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Emergency and Acute Medicine: Vaginal Discharge / Vaginitis
Vaginitis refers to inflammation of the vulva and vagina, which may occur with or without abnormal vaginal discharge. Common symptoms include itching, burning, irritation, pain, and dyspareunia. Although vaginal discharge can be normal, abnormal discharge is characterized by an increase in amount or a change in color or odor. Normal cervical mucus is typically clear but may appear white or yellow when exposed to air.
The most common cause of vaginitis is Bacterial vaginosis, which results from a loss of protective lactobacilli and overgrowth of organisms such as Gardnerella and anaerobes. Other important infectious causes include Trichomoniasis caused by Trichomonas vaginalis, and Vulvovaginal candidiasis caused by Candida species. Additional etiologies include bacterial infections (e.g., group A streptococcus), viral infections such as herpes simplex virus, chemical irritants, foreign bodies, atrophic vaginitis from estrogen deficiency, hypersensitivity reactions, and systemic diseases.
Patients typically present with vaginal discharge, pruritus, irritation, dysuria, and sometimes abnormal odor. Some may be asymptomatic. A careful history is essential and should include symptom duration, discharge characteristics, menstrual timing, sexual history, contraceptive use, hygiene practices, recent antibiotic use, and risk of pregnancy. Associated abdominal pain should prompt evaluation for pelvic inflammatory disease.
Physical examination includes abdominal assessment and a pelvic exam with inspection of the vulva, vagina, and cervix, often using a speculum. The essential diagnostic workup includes saline and potassium hydroxide (KOH) wet mount microscopy of vaginal discharge. Vaginal pH testing is also useful: a pH greater than 4.5 suggests bacterial vaginosis or trichomoniasis, whereas candidiasis typically has a normal pH.
Microscopy findings help distinguish causes. Clue cells indicate bacterial vaginosis, motile flagellated organisms confirm trichomoniasis, and pseudohyphae or budding yeast on KOH prep indicate candidiasis. The “whiff test” (amine odor after adding KOH) is positive in bacterial vaginosis and trichomoniasis. Additional testing may include nucleic acid amplification tests for sexually transmitted infections, cultures, and screening for Chlamydia infection, Gonorrhea, syphilis, and HIV when appropriate.
Treatment depends on the underlying cause. Bacterial vaginosis is treated with metronidazole or clindamycin. Candidiasis is managed with oral fluconazole or topical azole antifungals. Trichomoniasis requires metronidazole or tinidazole, and sexual partners must also be treated to prevent reinfection. Sexually transmitted causes such as chlamydia and gonorrhea require appropriate antibiotic therapy and partner treatment. Herpes simplex infections are treated with antivirals such as acyclovir. Noninfectious causes require removal of irritants, foreign body removal, or specialist referral.
Patients should be counseled to avoid sexual activity until treatment is completed when sexually transmitted infections are suspected or confirmed. Education on safe sexual practices and screening for other sexually transmitted infections is important. Most cases can be managed on an outpatient basis with follow-up in about one week.
Key clinical pearls include recognizing that vaginal pH helps differentiate causes, candidiasis often occurs after antibiotic use or in immunocompromised states, and trichomoniasis is associated with sexual transmission and requires partner treatment. Always consider coexisting sexually transmitted infections and ensure appropriate testing and counseling.
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