Explain in brief vaginal discharge obgy

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Vaginal Discharge - OB/GYN Overview

Definition

Vaginal discharge refers to fluid or mucus secreted from the vagina. It may be physiological (normal) or pathological (due to infection, inflammation, or malignancy). Many women have nonspecific discharge that does not correlate with objective infection - but unsolicited reports of increased amount or abnormal odor usually indicate a true pathology. - Harrison's Principles of Internal Medicine 22E

Physiological (Normal) Discharge

Called leukorrhea - thin, slippery, clear or white, non-offensive
Occurs cyclically (mid-cycle, premenstrual), in pregnancy, and in neonates (first 2-3 weeks of life due to maternal hormones)
Normal vaginal pH: ≤4.5, maintained by lactobacilli
No treatment needed

Pathological Vaginal Discharge - Major Causes

The three most common infectious causes are Bacterial Vaginosis (BV), Vulvovaginal Candidiasis (VVC), and Trichomoniasis. BV alone accounts for 40-50% of identified cases. - Campbell Walsh Wein Urology

Comparison Table (from Harrison's 22E)

Feature	Bacterial Vaginosis	Candidiasis	Trichomoniasis
Organism	Gardnerella vaginalis + anaerobes + mycoplasmas	Candida albicans	Trichomonas vaginalis
Discharge	White/gray, homogeneous, low viscosity, coats walls	White, clumped, "cottage cheese," adherent plaques	Yellow-green, frothy, profuse, homogeneous
Amount	Moderate	Scant	Profuse
Odor	Fishy (malodorous)	None	May be present
pH	>4.5	≤4.5	≥5
Inflammation	None	Vulvar erythema, fissures, itching	Erythema of vagina + vulva; "strawberry cervix"
KOH whiff test	Positive (fishy)	Negative	May be positive
Microscopy	Clue cells, few WBCs, no lactobacilli	Pseudohyphae/mycelium, WBCs	Motile trichomonads, WBCs
Treatment	Metronidazole 500 mg PO BID x 7 days OR metronidazole gel	Azole cream/tablet x 7 days OR fluconazole 150 mg PO single dose	Metronidazole OR tinidazole 2g PO single dose

Other Causes

Cervicitis - N. gonorrhoeae or C. trachomatis: mucopurulent cervical discharge (yellow, from cervical os), often with increased neutrophils in vaginal fluid; does NOT classically increase discharge quantity or cause odor. Treat with appropriate antibiotics (ceftriaxone + doxycycline/azithromycin)
Foreign body (especially in children): foul-smelling, possibly bloody discharge; most common foreign body in prepubertal girls is toilet paper
Atrophic vaginitis (postmenopausal): thin, watery or blood-tinged discharge due to low estrogen
Desquamative inflammatory vaginitis (DIV): purulent discharge, high pH, parabasal cells on microscopy
Cervical malignancy: persistent, watery or blood-stained, offensive discharge
Physiologic increase: during pregnancy, mid-cycle (ovulation), OCP use

Diagnosis Approach

History - onset, color, odor, associated symptoms (itch, burning, dysuria, dyspareunia, pelvic pain), sexual history, menstrual history
Examination - vulvar inspection, speculum exam (note site of discharge - vaginal vs. cervical os)
Investigations:
- Vaginal pH (litmus/pH paper)
- Whiff test (10% KOH → fishy odor = BV)
- Wet mount microscopy (clue cells, trichomonads, pseudohyphae)
- NAAT for gonorrhea and chlamydia
- Culture if needed

Amsel's Criteria (for BV diagnosis - 3 of 4 required)

Homogeneous, thin white discharge
Vaginal pH >4.5
Positive whiff (amine) test with KOH
Clue cells on microscopy (>20% of epithelial cells)

Complications

BV and trichomoniasis independently increase risk of preterm labor in pregnancy
BV increases risk of HIV transmission and can ascend to cause endometritis/salpingitis (PID)
BV, trichomoniasis, and VVC are each associated with increased HIV acquisition risk
Recurrent/chronic VVC may indicate diabetes mellitus or HIV immunosuppression
Harrison's Principles of Internal Medicine 22E, p. 982-995

Vaginal Discharge in Prepubertal Girls (Special Note)

In prepubertal girls, vulvitis is primary (not vaginitis). Common causes:

Poor perineal hygiene, tight clothing, bubble baths
Bacterial: Group A Strep, S. aureus, E. coli, Shigella
Candida is uncommon due to alkaline vaginal pH
Foreign body (toilet paper most common) - presents with foul, bloody discharge
Always consider sexual abuse if STI organisms (gonorrhea, chlamydia, trichomonas) are found
Berek & Novak's Gynecology; Tintinalli's Emergency Medicine

Quick Summary

	BV	Candidiasis	Trichomoniasis
Cause	Dysbiosis (anaerobes)	Fungal	Protozoan (STI)
Key feature	Fishy odor, clue cells	Itch, cottage cheese	Frothy, strawberry cervix
pH	>4.5	≤4.5	≥5
Rx	Metronidazole	Fluconazole/azole	Metronidazole/tinidazole

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