Download Vaginal discharge - Vaginitis

 Vaginal discharge - Vaginitis
Trichomoniasis, bacterial vaginosis, candidiasis
Recommend
 See “How to do an STI check”, page 466
 Treat for chlamydia/gonorrhoea if unsure and offer STI tests as part of your assessment
Background
 The cause of vaginal discharge can be difficult to diagnose on clinical examination
Related topics:
 Vaginal discharge – cervicitis, page 476
 Low abdominal pain in female – possible PID, page 484
1.
May present with:
Trichomonas is an STI that may present with:
 Positive test result
 Inflammation of the vulva and vaginal walls which may cause soreness or itching
 White or green vaginal discharge which is typically ‘frothy’ and has a ‘fishy’ odour
 Prelabour rupture of membranes and preterm delivery
Bacterial vaginosis (BV) (includes organisms such as gardnerella) is not sexually transmitted but is
caused by an overgrowth of bacteria and may present with:
 Laboratory report from the high vaginal swab notes the presence of ‘clue cells’ (Asymptomatic
infection)
 Vaginal discharge that is typically thin, white or grey and has a ‘fishy’ odour (similar to trichomonas
but not frothy and vaginal walls are not inflamed)
 Miscarriage, pre-labour rupture of membranes, preterm delivery
Candidiasis (thrush) is not sexually transmitted but is caused by an overgrowth of yeast and may present
with:
 Inflammation (redness, swelling) of the vulva or vagina causing itch or soreness
 Vaginal discharge is typically white, and sticks to the vaginal walls (curd like)
 Cracks or fissures in the skin folds (genital herpes must be excluded, see Genital sores / ulcers
 If found on a vaginal swab and the woman does not have symptoms – treatment is not required
 Candidiasis is common in healthy women, but can also overgrow as a result of high oestrogen
(pregnancy), high sugar (uncontrolled diabetes), immune suppression (HIV) or after taking some
antibiotics.
2.
Immediate management: not applicable
3.
Clinical assessment: See How to do an STI check
 History
 Examination
 if the woman complains of low abdominal pain or experiences pain during the examination
assess for PID. See Low abdominal pain in female – possible PID
 Testing:
 if the client presents with repeated episodes of vaginal thrush do a BGL and assess for risk of
HIV
 urinalysis: if nitrites are positive send mid stream urine for MC&S. See UTI (Adult)
 urine pregnancy test is indicated for all women of childbearing age (12-52 years)
 offer blood test for syphilis, HIV, hepatitis C and hepatitis B if not immune See Hepatitis and HIV
Infection
 If able to do a speculum examination take the following swabs
 endocervical swab for gonorrhoea and chlamydia PCR and MC&S and
 high vaginal swab for trichomonas PCR and for MC&S
 pap smear (+ Thin Prep) if due. See Pap smear
 If unable to do a speculum examination take the following
 self collected low vaginal swab for gonorrhoea and chlamydia PCR, for trichomonas PCR and
for MC&S
 If unable to do a speculum examination or self collected swabs
 first catch urine for gonorrhoea, chlamydia and trichomonas PCR
4.
Management: See How to do an STI check
Education
 Give information about trichomonas, BV and candida as appropriate
 Trichomoniasis is an STI but one that may persist in women for years

Discuss safe sex and provide condoms as appropriate
Medication Management
Treat for trichomonas if
 Vaginal discharge is typical of trichomoniasis
 Trichomonas is detected on a swab, urine specimen or Pap smear
Treat for bacterial vaginosis if
 Vaginal discharge is typical of BV
 High vaginal swab is suggestive of BV and the woman is pregnant or has symptoms
Treatment for trichomonas and bacterial vaginosis is the same; if not allergic treat with Metronidazole
(can be used if pregnant or breastfeeding)
DTP
IHW / RIN / SRH / NP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO
Rural and Isolated Practice/Sexual and Reproductive Health Program Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Form
Strength
Route of Administration
Recommended Dosage
Duration
Tablet
200mg; 400mg
Oral
2 gram
1 dose
Treatment with Metronidazole in the 1st trimester is contraindicated and in the 2nd and 3rd trimester should be
restricted to treatment for symptomatic disease
Provide Consumer Medicine Information if available: Avoid alcohol while and for 48hrs after taking this drug
Management of Associated Emergency: Consult MO
Schedule
4
Metronidazole
Or Tinidazole (not if pregnant or breastfeeding)
DTP
IHW / RIN / SRH / NP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO
Rural and Isolated Practice/Sexual and Reproductive Health Program Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Route of
Form
Strength
Recommended Dosage
Duration
Administration
Tablet
500mg
Oral
2 gram
1 dose
Provide Consumer Medicine Information if available: Avoid alcohol while and for 48hrs after taking this drug
Management of Associated Emergency:
Schedule
4
Tinidazole
If recurrent bacterial vaginosis consult MO as the woman may need a course,
rather than a single dose, of Metronidazole.
DTP
IHW / RIN / SRH / NP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO
Rural and Isolated Practice/Sexual and Reproductive Health Program Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Form
Strength
Route of Administration
Recommended Dosage
Duration
Tablet
200mg; 400mg
Oral
400 mg bd
7 days
Treatment with Metronidazole in the 1st trimester is contraindicated and in the 2nd and 3rd trimester should be
restricted to treatment for symptomatic disease
Provide Consumer Medicine Information if available: Avoid alcohol while and for 48hrs after taking this drug.
Management of Associated Emergency: Consult MO
Schedule
4
Metronidazole
Treat for candidiasis if:
 Inflammation or discharge is typical of candidiasis
 Candida is detected on a vaginal swab and symptoms are present
 Ask about allergy to anti-yeast/anti-fungal preparations
Schedule
3
Clotrimazole
Vaginal Cream
DTP
IHW / SRH / NP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO
Sexual and Reproductive Health Program Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Route of
Form
Strength
Recommended Dosage
Administration
Cream,
Cream 1%
For vaginal use
Use once daily, preferably in the evening for 6
35g tube
successive days, 1 applicator should be filled with
cream and inserted as deeply as possible into the
vagina with the client lying on her back.
Provide Consumer Medicine Information if available:
Management of Associated Emergency As for severe allergic reaction see
Duration
6 days
Contact Tracing:
Contacts - Trichomonas:
 Treat regular male partners. Men are usually asymptomatic but should have an STI check and be
treated with either Metronidazole or Tinidazole
 Women may remain infected with trichomonas for months or years. It is important that women and
their partners understand that detecting trichomonas on a swab or Pap smear may not necessarily
indicate that it has been recently acquired
 Contacts of women with BV and candidiasis do not need to be treated
5.
Follow up:
 Follow up at 1 week and at 2-3 months is important.
 See How to do an STI check
6.
Referral /Consultation:
 Consult MO if pregnant or if symptoms are recurrent or severe.