: clue cells, few leukocytes, absent/sparse lactobacilli
• Amsel's criteria (3 of 4): homogeneous discharge, pH >4.5, positive whiff test, clue cells on wet mount
• Gram stain: Nugent score ≥7

2. Vulvovaginal Candidiasis (VVC)

• Discharge: thick, curdy/cottage-cheese-like, white, adherent plaques
• Intense vulvar pruritus and erythema, fissures, dysuria
• pH usually ≤4.5 (normal)
• KOH whiff: negative
• Microscopy with 10% KOH: hyphae/pseudohyphae in up to 80%
• Risk factors: diabetes, antibiotics, immunosuppression, pregnancy, OCPs

3. Trichomonal Vaginitis

• Discharge: profuse, frothy, yellow-green, malodorous
• Vulvar erythema and pruritus
• "Strawberry cervix" (colpitis macularis) - pathognomonic but seen in ~2% clinically
• pH ≥ 5
• Microscopy wet mount: motile trichomonads (sensitivity ~80% in symptomatic)
• NAAT is gold standard
• Sexually transmitted - treat partner

4. Cervicitis (Gonorrhoea / Chlamydia)

• Mucopurulent cervical discharge from the os
• Cervical erosion/ulcer may be present
• Cervical motion tenderness raises concern for PID
• Gram stain of endocervical smear: intracellular diplococci (GC)

Diagnostic Summary Table (Harrison's 22e)

History to Elicit in OPD

• Amount, color, consistency, smell of discharge
• Duration and onset
• Genital itching, burning, soreness
• Dysuria, frequency
• Dyspareunia
• Vulval ulcers or swellings
• Last menstrual period (rule out pregnancy)
• Sexual history, partner symptoms
• History of antibiotic use, diabetes, immunosuppression
• Low backache (suggests PID)

Examination

1. Inspection of vulva/perineum - ulcers, fissures, erythema, discharge at introitus
2. Per speculum examination - character of discharge, cervical os appearance, cervical erosion/ulceration
3. Bimanual pelvic examination - uterine tenderness, adnexal tenderness (PID)

Investigations

Treatment

Syndromic Management (if lab not available)

• Secnidazole 2g orally, single dose (preferred for compliance) OR Tinidazole 500mg BD x 5 days
• Metoclopramide 30 min before Secnidazole (to prevent nausea)
• Fluconazole 150mg orally single dose OR Clotrimazole 500mg vaginal pessary x 1

• Cefixime 400mg orally single dose (GC)
• Azithromycin 1g orally single dose (Chlamydia)
• Treat both if vaginitis + cervicitis coexist

Specific Treatments (from Harrison's 22e)

Special Situations

• Pregnancy: Avoid oral metronidazole in first trimester; use topical preparations. Treat BV to reduce risk of preterm labor.
• Recurrent VVC: Screen for diabetes, HIV; consider maintenance fluconazole.
• Prepubertal girls: Candida is uncommon (alkaline vaginal pH). Consider foreign body, poor hygiene, group A Strep, E. coli, or sexual abuse.
• BV in pregnancy: Associated with preterm labor - treat even if asymptomatic.
• Untreated BV: Can progress to endometritis, salpingitis (PID).

Partner Notification

• Trichomoniasis: Always treat partner (STI)
• Gonorrhoea/Chlamydia: Mandatory partner notification and treatment
• BV/Candidiasis: Partner treatment not routinely required (unless recurrent)

Peripheral Management of Vaginal Discharge (No Lab Available)

Step 1 - The Only Tool You Have: Clinical Assessment

• Frothy green discharge from vaginal walls → Trichomoniasis
• Curdy white plaques on vaginal walls → Candidiasis
• Gray/white homogeneous discharge + fishy smell → BV
• Mucopurulent discharge from cervical OS + cervical erosion → Cervicitis

Step 2 - Decision Tree

Patient with vaginal discharge
        |
Is speculum examination possible?
        |
    YES                     NO
     |                       |
Differentiate:            Treat for BOTH
Vaginitis vs Cervicitis   Vaginitis + Cervicitis

Treatment Protocols at Periphery

A. VAGINITIS (discharge from vaginal walls, no cervical involvement)

• Secnidazole 2g orally, single dose ← preferred (single dose = better compliance)
• Give Metoclopramide 10mg 30 min before Secnidazole to prevent nausea/vomiting
• Alternative: Tinidazole 500mg BD x 5 days
• Alternative: Metronidazole 400mg BD x 7 days

• Fluconazole 150mg orally, single dose
• OR Clotrimazole 500mg vaginal pessary, single dose at bedtime

Give both steps together as a combined package - you cannot clinically distinguish BV/TV from Candida with 100% certainty.

B. CERVICITIS (mucopurulent discharge from os, cervical erosion/ulcer)

• Cefixime 400mg orally, single dose (covers GC)
• + Azithromycin 1g orally, single dose (covers Chlamydia) - give 1 hour before lunch
• If vomiting occurs within 1 hour of Azithromycin, give antiemetic and repeat the dose

C. BOTH VAGINITIS + CERVICITIS PRESENT (or speculum not possible)

1. Secnidazole 2g single dose (+ Metoclopramide 10mg before)
2. Fluconazole 150mg single dose OR Clotrimazole 500mg vaginal pessary
3. Cefixime 400mg single dose
4. Azithromycin 1g single dose

Special Situation: PREGNANCY at Periphery

• Candida: Clotrimazole vaginal pessary/cream only (oral Fluconazole is CONTRAINDICATED in pregnancy)
• BV/Trichomonas: Metronidazole vaginal pessary/cream intravaginally

• Secnidazole 2g single dose OR Tinidazole 500mg BD x 5 days
• Metoclopramide 30 min before to prevent gastric intolerance
• Always do speculum exam first to rule out abortion/PROM

Partner Management at Periphery

• Advise sexual abstinence during treatment course
• Provide condoms and counsel on consistent use
• Follow-up in 7 days

Counselling Points to Give at Periphery

• Avoid douching (disrupts vaginal flora)
• Complete the full course of treatment
• Return if symptoms persist or worsen
• Screen for diabetes if candida is recurrent
• If pregnant, BV must be treated - increases risk of preterm labor
• In recurrent infections: consider pregnancy, diabetes, HIV as underlying factors

Quick Prescription Card for Peripheral OPD

Clinical Analysis: Post-C-Section Eclamptic Patient - Day 1

Reading the Clinical Picture

PRIORITY 1 - STOP AND ASSESS THE METRONIDAZOLE INFUSION

What is happening?

Immediate Actions - RIGHT NOW:

• Do not restart until rigors fully settle

• Temperature (likely spiking or will spike shortly)
• SpO2
• Respiratory rate
• Urine output

• Inj. Tramadol 50mg IV slow (most effective for drug-induced rigors) OR
• Inj. Pethidine 25-50mg IV slow (gold standard for post-infusion rigors) - use cautiously in eclampsia as it lowers seizure threshold slightly
• Inj. Promethazine (Phenergan) 25mg IV slow - antihistamine, also very effective
• Inj. Chlorpheniramine 4mg IV - alternative antihistamine
• Warm blankets immediately
• Warm IV fluids if cold fluids running

Note: Once rigors settle, if metronidazole is still needed, restart at a slower rate (infuse over 60 min, not 30 min) and premedicate with Promethazine or Chlorpheniramine next time.

PRIORITY 2 - BP 160/100 ON POST-OP DAY 1 ECLAMPSIA

Is MgSO4 Still Indicated?

• Yes - standard protocol continues MgSO4 for 24 hours after the last seizure (or 24 hours postpartum if no further seizures)
• On Day 1 post-C-section: MgSO4 maintenance should still be running

Antihypertensive for 160/100 Right Now:

• Inj. Labetalol 20mg IV slow over 2 min → repeat 40mg after 10 min → then 80mg → max 300mg total
• OR Tab. Nifedipine 10mg oral (immediate release) → repeat after 30 min if needed
• OR Inj. Hydralazine 5mg IV slow over 2 min → repeat 5mg every 20 min (max 20mg)

Ongoing Antihypertensive (Maintenance):

• Tab. Labetalol 100-200mg BD/TDS (oral) OR
• Tab. Methyldopa 250-500mg TDS (safe postpartum) OR
• Tab. Nifedipine CR 30mg OD

PRIORITY 3 - TACHYCARDIA HR 150

• Rule out: sepsis (post-op wound/uterus), pulmonary embolism (D-Day 1 post-CS - high risk), haemorrhage (check uterine tone, lochia), pain, fever
• Check: temperature, abdomen, lochia, WBC if possible
• If sepsis suspected: blood cultures, broad-spectrum antibiotics (after metronidazole reaction settles, use an alternative like Cefazolin or Ampicillin-Sulbactam)

Summary Action Plan

RIGHT NOW (0-5 min):
1. STOP Metronidazole infusion
2. Warm blankets + warm IV fluids
3. Inj. Promethazine 25mg IV slow OR Inj. Tramadol 50mg IV slow → for rigors
4. Check patellar reflex + RR + SpO2 → assess MgSO4 toxicity
5. Keep Inj. Calcium Gluconate 10% 10ml ready at bedside

NEXT (5-20 min):
6. If BP ≥160/110 → Inj. Labetalol 20mg IV OR Tab. Nifedipine 10mg oral
7. Full vitals + temp + SpO2 + urine output check
8. Check uterine tone, lochia, wound (rule out bleeding/sepsis)

ONGOING:
9. Continue MgSO4 maintenance (1-2g/hr IV) until 24hrs after last seizure
10. Once rigors settle, re-assess need for metronidazole - restart slower with premedication
11. Oral antihypertensive once BP controlled acutely
12. Follow-up vitals every 30 min

Do NOT Do:

• Do not restart Metronidazole at same rate without antihistamine cover
• Do not stop MgSO4 without completing 24 hours post-seizure
• Do not drop BP below 140/90 rapidly - risk of fetal (if still relevant) or cerebral ischemia
• Do not give Pethidine in large doses if seizure risk is still present