Questionnaire/history: Onset of abnormal VD? Duration of abnormal VD? Colour of discharge (e.g. normal (white or clear), grey/white or yellow/green)? Odour of discharge (eg normal (non offensive) or fishy smelling)? Consistency of discharge (eg normal (thick and sticky for most of the menstrual cycle but clearer, wetter and stretchy for a short period around the time of ovulation) or frothy or curdy? Associated symptoms (eg itch, soreness, dysuria, post-coital or intermenstrual bleeding, dysuria, deep dyspareunia, pelvic or abdominal pain)? Exacerbating factors (eg intercourse)? Any treatments tried and their effects? Use of vaginal products, such as douches, deodorant or vaginal washes? Cyclical symptoms? Risk of sexually transmitted infection (STI) (eg younger than 25 years, new sexual partner or more than 1 sexual partner in the last 12 months or had a previous STI)? Past medical history? Drug history (including contraceptive use)? Drug allergies? Examination: Examination may be omitted: If symptoms of BV and all of the following applies: - Low risk of STI? - No symptoms of other conditions causing vaginal discharge or which have developed pre or post a gynaecological procedure? - Postnatal or post miscarriage or pre or post termination? - First episode of BV or if recurrent a previous episode of recognizably similar symptoms was previously diagnosed to be BV following examination? - Not pregnant? Characteristic symptoms of vaginal candidiasis and all of the following applies: - Low risk of STI? - No symptoms of other conditions causing vaginal discharge? - Symptoms have not developed following a gynaecological procedure? - First episode of suspected vaginal candidiasis or if recurrent, recurrence is infrequent (less than four times a year)? Chaperone offered? Palpation of abdomen (eg tenderness or mass)? Inspection of vulva (eg lesions, discharge, vulvitis, ulcers or other changes)? If history suggestive of pelvic inflammatory disease (PID) bimanual pelvic examination to identify cervical motion tenderness, adnexal tenderness or abdominal masses? Speculum examination to visualize the cervix and vagina to look for signs of cervicitis, vaginal discharge and any possible foreign body (such as a tampon or condom)? PH of the vaginal discharge from the lateral wall of the vagina with a swab to rub onto narrow-range pH paper (pH 3.8-5.5)? - Bacterial vaginosis (BV) and trichomoniasis: pH higher than 4.5? - Vaginal candidiasis: pH 4.5 or less? (- Normal vaginal pH in a woman of child-bearing age: 3.5-4.5) Investigations: High vaginal swab (or self-taken lower vaginal swab) for Gram staining to exclude other causes of symptoms from all women of reproductive age with vaginal discharge if: - Postnatal or post miscarriage? - Pre or post gynaecological surgery or pre or post termination of pregnancy? - Vaginitis without discharge? - Symptoms not characteristic of BV? - Symptoms recurrent (four or more cases a year)? - Within 3 weeks of intrauterine contraceptive insertion? - Previous treatments have failed? If at high risk of an STI test for chlamydia, gonorrhoea and trichomoniasis? Blood test for HIV and syphilis offered if tested for gonorrhoea and chlamydia? Chlamydia screening offered to sexually active person younger than 25 years, annually, or more frequently if changed partner? Urine pregnancy test? Urine dipstick? Management: High risk of an STI or characteristic features of trichomoniasis, cervicitis or PID? -> Referred to genito-urinary medicine (GUM) clinic or local specialist sexual health service to facilitate screening for infections and partner notification Suspected cancer? -> Cancer pathway referral Suspected pelvic inflammatory disease (PID)? -> Referral (for same day assessment) to a genito-urinary medicine (GUM) clinic or -> Empirical treatment if same day treatment in a GUM clinic not possible -> Urgent admission for women who are pregnant or have severe symptoms and signs (such as nausea, vomiting and a fever greater than 38 degrees Celsius) Suspected or confirmed chlamydia, gonorrhoea or trichomoniasis or symptoms recurrent or persistent or doubt about the diagnosis? -> Referral to GUM clinic Suspected BV or vaginal candidiasis? -> Empirical treatment Cervicitis? -> Treat for chlamydia while awaiting swab result Other? - Manage or refer Advised: - On basic personal hygiene - Avoidance of feminine hygiene products (such as douches and vaginal swabs) and tight, synthetic clothing - Safe sexual behaviours and practices - To read NHS info Vaginal Discharge

Reference(s):

NICE CKS: Vaginal discharge Information for patient/carer(s): NHS A to Z: Vaginal discharge