Leucorrhoea
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vaginal discharge differential diagnosis pathological physiological
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The retrieval returned limited results. Drawing on the Harrison's reference and my own comprehensive clinical knowledge to provide a thorough overview.
Leucorrhoea
Leucorrhoea refers to a whitish or yellowish vaginal discharge. It is one of the most common gynaecological complaints and may be physiological or pathological.
Classification
| Type | Description |
|---|---|
| Physiological | Normal discharge; no infection or pathology |
| Pathological | Abnormal discharge due to infection, inflammation, or neoplasia |
Physiological Leucorrhoea
Occurs in response to normal hormonal fluctuations. It is typically white/clear, non-offensive, non-irritating, and does not require treatment.
Common settings:
- Neonatal period (maternal oestrogen influence)
- Puberty (rising oestrogen)
- Mid-cycle (around ovulation — increased, clear, stretchy discharge)
- Premenstrual phase
- Pregnancy (increased vascularity and glandular activity)
- Sexual arousal
- Oral contraceptive pill use
Pathological Leucorrhoea
Causes by Source
| Source | Conditions |
|---|---|
| Vulva | Vulvitis, contact dermatitis |
| Vagina | Bacterial vaginosis (BV), trichomoniasis, candidiasis, foreign body, atrophic vaginitis |
| Cervix | Cervicitis (Chlamydia, Gonorrhoea), cervical ectropion, cervical polyp, cervical carcinoma |
| Uterus | Endometritis, submucous fibroid, endometrial carcinoma, IUCD |
| Tubes | Salpingitis (PID), pyosalpinx |
Differential Diagnosis of Common Vaginal Discharges
| Feature | Bacterial Vaginosis | Trichomoniasis | Vulvovaginal Candidiasis |
|---|---|---|---|
| Organism | Gardnerella vaginalis + anaerobes | Trichomonas vaginalis | Candida albicans |
| Colour | Grey/white | Yellow-green, frothy | White, "cottage cheese" |
| Odour | Fishy (amine) | Offensive | Odourless or yeasty |
| pH | >4.5 | >4.5 | <4.5 (normal) |
| Itching/irritation | Minimal | Marked | Intense pruritus |
| KOH "whiff test" | Positive | May be positive | Negative |
| Microscopy | Clue cells | Motile trichomonads | Pseudohyphae, spores |
| Treatment | Metronidazole 400 mg BD × 7 days (or 2 g single dose) | Metronidazole 2 g single dose (treat partner) | Clotrimazole vaginal cream/pessary or Fluconazole 150 mg oral |
(Harrison's, p. 4077)
Clinical Assessment
History
- Onset, duration, amount
- Colour, consistency, odour
- Associated symptoms: pruritus, dysuria, dyspareunia, pelvic pain, intermenstrual/postcoital bleeding
- Sexual history, contraception, recent antibiotics
- Menstrual and obstetric history
Examination
- Per speculum: assess discharge character, cervical appearance (ectropion, polyp, contact bleeding)
- Bimanual: uterine/adnexal tenderness (suggests PID)
Investigations
- Vaginal pH (lateral wall swab)
- Wet mount/saline preparation: clue cells, trichomonads
- KOH preparation: pseudohyphae (candida)
- High vaginal swab (HVS) for culture
- Endocervical swab / NAAT for Chlamydia and Gonorrhoea
- Pap smear if indicated
- Pelvic ultrasound (if PID, fibroids, or endometrial pathology suspected)
Specific Management
Bacterial Vaginosis
- Metronidazole 400–500 mg orally BD × 7 days or 2 g single dose
- Alternatives: Clindamycin 300 mg BD × 7 days, or vaginal clindamycin cream
- Partner treatment not routinely recommended
Trichomoniasis
- Metronidazole 2 g oral single dose (treat partner simultaneously)
- Alternative: Tinidazole 2 g single dose
Vulvovaginal Candidiasis
- Uncomplicated: Clotrimazole 500 mg pessary (single dose) or Fluconazole 150 mg oral
- Recurrent (≥4 episodes/year): Fluconazole 150 mg weekly × 6 months
- Avoid precipitating factors: antibiotics, tight synthetic clothing, diabetes
Cervicitis (Chlamydia/Gonorrhoea)
- Chlamydia: Doxycycline 100 mg BD × 7 days (or Azithromycin 1 g single dose)
- Gonorrhoea: Ceftriaxone 500 mg IM single dose
- Treat sexual partner(s); abstain until treatment complete
Atrophic Vaginitis (post-menopausal)
- Topical oestrogen (cream, pessary, or ring)
Complications if Untreated
- Ascending infection → PID → tubo-ovarian abscess, chronic pelvic pain, ectopic pregnancy, infertility
- Preterm labour (BV in pregnancy)
- Increased HIV susceptibility (disrupted vaginal flora)
- Psychological distress
Key Points
- Always distinguish physiological from pathological before initiating treatment.
- Vaginal pH is a simple, rapid first test: normal pH <4.5 suggests candidiasis; elevated pH >4.5 points to BV or trichomoniasis.
- In sexually active women with mucopurulent cervical discharge, empirical treatment for both Chlamydia and Gonorrhoea is appropriate pending NAAT results.
- Always screen for STIs when a pathological cause is identified.
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