Vaginal Discharge
Jan 2014
Q1. A 24-year-old woman presents due to an itchy vulva and pain during sex. She also
mentions a green, offensive vaginal discharge for the past 2 weeks. What is the most
likely diagnosis?
Candida
Bacterial vaginosis
Gonorrhoea
Trichomonas vaginalis
Chlamydia
Q2. A 30-year-old woman presents with a white, malodorous vaginal discharge. There is
no associated itch or dyspareunia. A diagnosis of bacterial vaginosis is suspected.
Overgrowth of which one of the following organisms is most likely to cause this
presentation?
Lactobacilli
Trichomonas
Candida
Mycoplasma hominis
Gardnerella
Vaginal discharge
Vaginal discharge is a common presenting symptom and is not always pathological
Common causes
-physiological
-Candida
-Trichomonas vaginalis
-bacterial vaginosis
Less common causes
-Chlamydia and Gonorrhoea can cause a vaginal discharge this is rarely the presenting
symptoms
-ectropion
-foreign body
-cervical cancer
Condition
Key features
Candida ( Thrush)
'Cottage cheese' discharge
Vulvitis
Dysuria
Itch
Tx-fluconazole po, clotrimazole
,econazole and miconazole come in
pessary form.
Trichomonas vaginalis
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Bacterial vaginosis
Offensive, thin, white/grey, 'fishy' discharge
Q3.A 41-year-old female is diagnosed as having Trichomonas vaginalis. What is the
most appropriate management
•
•
•
•
•
Clotrimazole pessary
Oral doxycycline
Advice regarding hygiene and cotton underwear
Oral itraconazole
Oral metronidazole
Q4. Which one of the following features is least consistent with Trichomonas vaginalis
•
•
•
•
•
Strawberry cervix
Vulvovaginitis
Vaginal pH < 4.5
Urethritis in men
Frothy green discharge
Trichomonas vaginalis
Trichomonas vaginalis is a highly motile, flagellated protozoan parasite
Features
vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis
strawberry cervix
pH > 4.5
in men is usually asymptomatic but may cause urethritis
Investigation
microscopy of a wet mount shows motile trophozoites
Management
oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off
dose of 2g metronidazole
Q5.A 25-year-old woman attends clinic for her regular cervical smear test. She is not
complaining of any symptoms.
The results of the smear show no evidence of dysplasia but the pathologist notes the
presence of fusiform protozoa in the specimen.
Which of these is the most likely diagnosis?
•Bacterial Vaginosis
•Candida Infection
•Group A Streptococcus infection
•Herpes simplex virus infection
•Trichomonas vaginalis infection
Q6. A 23-year-old female presents 16 weeks into her pregnancy with a vaginal
discharge. Further investigation confirms infection with Chlamydia trachomatis.
Which of the following is the most appropriate treatment for this patient?
•Azithromycin
•Cotrimoxazole
•Doxycycline
•Erythromycin
•Metronidazole
Current UK guidelines recommend three different options in pregnancy:
Erythromycin 500 mg QDS for 7 days or BD for 14 days
Amoxicillin 500 mg TDS for 7 days
Azithromycin 1 g stat - the BNF cautions that this should only be used if there are no
Q7.A 31-year-old woman presents as she has noted an offensive, fishy vaginal discharge.
She describes a grey, watery discharge. What is the most likely diagnosis?
•Trichomonas vaginalis
•Candida
•Chlamydia
•Bacterial vaginosis
•Physiological discharge
Q8 .A 30-year-old woman presents with a week long history of an offensive smelling
greenish-yellow vaginal discharge with associated vulval itching. She does not complain
of lower abdominal pain.
She has not been seen by you personally at the clinic and has social problems with
frequent episodes of homelessness. She is unkempt and admits to sleeping on the
streets. She refuses your request that she should be seen at the local genito-urinary
medicine (GUM) clinic. Her scant records are full of "did not attend" entries. Examination
reveals a greenish-yellow discharge but is otherwise unremarkable.
Which of the following is the most appropriate approach for this woman?
•Admit to hospital
•Empirically treat with ciprofloxacin, azithromycin, metronidazole and clotrimazole
•Empirically treat with ciprofloxacin only
•Routine referral to gynaecology
•Take a swab and ask patient to return in one week for the results
Bacterial vaginosis
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms
such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing
aerobic lactobacilli resulting in a raised vaginal pH.
Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually
active women.
Features
•vaginal discharge: 'fishy', offensive. There is no associated soreness, itching or irritation
•asymptomatic in 50%.
•There may be a white, homogenous discharge coating the walls of the vagina and
vestibule but usually no signs of inflammation
Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present
•thin, white homogenous discharge
•clue cells on microscopy
•vaginal pH > 4.5
•positive whiff test (addition of potassium hydroxide results in fishy odour)
Management
•oral metronidazole for 5-7 days
•70-80% initial cure rate
•relapse rate > 50% within 3 months
the BNF suggests topical metronidazole or topical clindamycin as alternatives
Risk factors for BV include:
Vaginal douching
Recent change of sex partner
Smoking
Receptive cunnilingus
Black ethnicity, and
The presence of other infections such as Chlamydia or herpes.
Treatment is indicated for symptomatic women and women undergoing some
surgical procedures. the recommended regimes are:
Metronidazole 400 mg twice daily for 5-7 days
Metronidazole 2 g single dose
Intravaginal metronidazole gel (0.75%) once daily for 5 days
Intravaginal clindamycin cream (2%) once daily for 7 days
Alternative regimens include:
Tinidazole 2 g single dose (A), or
Clindamycin 300 mg twice daily for 7 days (A).
Q9 A 28-year-woman presents with a vaginal discharge. This is clear, intermittent and
has been present for a number of months. She has no other symptoms and is in a stable
relationship.
With respect to the discharge which one answer is true?
(Please select 1 option)
•The most likely cause is a physiological discharge
•The most likely cause is bacterial vaginosis
•The most likely cause is candidiasis
•She should be screened for STI
•With these symptoms a speculum and cervical swab is indicated
Q10. A 30-year-old woman in a stable relationship is complaining of a vaginal discharge.
There is no irritation but a fishy odour.
Swabs are all negative. She is allergic to metronidazole.
What is the best option for treatment?
Clindamycin cream
Clotrimazole cream
Oral co-amoxiclav
Oral erythromycin
Oral fluconazole
Q10.A 21-year-old woman with persistent dysuria tests positive for Chlamydia.
She agrees for referral to GUM for contact tracing. Who should be contacted?
•All partners from the 3 months prior to the onset of symptoms
•All partners from the last 6 months or the most recent sexual partner
•All partners from the last 3 months or the most recent sexual partner
•All partners from the last 12 months or the most recent sexual partner
•All partners from the 4 weeks prior to the onset of symptoms
Chlamydia - partner notification:
symptomatic men: all partners from the 4 weeks prior to the onset of symptoms
women + asymptomatic men: all partners from the last 6 months or the most
recent sexual partner
Q11.What is the most appropriate antibiotic to treat uncomplicated Chlamydia infection
in a 21-year-old female who is not pregnant?
•Erythromycin
•Ciprofloxacin
•Metronidazole
•Cefixime
•Azithromycin
Q12.A 30-year-old man comes to surgery. He has been handed a slip from an exgirlfriend stating she has tested positive for Chlamydia. He last slept with her 2 months
ago. He has no symptoms of note, in particular no dysuria or discharge. What is the most
appropriate management?
Reassure symptoms would have presented by now
Offer antibiotic therapy
Offer Chlamydia testing and antibiotic treatment immediately without waiting for the
results
Offer Chlamydia testing and antibiotic treatment if positive
Notify public health
Chlamydia
Chlamydia is the most prevalent sexually transmitted infection in the UK and is caused
by Chlamydia trachomatis, an obligate intracellular pathogen.
Approximately 1 in 10 young women in the UK have Chlamydia.
The incubation period is around 7-21 days, although it should be remembered a large
percentage of cases are asymptomatic
Features
asymptomatic in around 70% of women and 50% of men
women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria
Potential complications
epididymitis
pelvic inflammatory disease
endometritis
increased incidence of ectopic pregnancies
infertility
reactive arthritis
perihepatitis (Fitz-Hugh-Curtis syndrome)
Investigation
traditional cell culture is no longer widely used
nuclear acid amplification tests (NAATs) are now rapidly emerging as the investigation of
choice
urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the
NAAT technique
Screening
in England the National Chlamydia Screening Programme is open to all men and women
aged 15-24 years
the 2009 SIGN guidelines support this approach, suggesting screening all sexually active
patients aged 15-24 years
relies heavily on opportunistic testing
Management
•Doxycycline (7 day course) or azithromycin (single dose).
•The 2009 SIGN guidelines suggest azithromycin should be used first-line due to
potentially poor compliance with a 7 day course of doxycycline
if pregnant then erythromycin or amoxicillin may be used.
The SIGN guidelines suggest considering azithromycin 'following discussion of the
balance of benefits and risks with the patient’
Q13.A 32-year-old woman complains of lower abdominal pain/ pelvic pain over the last
five days. She also has a raised temperature.
She had an IUCD inserted three weeks ago.
A pregnancy test is negative, she has a small amount of vaginal discharge, and she has
white blood cells present on dipstick test of her urine.
What is the most likely cause of these symptoms in this patient?
Ectopic pregnancy
Pelvic inflammatory disease (PID)
Ruptured ovarian cyst
Urinary tract infection
A 24-year-old female attends complaining of an offensive frothy yellow vaginal discharge
with associated vulva itch, and dysuria. Pelvic examination reveals punctuate mucosal
haemorrhages on the cervix.
What is the most appropriate treatment regime based on the history and clinical
examination?
Oral azithromycin 1 g as a single dose
Oral doxycycline 100 mg BD for seven days
Oral fluconazole 150 mg single dose
Oral metronidazole 400 mg BD for seven days