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Online exclusive: Clinical Case Report

Primary care management of women with persistent vaginal discharge

Morgan, Hilary S. PhD, CNM

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doi: 10.1097/01.NPR.0000508174.26163.7f
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NPs see a variety of common primary care complaints. In women's health, vaginal symptoms—specifically vaginal discharge with or without accompanying pruritus and odor—account for 10% of office visits.1 Most often, the patient is diagnosed with a vaginal infection, such as vulvovaginal candidiasis, bacterial vaginosis, or trichomoniasis. These infections account for over 75% of vaginitis complaints, with vulvovaginal candidiasis and bacterial vaginosis causing up to 90% of vaginal infections.2,3

Appropriate diagnosis and treatment result in symptom relief for patients; however, up to 30% of women remain without a diagnosis after workup and may receive an inappropriate treatment just to placate them.4 Not surprisingly, these women continue to seek a diagnosis from different providers or chose to self-medicate with over-the-counter (OTC) medications in an attempt to find a cure, increasing the cost to themselves and the healthcare system. The failure to appropriately treat may also aggravate symptoms rather than alleviate them.5

Additionally, the chronic nature of persistent vaginal discharge may impact a woman's psychosocial health. Women may view vaginal complaints as a threat to their reproductive health, which may lead to poor self-image and a withdrawal from intimate relationships.6-8 The NP must recognize other, noninfectious causes of vaginal discharge and diagnose and treat the patient appropriately. If the NP cannot relieve the patient of her symptoms, a referral to a gynecologic specialist is warranted.

Normal vaginal flora

Women of reproductive age have vaginal flora that consists predominately of lactobacillus, a Gram-positive rod that produces lactic acid from glucose and contributes to a normal vaginal pH between 4.0 and 4.7.5,9 The acidity of the vagina protects it from pathogens.10 After menarche, estrogen aids in the deposit of glycogen in the vaginal epithelial cells, which in turn converts the glycogen to glucose. The lactobacillus then converts the glucose to lactic acid.9

A thickening of the vaginal mucosa also occurs with puberty due to the influence of estrogen.11 As women age, estrogen levels decline, resulting in a higher vaginal pH (over 4.7). There is less glycogen in the epithelial cells and fewer lactobacilli present to convert the glucose to lactic acid, resulting in less lactic acid production and a higher vaginal pH.5,11 Additionally, the loss of estrogen leads to vaginal atrophy and thinning.8

It is normal for women to have a physiologic vaginal discharge. The endocervix produces mucus, which combines with epithelial sloughing, normal vaginal flora, and transudate to produce a vaginal discharge.2 This discharge is considered part of a self-cleansing mechanism in a woman's vagina and varies throughout the menstrual cycle due to effects of estrogen and progesterone. The consistency of vaginal discharge is clear and stretchy during ovulation and thick, white, and tacky during the remainder of the cycle.5,12 The amount of vaginal discharge produced varies among women but averages approximately 1 mL to 4 mL fluid per 24 hours.2

Patient history

A detailed history is paramount if the NP is to succeed in correctly diagnosing women complaining of persistent vaginal discharge. Although the NP may consider a patient presenting with a complaint of vaginal discharge a problem-focused visit, a thorough history (including medical and surgical history, reproductive and menstrual history, and nutritional history) may provide important information aiding in diagnosis. The NP should keep in mind that although some patients may be of reproductive age, there are medical conditions and treatments that inhibit normal ovarian function, including surgical removal of the ovaries and medications used to treat endometriosis, such as leuprolide acetate.13 The NP needs to carefully avoid assumptions based on a woman's age.

It is important to know if the woman's symptoms are recent or chronic or if she has been treated successfully in the past and now the symptoms have recurred. Recurrence is more likely indicative of reinfection, whereas a woman with chronic symptoms not relieved with previous treatment should lead the NP to suspect inflammation unrelated to infectious process (see Evaluation of vaginal discharge by pH measurement).14 The timing of the symptoms in relation to the menstrual cycle may also yield clues, as a heavier discharge is noted at ovulation.

Evaluation of vaginal discharge by pH measurement14

Other symptoms, such as vulvovaginal burning and pruritus, bleeding, dysuria, or dyspareunia may provide information.5,15 The NP should ask if there are other associated symptoms, such as fever, nausea, vomiting, and pelvic pain, which may indicate a more systemic issue. The severity of the complaints should be elicited as well as any aggravating or alleviating factors. Any history of sexually transmitted infections and use of any type of contraceptives should also be obtained.

The woman's sexual history must also be gathered, including if she is having sex with men, women, or both, and if they are stable or new partners. Women who have sex with women are at an increased risk of bacterial vaginosis.16,17 Although rare, allergy to semen has been noted, but the symptoms are usually irritative rather than vaginal discharge.18 The NP should also inquire if the woman's symptoms are noted by her partner as well.

It is also important to ask about any medications, both prescription and OTC. Recent intake of antibiotics may make a woman susceptible to vulvovaginal candidiasis, and contraceptives containing estrogen may contribute to a heavier vaginal discharge.19 Antihistamines may cause vaginal dryness.20 Women who use an intrauterine device for contraception may also note a heavier discharge.21

Lastly, the woman's hygienic practices must be evaluated. Vaginal tissue is very sensitive to chemicals and allergens, and the use of products such as perfumed soaps and douches, scented panty liners, spermicides, latex condoms, and topical lotions may cause inflammation that contributes to vaginal discharge.22 Shared use of sex toys between partners without adequate cleaning between use may also be a contributing factor.17

Physical exam and diagnostic testing

Although it is common to diagnose a patient with a vaginal infection based on history, a speculum exam should be done in women with persistent vaginal discharge. A diagnosis based solely on history is strongly discouraged. Normal vaginal discharge in women with functioning ovaries or who are receiving estrogen supplementation is white or clear and odorless.2 The speculum exam allows the NP to see the color, consistency, and amount of the vaginal discharge. A thorough exam of the mons, vulva, perineum, vaginal canal, cervix, and cervical os should be performed along with palpation of the urethra and the Bartholin and Skene glands.

Inspection for retained foreign bodies, the presence of lesions, skin disorders, atrophy, and other signs of irritation should be done and managed by the NP. The NP should note any unusual or foul odors. A bimanual exam assessing for cervical motion tenderness, uterine size, consistency and tenderness, adnexal tenderness, and the presence of any masses should be performed.

pH testing and microscopy

The value of measuring the vaginal pH to help achieve diagnosis cannot be overemphasized. Several commercial options are available to the NP to obtain vaginal pH results. These products utilize nitrazine dye either on a swab or as paper that changes color in contact with an elevated vaginal pH. No change in color occurs if the vaginal pH is normal. If a color change occurs, compare the pH paper to the color chart supplied with the pH paper. These tests are easily performed and done at the point of care with the patient. The sensitivity and specificity of the swab in diagnosing bacterial vaginosis and trichomoniasis based on elevated pH results is 82.3% and 94.2%, respectively; the sensitivity and specificity of the pH paper is 91.1% and 94.2%.23 An elevated vaginal pH in a reproductive-age woman (pH over 4.7) is associated with bacterial vaginosis or trichomoniasis. Candida vulvovaginitis will typically have a vaginal pH between 4 and 4.5.5,24

The use of microscopy in diagnosing vaginal discharge consists primarily of saline and potassium hydroxide (KOH) wet mounts, and identification of causative organism. Trichomonads and clue cells may be seen under the microscope using the saline mount, whereas hyphae and buds indicative of candidiasis are noted with KOH. The amine test (whiff test) is also helpful in diagnosing bacterial vaginosis and involves mixing vaginal discharge with KOH and evaluating for the presence of a fishy odor.2

Amsel criteria for the diagnosis of bacterial vaginosis include a vaginal pH over 4.5, a positive whiff test, milky discharge, and the presence of clue cells on microscopy.25 Many NPs prefer submitting specimens for vaginal or cervical cultures to a lab to aid in identifying pathology.2 Infection with Neisseria gonorrhoeae or Chlamydia trachomatis should be ruled out.

Noninfectious conditions

Careful assessment and diagnostic testing will likely provide a diagnosis if the vaginal discharge is due to an infectious cause. If testing does not provide a diagnosis, the NP should consider noninfectious causes of persistent vaginal discharge. Again, pH findings may be helpful. An elevated pH may indicate genitourinary syndrome of menopause (the more recent terminology for atrophic vaginitis and vulvovaginal atrophy), lichen planus, lichen sclerosus, or desquamative inflammatory vaginitis. A normal vaginal pH with negative diagnostic testing suggests physiologic leukorrhea or vulvar dermatitis. A low vaginal pH may point toward cytolytic vaginosis.2,5

Physiologic leukorrhea. Many women, particularly those of younger reproductive age, may not realize the cyclic variation in vaginal discharge. It is important to educate them that all women will have some vaginal discharge. Physiologic leukorrhea refers to the normal increased production of discharge that occurs during ovulation and pregnancy. Physiologic leukorrhea may also be influenced by diet, sexual activity, medications, hormonal contraception, and stress. A vaginal discharge that is mostly clear, odorless, without accompanied erythema and significant irritative symptoms, and has a pH under 4.7 is generally considered benign.2 Physiologic leukorrhea was diagnosed in 9% of women in a prospective analysis of affected women.26

Cytolytic vaginosis. Also known as Döderlein's cytolysis, cytolytic vaginosis is characterized by an overgrowth of lactobacillus.7 The overabundance of lactobacillus leads to vaginal hyperacidity, which damages the vaginal epithelial cells and increases vaginal discharge. According to Cibley and Cibley, diagnostic criteria include the absence of trichomonas, monilia and bacteria on microscopy, an increase of lactobacilli, rare white blood cells, evidence of cytolysis, and the presence of vaginal discharge with pH between 3.5 and 4.5.27 Cytolytic vaginosis occurs more commonly during the luteal phase of a women's menstrual cycle.27

Cerikcioglu and Beksac tested 210 women with complaints of vaginal discharge and other symptoms suggestive of vulvovaginal candidiasis and diagnosed 7.1% with cytolytic vaginosis based on lab findings. Patients diagnosed with cytolytic vaginosis were found to have abundant lactobacilli, fragmented epithelial cells, and free nuclei due to cytolysis. Additionally, no fungal growth was identified microscopically in these women.28 These findings were confirmed in another study by Hu and colleagues, which compared the morphologic characteristics of vaginal discharge of patients diagnosed with cytolytic vaginosis and vulvovaginal candidiasis.29

The treatment for cytolytic vaginosis involves restoring the vaginal pH to normal levels through the use of sodium bicarbonate suppositories. Patients may prepare the appropriate treatment by filling empty gelatin capsules with baking soda and inserting the capsules in their vagina twice a week for 2 weeks.9 Gelatin capsules may be purchased inexpensively at local pharmacies. Patients should experience symptom relief within 2 to 3 weeks.9

Retained foreign body. Women of all ages, particularly younger women of reproductive age, may inadvertently leave a tampon in their vagina for a prolonged period of time, and this irritation may lead to a heavy discharge (usually with odor). Surgical gauze has also been removed from women returning for their postpartum or postgynecologic surgery exam. In both situations, removing the foreign body removes the irritant, and the resulting discharge resolves fairly quickly. Some NPs prefer to treat the patient with vaginal antibiotic cream, although the evidence is not clear that this is necessary.30

Vulvar contact dermatitis. A study by Nyirjesy and colleagues identified contact dermatitis as a leading cause (21%) of vaginal vulvar complaints.26 Contact dermatitis may be either due to irritants or allergens. Severe outbreaks may be painful and associated with erosion and lesions, whereas milder cases may present with erythema and irritation. Chronic dermatitis may present as eczema with dry, scaly patches and lichenification of tissue. The primary symptoms in both types of contact dermatitis include itching, erythema, edema, and weeping from vulvar lesions may be present. The vaginal pH is typically under 4.7.22,31

Soaps, laundry detergent, sanitary products, toilet tissue, and powders are all potential sources of irritation. Treatment involves avoidance of known irritants, changing personal hygiene practices, and avoiding tight-fitting clothing. Medication such as antihistamines and corticosteroids may be necessary to relieve inflammation.31 NP management may include identifying causative exposure and inflammation treatment. Additionally, patient education on avoidance of identified irritating exposures is imperative to avoid reoccurrence. Referral to a gynecologic specialist for biopsy and/or cultures may be necessary.

Estrogen deficiency. As women age, estrogen levels decrease, and the vagina becomes atrophic. Estrogen is no longer present at high enough levels to keep the vagina well epithelialized and elastic. Over time, the vaginal tissue thins, dries, and may become inflamed. With a decline in glycogen levels, lactic acid production is diminished and the vaginal pH rises, usually over 5.32

The vaginal tissue is more easily traumatized and susceptible to infection and inflammation. Even without a source of infection, this inflammatory process results in an increased discharge that often both the patient and NP believe may be the result of a pathogen. However, if diagnostic testing comes up negative, the NP should consider treating the woman with estrogen vaginal products. The results may take a few months to demonstrate but most women will find their vaginal discharge lessens after use of vaginal estrogen products.31 Low-dose vaginal estrogen can be highly effective in treating genitourinary conditions related to estrogen deficiency (provided there are no contraindications to its use). Contraindications include history of breast, ovarian, or uterine cancer; undiagnosed vaginal bleeding; pregnancy or lactation; thromboembolic disorders; or impaired liver function.33

Estrogen deficiency may also occur in premenopausal women, particularly during the postpartum period and while lactating. Additionally, contraceptives containing low or no estrogen amounts such as depot medroxyprogesterone acetate may contribute to a lower vaginal estrogen level, production of less lactic acid, and a higher vaginal pH.24,31,34,35 In this case, the NP may need to consider an alternative contraceptive option. Postpartum and lactating women should be educated that their condition is self-limiting and once lactation is discontinued, estrogen levels will return to normal.

Lichen planus and lichen sclerosus. These dermatologic conditions are caused by chronic inflammation. Lichen planus is a cell-mediated immune response disease that usually affects cutaneous areas, such as the vulva and vagina, and the oral and esophagus regions.36,37 It is considered an autoimmune disorder, although no defining antigen has been identified. Lichen planus is characterized by either erosive or papular lesions on the vulva; a friable vaginal epithelium may be noted as well as loss of vaginal architecture.

Pain is the most common complaint, but an irritating vaginal discharge may also be noted. Microscopy will reveal a marked increase in white blood cells, immature epithelial cells (arising from erosive areas), an elevated vaginal pH, and an absence of lactobacilli.36 Lichen planus is most commonly seen in women ages 50 to 60, and diagnosis is achieved through biopsy. Treatment is difficult and usually involves topical corticosteroids.37

Like lichen planus, lichen sclerosus is considered an autoimmune disorder without a specifically identified causative antigen. Lichen sclerosus primarily affects the anogenital area, and although it shares characteristics with lichen planus, the two are different diseases. Genetic and environmental factors are hypothesized to contribute to the development of lichen sclerosus; additionally, periods of low estrogen are also thought to play a role.38,39 Recent studies have suggested the use of oral contraceptives having antiandrogenic properties that might trigger an early onset of lichen sclerosus in young women.38

Lichen sclerosus primarily affects women ages 50 to 70, but children may be affected as well. Lichen sclerosus is characterized by intractable pruritus and burning that worsens at night. The vulvar skin becomes thin (although sometimes thickened) and is often accompanied by white plaques. Progressive scratching and development of tissue adhesions may lead to occlusion of the introitus. The vaginal tissue may lose its elasticity, resulting in tears and erosion and contributes to a vaginal discharge. Diagnosis is via exam, and biopsy and treatment, like lichen planus, also entail topical corticosteroids.38,39

Early identification and diagnosis of lichen planus and lichen sclerosus are crucial to preserving vaginal structure and integrity. Lichen planus and lichen sclerosus may be missed if a pelvic exam is not performed on a patient complaining of vaginal discharge. NPs who identify signs of lichen planus and lichen sclerosus should not hesitate to refer the patient to a gynecologic specialist for evaluation.

Granulation tissue. The presence of persistent granulation tissue following gynecologic surgery has also been identified as a cause of vaginal discharge. A recent review found persistent granulation tissue occurred in 19% of postoperative cases for vaginal prolapse repair.40 Although more likely to cause vaginal spotting, discharge may also occur. The presence of blood in the vaginal vault may contribute to a vaginal pH of 4.7 or higher. If the patient has had gynecologic surgery within the past year, a careful inspection of the vulva, perineum, vagina, cervix, and/or vaginal cuff is warranted. If the bleeding or discharge is found to originate from granulation tissue, treatment with application of silver nitrate may be beneficial, although in some cases, repeat surgery intervention is required.41

Desquamative inflammatory vaginitis. Although a rare diagnosis, desquamative inflammatory vaginitis should be considered as a possible cause of vaginal discharge, particularly in perimenopausal women. It is characterized by profuse vaginal discharge accompanied by vaginal pain and inflammation. Vaginal exam reveals ecchymotic rash, erythema, and erosion. Microscopy does not identify a causative agent; however, the vaginal pH is increased (over 4.7), and vaginal flora is marked by an absence of lactobacilli. Unlike with vaginal atrophy, the vaginal structure with desquamative inflammatory vaginitis is maintained.41

However, vaginal atrophy and desquamative inflammatory vaginitis are often confused. Treatment with estrogen products does not alleviate symptoms with desquamative inflammatory vaginitis.40 Instead, the treatment of desquamative inflammatory vaginitis involves use of a vaginal antibiotic cream, such as clindamycin and/or hydrocortisone cream, intravaginally for a period of 4 to 6 weeks until the signs and symptoms are in remission.42 If the NP suspects desquamative inflammatory vaginitis, it maybe treated in the primary care setting, but if there is no relief of symptoms after 2 months, referral to a gynecologic specialist is advised.

Patient education

Patients must be instructed that often, a medical diagnosis is achieved through an elimination process, and if the symptoms do not improve within a specified period of time, the patient needs to return to the same provider. Too often, patients who are not cured on initial visit feel they have not been cared for appropriately and present to a different provider seeking answers, and the investigative process and treatment begins again. Patients must be educated that follow-up care with the same provider is imperative to arrive at a correct diagnosis.

Vaginal discharge in women may be due to a variety of both infectious and noninfectious causes. Do not assume that the patient has the common infectious causes of vaginal discharge, such as vulvovaginal candidiasis, bacterial vaginosis, or trichomoniasis. Treating a patient for a condition she does not have may exacerbate the symptoms and lead to frustration. The NP must take a careful history, perform a thorough physical exam, and necessary diagnostic testing before deciding on a course of action. Once vaginal infections have been ruled out, consider noninfectious causes of vaginal discharge.


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atrophic vaginitis; bacterial vaginosis; desquamative inflammatory vaginitis; genitourinary syndrome of menopause; lichen planus; lichen sclerosus; persistent vaginal discharge; trichomoniasis; vaginal discharge; vulvovaginal candidiasis

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