Signs and Symptoms

Discharge may be accompanied by itch, odour, or bleeding

History and Examination

If empirical treatment fails then examination, endo-cervical and high vaginal swabs are indicated

Differential Diagnosis

• Physiological discharge is common and seen particularly after a change in contraception. If there is no itch, odour, or blood then reassure, but examine if persists
• Itch predominant - candida most likely
• Odour prominent - bacterial vaginosis most likely
• Post-menopausal atrophic vaginitis and bacterial overgrowth can co-exist
• Group A, C, and G streptococci less common but important cause postmenopausally
• Other STIs - if high risk then GUM referral most appropriate
• Malignancy
• Fistula
• Foreign body

Bleeding or blood stained discharge- follow appropriate post coital, inter-menstrual, post-menopausal bleeding Clinical Referral Guidelines.

Suspicion of malignancy on examination – 2ww gynaecology

In the absence of red flag symptoms empirical treatment and a self-taken Lower Vaginal Swab for chlamydia in sexually active women are appropriate first line investigations.

Failure of empirical treatment should prompt examination, Endo-cervical Swab and High Vaginal Swab - ensure that adequate clinical details are available to microbiology on the request form e.g. 'post-menopausal vaginal discharge, no response to clotrimazole'

If symptoms persist and there is a strong clinical suspicion of infection, based on examination, and microbiology results have not identified a cause, then consider discussing with the local laboratory about the need to do more extended testing on a repeat swab

Formulary chapter 7.2.2 - vaginal and vulval infections

If empirical treatment is successful, but recurrent symptoms, retreat.

See formulary treatment of vulvovaginal candida, treatment of bacterial vaginosis, and Recurrent Vulvo-Vaginal Candidiasis

Formulary chapter 5 - Genital tract infections

Post-menopausal discharge - both bacterial overgrowth and atrophy are likely to be reduced with use of topical oestrogens.

Treat as guided by microbiology, if this fails discuss with microbiology and consider referral to GUM.

Devon Sexual Health - Contraception, Sexual Health and HIV Service

Referral Criteria

Any bleeding or blood-stained discharge, or concern about malignancy on examination - use appropriate 2WW proforma or Clinical Referral Guidelines to refer.

GUM referrals- patient self-referral, if has already undergone examination and investigation in primary care a supporting letter from GP is helpful

Referral Instructions

2ww referral see – Gynaecology 2ww guideline

Gum referral

To book an appointment please contact:

• 0300 303 3989

Referral Form

2ww gynaecology referral form

Patient Information

Devon Sexual Health - Contraception, Sexual Health and HIV Service

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: November 2018