Vaginal discharge is any fluid that comes from the vagina. It plays a protective role in keeping the vagina moist, clean, and infection-free. It is a usual chief complaint among women of reproductive age. A thorough history, examination, and testing can help distinguish between physiological and pathological discharge and its causes.
Physiological discharge
Physiological vaginal discharge is clear, colorless/white, odorless, and contributed by lactobacilli (normal vaginal flora), ensuring the normal vaginal pH is maintained between 3.8 and 4.5. Hormonal levels influence the consistency and quantity of the discharge. They are variable throughout the menstrual cycle, being very wet and stretchy like raw egg white during the ovulatory phase and thick and sticky for most of the remaining cycle. Furthermore, the discharge becomes excessive during pregnancy, arousal, and contraceptive usage. It reduces with menopause due to a decline in estrogen levels.
Abnormal pathological discharge
A difference in color, consistency, quantity, and odor frequently depicts abnormal vaginal discharge. Accompanying symptoms may include itching, burning, dyspareunia, dysuria, lower abdominal/pelvic pain, and postcoital/intermenstrual bleeding.
Etiological factors include:
- Infective causes:
- Non-STIs:
- Bacterial Vaginosis
- Vulvovaginal Candidiasis (yeast infection)
- Sexually transmitted infections (STIs):
- Trichomonas Vaginalis
- Gonorrhea
- Chlamydia
- Irritants:
- Perfumes, deodorants
- Douching
- Excessive washing intravaginally
- Drug-Induced
- Foreign body:
- Intrauterine contraceptive devices (IUCDs)
- Retained tampons
- Atrophic Vaginitis
- Fistulae
- Benign & malignant tumors of the genital tract
- Trauma:
- Perineal repair or vaginal surgery
- Vaginal vault granulation tissue (often seen after total abdominal hysterectomy)
- Non-STIs:
Infections are the leading cause of the pathological discharge and have unique distinguishing factors.
Bacterial vaginosis is one of the most typical causes of abnormal vaginal discharge. It is characterized by a gray/white, thin discharge having a “fishy” odor and associated vaginal pruritis and burning urination when accompanied by candidiasis.
Vulvovaginal candidiasis, another common cause of pathological discharge, presents with a white, thick, curdy “cottage cheese” discharge, commonly odorless and associated with vulvovaginal pruritis, swelling, skin excoriation, and burning urination.
Trichomonas vaginitis presents a yellow-green, frothy discharge with a “fishy” odor and associated soreness, pruritis, dyspareunia, and dysuria. A pelvic examination usually reveals a strawberry cervix. The male partner may also complain of dysuria, pain during ejaculation, thin, white penile discharge, and swelling and redness around the glans penis.
Gonorrhea presents a green or yellow, thick discharge with a “mushroom-like” odor and associated dysuria and intermenstrual bleeding. Similar discharge and dysuria may be seen in the male partner, although infected men and women may be asymptomatic. Moreover, it can also be passed from an infected mother to a newborn infant after vaginal delivery.
Chlamydia presents a thick, white, yellow, or gray discharge with a strong smell. It may cause cervicitis, pelvic inflammatory disease (PID), urethritis (commonly observed in men), perihepatitis (Fitz-Hugh-Curtis syndrome), epididymitis, proctitis, prostatitis, reactive arthritis, conjunctivitis, pneumonia, pharyngitis and lymphogranuloma venereum. Moreover, it can also be passed from an infected mother to a newborn infant after vaginal delivery. Associated symptoms depend upon the location and degree of involvement but generally include lower back/abdominal pain, fever, dysuria, and postcoital/intermenstrual bleeding.
Atrophic Vaginitis, commonly occurring in postmenopausal women, results in vaginal dryness, thinning, inflammation, dyspareunia, and thick discharge.
Genital tract tumors, whether benign (cervical/endometrial polyps) or malignant (cervical/endometrial carcinomas), often present with brown, bloody discharge and should especially raise concern in postmenopausal women so that prompt management and removal are possible.
Evaluation, investigations, and diagnosis
Accurate diagnosis of any vaginal discharge requires a thorough history, physical/pelvic examination followed by high vaginal swabs, wet prep, cell cultures, gram staining, DNA hybridization probes, and curettage/biopsy, as ordered by the primary physician or attending gynecologist.
Management of vaginal discharge
Prevention of causative factors should be the mainstay of management. Proper patient counseling can prove very fruitful in preventing future concerns. Use of barrier contraceptives (condoms), non-promiscuity, disuse of irritants/causative drugs, removal of foreign bodies, and gentle cleaning of the intravaginal area can ward off several etiological elements.
Infective bacterial causes are better treated with antibiotics like Metronidazole, Clindamycin, etc. Candidiasis is treated with oral/topical antifungals like Clotrimazole, Fluconazole, Itraconazole, etc. (type and dosage of antibiotics and antifungals are to be decided by the attending physician/gynecologist).
Tumors of the genital tract are primarily treated with surgical excision, which may be followed by radio/chemotherapy in malignant cases. Atrophic Vaginitis is best treated with topical estrogen therapy.
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In conclusion, prevention is better than treatment. Proper management of any cause of vaginal discharge should be done by a healthcare professional. Self-medication with over-the-counter drugs can cause more harm than benefit by creating resistance in cases of infections.
Any new vaginal discharge with changed characteristics should be reported to your primary physician as soon as possible, as timely treatment can prevent progression, prove life-saving and be cost-effective.
