Changes

February 2024 — reviewed. A literature search was conducted in October 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Assess women with vaginal discharge.
• Identify women with abnormal vaginal discharge.
• Manage women with abnormal vaginal discharge.
• Provide appropriate information and advice to women with vaginal discharge.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

What is it?

• Vaginal discharge may be physiological (normal) or pathological (abnormal).
  • Physiological vaginal discharge is a white or clear, mucus-like, non-offensive discharge that varies with the menstrual cycle and in the different reproductive stages. For example:
    • It is thick and sticky for most of the menstrual cycle but becomes clearer, wetter, slippery, and stretchy before ovulation (due to a rise in oestrogen levels).
    • It is heavier and more noticeable during pregnancy, with contraceptive use, and with sexual stimulation (due to high oestrogen levels).
    • It decreases in volume at menopause (due to a fall in oestrogen levels).
  • Pathological vaginal discharge is characterized by a change in colour, consistency, volume, and/or odour. It may be associated with symptoms such as itch, soreness, dysuria, pelvic pain, or intermenstrual or post-coital bleeding. It is most commonly caused by infection, but there can be non-infective causes.

[CoSRH, 2012; Colver, 2013; Powell, 2015; BMJ Best Practice, 2023]

What are the causes of abnormal vaginal discharge?

• Abnormal vaginal discharge can be due to infective or non-infective causes. 
  • Infective (non-sexually transmitted) causes include:
    • Bacterial vaginosis.
    • Vulvovaginal candidiasis. 
  • Infective (sexually transmitted) causes include:
    • Chlamydia trachomatis.
    • Neisseria gonorrhoeae.
    • Trichomonas vaginalis.
  • Non-infective causes include:
    • Inadequate hygiene.
    • Retained foreign body (such as a tampon, condom or vaginal sponge).
    • Irritant and allergic vaginitis.
    • Behçet's syndrome.
    • Desquamative inflammatory vaginitis.
    • Erosive lichen planus.
    • Vaginal fistulae.
    • Gynaecological cancers.
    • Genitourinary syndrome of menopause.

How should I assess a woman with vaginal discharge?

• Take a detailed clinical history to assess whether it is a normal physiological discharge or whether an infective or non-infective cause is likely.
  • Ask about:
    • The characteristics of the discharge, including the onset, duration, colour, smell, and consistency. 
    • Associated symptoms, including itch, abdominal pain, superficial dyspareunia, vulval or vaginal pain, abnormal bleeding (heavy, intermenstrual, or postcoital), deep dyspareunia, pelvic or abdominal pain, or fever.
    • Any exacerbating factors, such as after intercourse.
    • Previous treatments (prescription or over-the-counter) and their effects.
    • The use of vaginal products, such as douches, deodorant, and vaginal washes.
    • Cyclical symptoms.
    • Past medical history. 
    • Drug history, including contraceptive use.
  • Assess the woman's risk of sexually transmitted infection (STI). Women are considered at increased risk of an STI if they:
    • Have condomless sex with new or casual partners or
    • Are younger than 25 years of age, or
    • Have had a new sexual partner or more than one sexual partner in the last 12 months or
    • Have had a previous STI, or
    • Are of Black ethnicity.
  • An examination may be omitted and empirical treatment started if:
    • History indicates vulvovaginal candidiasis or bacterial vaginosis, and
    • The risk of STI is low, and
    • There are no symptoms indicative of upper genital tract infection (such as abnormal bleeding, deep dyspareunia, pelvic or abdominal pain, or fever).
• If examination is indicated, obtain consent and offer a chaperone.
  • Inspect the vulva for obvious discharge, lesions, vulvitis, ulcers, and other changes.
  • Perform a speculum examination (except in a pregnant woman with a low-lying placenta) to visualize the cervix and vagina to look for foreign bodies and characteristic signs of an infective or non-infective cause of vaginal discharge.
  • Test the pH of the vaginal discharge (using a narrow-range pH paper) to help distinguish between bacterial vaginosis (pH 4.5 or above) and vaginal candidiasis (pH less than 4.5). 
    
    • The normal vaginal pH in a woman of childbearing age is less than 4.5.
    • pH testing cannot be used to differentiate between bacterial vaginosis and trichomoniasis, as both conditions reduce the normal acidity of the vagina (to pH 4.5 or above). 
  • If there is any suggestion of upper genital tract infection (such as abnormal bleeding, deep dyspareunia, pelvic or abdominal pain, or fever): 
    • Palpate the abdomen (if appropriate) to assess for tenderness or a mass (which may also indicate malignancy).
    • Consider a bimanual pelvic examination to assess for adnexal tenderness (with or without a palpable mass), cervical motion tenderness, or uterine tenderness.
    • Consider a diagnosis of pelvic inflammatory disease in any woman aged under 25 years who has recent onset bilateral lower abdominal pain associated with local tenderness on bimanual examination, in whom pregnancy has been excluded.
  • High vaginal swabs may be used to aid the diagnosis of bacterial vaginosis, vulvovaginal candidiasis, Trichomonas vaginalis, or other genital tract infections (such as streptococcal organisms), but their use should generally be reserved for when:
    • Symptoms, signs, or pH are inconsistent with a specific diagnosis.
    • The woman is pregnant, postpartum, post-abortion, post-miscarriage, post-instrumentation, or pre-or post-gynaecological surgery.
    • It is within 3 weeks of intrauterine contraceptive insertion.
    • Symptoms are recurrent (four or more cases a year).
    • There is no, partial, or poor response to treatment.
•  Arrange investigations depending on history and examination.
  • If the woman is at high risk of an STI, offer testing for chlamydia, gonorrhoea, trichomoniasis, HIV, and syphilis. 
    
    • Strongly recommend referral to a genito-urinary medicine (GUM) clinic to facilitate testing and, if needed, treatment and partner notification.
    • If the woman is unwilling or unable to attend a GUM clinic, testing can be done in primary care if the appropriate expertise is available. For more information on testing, see the CKS topics on Chlamydia - uncomplicated genital, Gonorrhoea, Trichomoniasis, HIV infection and AIDS, and Syphilis.
  • Consider the following additional tests if appropriate:
    • Urine pregnancy test — to exclude pregnancy.
    • Urine dipstick — to exclude a urinary tract infection. For more information, see the CKS topics on Urinary tract infection (lower) - women and Urinary tract infection - children.

Infective Causes of Vaginal Discharge

• Infective causes of vaginal discharge include:
  • Bacterial vaginosis
    • The most common cause of abnormal vaginal discharge in women of reproductive age.
    • Caused by an overgrowth of predominantly anaerobic organisms (such as Gardnerella vaginalis, Prevotella species, Mycoplasma hominis, and Mobiluncus species).
    • Typically presents with an offensive fishy-smelling vaginal discharge and is not associated with soreness, itching, or irritation. Many women (approximately 50%) are asymptomatic.
    • On examination, a thin, grey/white, homogenous discharge coating the walls of the vagina and vestibule may be seen. There is usually no vulvovaginal inflammation or soreness unless there is associated candidiasis.
    • For more information, see the CKS topic on Bacterial vaginosis.
  • Vulvovaginal candidiasis 
    • Caused by yeasts that belong to the genus Candida; C. albicans is the most common and accounts for 80–89% of cases.
    • Typically presents with a vulval itch and a non-offensive vaginal discharge. Other symptoms can include soreness or burning, superficial dyspareunia, and cyclical symptoms.
    • On examination, erythema, fissuring, swelling/oedema, and vaginal discharge (typically non-offensive and curdy but may be thin or absent) may be seen. There may also be satellite lesions and excoriation marks. 
    • For more information, see the CKS topic on Candida - female genital.
  • Chlamydia 
    • The most common bacterial sexually transmitted infection (STI) in the UK.
    • Caused by Chlamydia trachomatis.
    • About 70% of women will be asymptomatic. When present, symptoms include increased vaginal discharge, post-coital and intermenstrual bleeding, dysuria, lower abdominal pain, and deep dyspareunia.
    • On examination, there may be mucopurulent cervicitis with or without contact bleeding, pelvic tenderness, and cervical motion tenderness.
    • For more information, see the CKS topic on Chlamydia - uncomplicated genital.
  • Gonorrhoea 
    • An STI caused by Neisseria gonorrhoeae.
    • Up to 50% of women will be asymptomatic.
    • The most common symptom is an increased or altered vaginal discharge. In about 25% of people, lower abdominal pain is present. Gonorrhoea rarely causes intermenstrual bleeding and menorrhagia.
    • On examination, a mucopurulent endocervical discharge may be seen, and easily induced endocervical bleeding may be present. Pelvic and lower abdominal tenderness are uncommon examination findings in the absence of co-infection with C. trachomatis.
    • For more information, see the CKS topic on Gonorrhoea.
  • Trichomoniasis  
    
    • Relatively rare in the UK.
    • An STI caused by the flagellated protozoan Trichomonas vaginalis.
    • About 10–50% of women are asymptomatic. When present, the most common symptoms include vaginal discharge, vulval itching, dysuria, or offensive odour, but these are not specific for T. vaginalis. Occasionally, the presenting complaint is of lower abdominal discomfort or vulval ulceration.
    • On examination, vaginal discharge may be seen (in up to 70% of women). Vaginal discharge varies in consistency from thin and scanty to profuse and thick; the classical frothy yellow discharge occurs in 10–30% of women. Other signs include vulvitis and vaginitis. About 2% of women will have a strawberry cervix appearance to the naked eye (higher rates are seen on colposcopic examination). About 5–15% of women will have no abnormalities on examination.
    • For more information, see the CKS topic on Trichomoniasis.
• Pelvic inflammatory disease (PID) is a general term for infection of the upper genital tract, which typically affects sexually active young women.
  • It is commonly, but not exclusively, caused by STIs; N. gonorrhoea and C. trachomatis account for a quarter of UK cases.
  • The infection spreads upwards from the vagina and endocervix due to damage to the genital tract epithelium, causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess, and/or pelvic peritonitis.
  • PID typically presents with lower abdominal pain (typically bilateral), deep dyspareunia, abnormal vaginal bleeding (including post-coital, inter-menstrual, and menorrhagia), secondary dysmenorrhoea, and abnormal vaginal or cervical discharge (often purulent).
  • Examination may reveal lower abdominal tenderness (usually bilateral), adnexal tenderness, cervical motion tenderness, and fever (over 38°C).
  • Delaying treatment is likely to increase the risk of long-term sequelae, such as ectopic pregnancy, infertility, and pelvic pain. Due to this and the lack of definitive diagnostic criteria, a low threshold for empiric treatment is recommended. 
  • For more information, see the CKS topic on Pelvic inflammatory disease.

Non-Infective Causes of Vaginal Discharge

• Non-infective causes of vaginal discharge include:
  • Inadequate hygiene
    • Can result from practices such as inadequate vaginal cleaning, not changing tampons and pads regularly, and wiping from back to front after using the toilet.
    • Typically presents with itching and malodour. The person may have a history of frequent vaginal fungal infections.
    • On examination, vaginal discharge and smegma (a white, cheese-like substance that collects in the labial folds) may be seen.
  • Retained foreign body, such as a tampon, condom, or vaginal sponge
    • May present with foul-smelling or bloody vaginal discharge.
    • On examination, irritation of the labia and inner thighs may be seen.
    • A longstanding foreign body can lead to extensive adhesion formation with near-complete obstruction of the vagina inferior to the location of the foreign body.
  • Irritant or allergic vaginitis
    • Associated with the use of chemical irritants (such as soaps, tampons, pads, and condoms) or caused by a reaction to latex, sperm, douching, or dyes.
    • On examination, vulvar erythema and non-specific vaginal discharge may be seen.
    • Discontinuation of the irritant usually results in symptom resolution.
  • Behçet's syndrome
    • A rare disorder that causes inflammation of the blood vessels and tissues.
    • Typically presents with a history of oral and genital ulcers and uveitis. It may also involve the joints, skin, central nervous system, and gastrointestinal tract. 
    • On examination, vulval or vaginal ulcers, scarring, and vaginal discharge may be seen.
  • Desquamative inflammatory vaginitis
    • Chronic and exudative vaginitis associated with purulent and copious discharge. Other symptoms may include dyspareunia, dysuria, bleeding after intercourse, malodour, and vulval symptoms (such as irritation, burning, dryness, or itching). 
    • On examination, a blood-stained or yellow, profuse or sticky vaginal discharge may be seen, as well as vaginal petechiae. There may be mucosal erythema with bruising or erosions.
  • Erosive lichen planus
    • A chronic and painful condition affecting mucosal surfaces, mainly the mouth and the genitals.
    • Genital erosive lichen planus affects the inner aspects of the vulva, especially the labia minora and vestibule. Lesions are usually very itchy and can be very painful.
    • On examination, the affected mucosa is bright red and raw. The clitoral hood may disappear, and the labia minora can shrink and stick to each other or the labia majora. 
  • Vaginal fistula
    • There may be a history of pelvic or vaginal surgery, radiation, or Crohn's disease, with continuous discharge consistent with urine or liquid stool.
    • Vaginal fistulas can also develop after childbirth (with perineal or vaginal lacerations or episiotomy) or vaginal surgery. Vaginal discharge may result from granulation tissue or a surgical site infection.
  • Gynaecological cancers
    
    • Some gynaecological cancers may present with abnormal vaginal discharge. 
    • For more information, see the section on Symptoms suggestive of gynaecological cancers in the CKS topic on Gynaecological cancers.
  • Genitourinary syndrome of menopause
    • Describes combined vulvovaginal and urinary tract symptoms caused by thinning and shrinking of the tissues of the vulva, vagina, urethra, and bladder due to oestrogen deficiency. 
    • Presents with itching, burning, discomfort, dyspareunia, yellowish malodorous vaginal discharge, or vaginal bleeding.
    • On examination, the vaginal epithelium appears pale, smooth, and shiny. Inflammation with patchy erythema, petechiae, and increased friability may be present.
    • For more information, see the CKS topic on Menopause.

Scenario: Management of vaginal discharge

From age 12 years onwards (Female).

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of vaginal discharge.

Search dates

April 2018 - October 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Vaginal Discharge/, vaginal discharge$.tw.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.