0.1. Introduction:

• Very common gynecological problem
• Management depends on the cause

0.2. Physiological discharge:

• Does not require treatment.
• Common in women of reproductive age, results from normal cervical and vaginal secretions.
• Increases in pregnancy and oral contraceptive users.
• Can also be associated with cervical erosion (ectropion).

0.3. Infective discharge:

0.3.1. Monilial Vaginosis (vulvovaginal candidiasis)

• A mycotic disease mostly caused by Candida albicans, a commensal of the genital and digestive tract. Not sexually transmitted.
• Characterized by vulval itching and rarely soreness and burning, with white curdish discharge.
• Diagnosis can be confirmed by microscopy (pseudohyphae), or culture of the discharge (more than 10 yeast colonies).
• Can be acute or recurrent (more than 4 episodes annually).
• Prevalence of C. albicans is 20-25% in healthy young women, 75% have at least one attack in their life-time and recurrence occurs in less than 5%.
• Most episodes occur without obvious cause, but sometimes associated with:
  • Broad spectrum antibiotics.
  • Diabetes mellitus.
  • Immune-suppression.
  • Pregnancy.
  • Oral contraceptive use.
• Effectively treated by the azoles (clotrimazole, econazole, miconazole), oral and intra-vaginal.
• Oral anti-fungals should not be used in pregnancy and is best outside pregnancy.
• Exclude D.M in women with recurrent symptoms.

0.3.2. Bacterial Vaginosis

• The commonest cause of vaginal discharge in young women.
• Not sexually transmitted.
• Caused by the over-growth of anaerobes (Gardnerella vaginalis, mycoplasma homines and others) to replace the lactobacilli when the vaginal PH increases from 4.5 to 7 for reasons not known but more common in:
  • Blacks.
  • IUCD.
  • Smokers.
• May be asymptomatic in 50% of women.
• Discharge is usually offensive and fishy smelling.
• In pregnancy associated with late miscarriage, preterm labour, preterm PROM and post-partum endometritis.
• Diagnoses depends on the presence of three of four of the following (Amsels criteria):
  • Thin white homogenous discharge.
  • Clue cells on microscopy.
  • PH > 4.5.
  • Fishy odor on adding alkali.
• Management includes general advice against vaginal douching, and antiseptic virginal bath plus metronidazole (oral or intra-vaginal) or clindamycin 2% intra-vaginal cream.

0.3.3. Trichomonal infection

• Caused by Trichomonas vaginalis, a flagellated protozoon.
• Almost exclusively sexually transmitted and can be acquired perinatally.
• Discharge can vary but often frothy, yellow and associated with vulval itching, soreness, dysuria and offensive odor.
• Diagnosis is made by observation of a wet vaginal smear or culture and recently PCR.
• Treatment is systemic metronidazole (N.B 25% spontaneous cure rate).
• Vaginal discharge associated with PID.

0.3.4. Chlamydia trachomatis

• This is an obligate intracellular parasite and is the commonest cause of PID world-wide. It is sexually transmitted.
• Discharge is purulent or mucopurulent.
• Complications include infertility and neonatal conjunctivitis (opthalmia neonatorum) in pregnancy.
• Diagnosis is made by ELISA and cell culture.
• Treatment is by doxycycline or erythromycin (also partner).

0.3.5. Gonorrhea

• Sexually transmitted and caused by the gram negative diplococcus N. gonorrhea.
• Mucopurulent discharge (or nil).
• Complications include tubal damage and opthalmia neonatorum in pregnancy.
• Diagnosis by culture.
• Treatment include penicillin, ciprofxacin, ofloxacin and ampicilln including partner.

0.4. Non-infective causes of vaginal discharge:

1-    Malignancy: eg. Endometrial, cervical and vaginal cancer

2-    Foreign body e.g. lost tampon, vaginal ring