[CG] Vaginal discharge: management

Warning

exp date isn't null, but text field is

Please report any inaccuracies or issues with this guideline using our online form

Recurrent symptoms, symptoms of PID, postpartum or post abortion, post gynaecological instrumentation or pregnant

Offer face to face appointment in an appropriate clinic, i.e TOPAR/ GU Complex / Urgent Care or in the case of post partum infection refer back to Obstetric services.

Investigations

  • Examination and pH
  • Microscopy (*dry slide for Gram staining and **wet prep)
  • Endocervical GC culture (if plates available)
  • High Vaginal Swab (HVS) if recurrent or persistent
  • Vulvovaginal CT/GC NAAT

Management of results (please refer to appropriate guidelines)

  • Trichomonas Vaginalis (TV) seen – TV
  • pH >4.5 +/- Clue cells and abnormal flora – BV
  • pH <4.5 +/- Yeast cells – Candida
  • Gram Negative Diplococci (GNDC) seen – GC
  • High AV score: discuss with senior

*Dry slide (vaginal and cervix) for Gram stain.
**Wet prep taken from the vaginal posterior fornix. Connect a HVS is taken using a charcoal swab for wet prep.
HVS – taken from lateral vaginal wall. Stored at 4°C for maximum 48 hours.

Microscopy venue: Sandyford Central.
CONNECT: If microscopy requested please leave the registration form of client with the Connect nurse to follow up client with result.

Aerobic Vaginitis (AV)

Defined as “Disruption of the lactobacillary (LB) flora, accompanied by signs of inflammation and the presence of predominantly aerobic microflora composed of enteric commensals or pathogens.”

Vaginal Flora Grade – Modified Hay-Ison Score

Grade

Description

0

No flora

I

Normal vaginal flora (LB alone)

II

Mixed

III

Abnormal

IV

Gram positive cocci only

AV Donder’s Score

This is calculated from a WET film. Not all people who can read slides are trained to do this assessment please confirm on the day. It is based on the following criteria, each given a score from 0-2.

  1. Lactobacillary (LB) flora
  2. Number of leucocytes
  3. Proportion of toxic leucocytes
  4. Background flora
  5. Proportion of parabasal cells (epithelial damage)

Severity

  • Mild 1-4
  • Moderate 5-6
  • Severe 7-10
  • Scores above 5-6 (moderate) or 7 or higher (severe) require clinician to consider AV as well as other causes for an inflammatory vaginitis, including TV and Group A streptococcus.
  • Always take a HVS culture swab (self-taken is fine) if moderate or high AV score.
  • No clear evidence base for treatment. Discuss with senior clinician. Consider using clindamycin vaginal cream (covers aerobic organisms) instead of metronidazole

Advice on vaginal health

Advice should be given to the client that some factors may affect normal vaginal health causing a disruption to the normal flora and pH.

Some causes of irritation include:

  • Antibiotics
  • Some types of clothing (tightly fitted/synthetic material)
  • Over-washing/bathing douching or the use of shower gels or antiseptic agents, bath oils
  • Avoid using feminine hygiene sprays, perfumes or wipes
  • Avoid using daily pads or fragranced sanitary products
  • Avoid use of flavoured/coloured condoms or lubricant
  • Avoid using fabric conditioner and biological washing powder
  • Advise to wash with water or a soap substitute. Offer and prescribe soap substitutes such as aqueous cream or emulsifying ointments.
  • Consider providing a Sandyford genital skin information leaflet via SMS
References

BASHH CEG UK National Guideline on the Management of Bacterial Vaginosis 2012  [accessed Mar 2022]
Donders G, Bellen G, Rezeberga D. Aerobic vaginitis in pregnancy. BJOG 2011. DOI: 10.1111/j,1471-0528.2011.03020.x. [accessed Mar 2022]
Sherrard J, Wilson J, Donders G, Mendling W, Jensen JS. 2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge. Int J STD AIDS. 2018 Nov;29(13):1258-1272. doi: 10.1177/0956462418785451. Epub 2018 Jul 27. PMID: 30049258

Last reviewed: 31 March 2022

Next review: 31 March 2024

Author(s): Dr. Kay McAllister

Version: 4

Approved By: Gynaecology Clinical Governance Group

Document Id: 317