SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Vaginal Discharge

Vaginal discharge is common and usually benign, but the cause must be found. This guide covers normal and abnormal discharge, the four common pictures, bedside tests, treatment by cause, special groups, and counselling, using the SWAB approach.

🎯 AT A GLANCE — VAGINAL DISCHARGE

Vaginal discharge is one of the commonest reasons women attend a clinic; most is normal or caused by bacterial vaginosis, candidiasis, or trichomoniasis, but cervicitis, pelvic inflammatory disease, and cancer can present the same way

Normal discharge is clear to white, odourless, non-itchy, and varies with the cycle; the vaginal pH is 3.8–4.5

Diagnose with a speculum examination, vaginal pH, the whiff test, and a wet mount rather than guessing from the smell or colour

Treat the cause: metronidazole for bacterial vaginosis and trichomoniasis, an azole for candidiasis, and treat the partner for trichomoniasis and gonorrhoea or chlamydia

Where tests are not available, use syndromic management as in the national programme, and always screen for HIV and syphilis

Never treat blindly more than once: persistent or recurrent discharge needs a speculum examination and tests

🚨 ACT NOW IF

Lower abdominal pain, fever, pain on intercourse, or cervical motion tenderness — pelvic inflammatory disease: start treatment and consider admission

Blood-stained or foul discharge, post-coital bleeding, or any discharge after menopause — exclude cervical or endometrial cancer

Watery leaking in pregnancy — suspect rupture of membranes; offensive discharge with fever after delivery, abortion, or a procedure — retained products or infection

Discharge in a young girl who has not reached puberty — foreign body, worms, or abuse; refer

Discharge after sexual assault, or with genital ulcers or warts — treat, test, and counsel

🗺️ THE PATHWAY AT A GLANCE

1 · AskColour, smell, itch, timing, partners, pregnancy, drugs, and danger signs

2 · ExamineVulva, speculum, cervix, vaginal walls, and bimanual if pain

3 · TestpH, whiff test, wet mount, and nucleic acid tests for chlamydia, gonorrhoea, trichomonas

4 · DiagnoseBacterial vaginosis, candidiasis, trichomoniasis, cervicitis, or other

5 · TreatThe cause, plus the partner when needed

6 · CounselHIV and syphilis tests, condoms, hygiene, review if not better

STEP 1 · NORMAL OR ABNORMAL — know what is physiological

🔬 WHAT IS NORMAL

Topic	Details
Normal discharge	Clear to white and thin, no smell, no itch; more mucus at mid-cycle (egg-white), in pregnancy, with arousal, and with hormonal contraception
Normal pH	3.8–4.5, kept acidic by lactobacilli making lactic acid
What upsets it	Douching, scented products, antibiotics, diabetes, new partners, sex without condoms, pregnancy, and smoking
When it is abnormal	Change in colour, smell, or amount; itch, soreness, pain on passing urine or on intercourse; bleeding

🧫 THE FOUR COMMON PICTURES

Cause	Typical features
Bacterial vaginosis	Thin grey-white discharge with a fishy smell (worse after sex or periods), little itch; not sexually transmitted in the strict sense but linked to new partners
Vulvovaginal candidiasis	White curdy (cottage-cheese) discharge with itch, soreness, redness, and pain on passing urine; more common in pregnancy, diabetes, and after antibiotics
Trichomoniasis	Frothy yellow-green discharge, itch, smell, and a 'strawberry' cervix; sexually transmitted
Cervicitis (chlamydia, gonorrhoea)	Mucopurulent discharge, bleeding after sex or between periods, pain on passing urine; often no symptoms

STEP 2 · ASSESS — history, examination, and tests

🩺 HISTORY AND EXAMINATION

Step	Details
History	Onset and duration, colour, smell, itch, pain, bleeding, last period, pregnancy, contraception, partners, condom use, previous infections, diabetes, drugs (antibiotics, steroids), and douching
Examine the abdomen	Lower abdominal tenderness and masses
Inspect the vulva	Redness, fissures, ulcers, warts, and the discharge at the introitus
Speculum examination	Colour and amount of discharge, the cervix (mucopus, friability, 'strawberry' spots), and any foreign body, growth, or fistula
Bimanual examination	If there is pain or fever: cervical motion tenderness, uterine or adnexal tenderness suggests pelvic inflammatory disease
Always consider	A pregnancy test and, in the right setting, cervical screening

📋 BEDSIDE TESTS

Test	What it shows
Vaginal pH (swab on pH paper)	Above 4.5 in bacterial vaginosis and trichomoniasis; 4.5 or below in candidiasis and normal
Whiff test (10% potassium hydroxide on the discharge)	A fishy smell suggests bacterial vaginosis (or trichomoniasis)
Wet mount (saline) microscopy	Clue cells (bacterial vaginosis), motile trichomonads, and many white cells (cervicitis, trichomoniasis)
Potassium hydroxide wet mount	Yeast buds and hyphae in candidiasis
Amsel criteria for bacterial vaginosis	Three of four: thin homogeneous discharge, pH above 4.5, positive whiff test, clue cells (20% or more of epithelial cells)
Nucleic acid amplification tests	For chlamydia, gonorrhoea, and trichomonas (vaginal swab or first-void urine); culture or microscopy if not available
Other tests	Pregnancy test, blood glucose if recurrent candidiasis, and HIV, syphilis, and hepatitis B serology

STEP 3 · TREAT — by cause, with the partner when needed

💊 TREATMENT (ADULT, NON-PREGNANT)

Condition	First-line treatment (varies by guideline)
Bacterial vaginosis	Metronidazole 400 mg or 500 mg twice daily for 7 days, or metronidazole 0.75% gel or clindamycin 2% cream vaginally at night for 5–7 nights; partner treatment is not routinely needed
Vulvovaginal candidiasis	Clotrimazole 500 mg vaginal pessary as a single dose (or 200 mg for 3 nights), or fluconazole 150 mg by mouth as a single dose; treat only if symptomatic
Recurrent candidiasis (4 or more a year)	Confirm with culture, check for diabetes, induction with fluconazole then weekly fluconazole for 6 months (specialist advice)
Trichomoniasis	Metronidazole 500 mg twice daily for 7 days (or 2 g as a single dose in some programmes); treat the partner at the same time; avoid sex until both finish
Cervicitis (chlamydia, gonorrhoea)	Doxycycline 100 mg twice daily for 7 days plus ceftriaxone 500 mg intramuscularly once (or the national programme combination of azithromycin and cefixime); treat the partner and retest
Pelvic inflammatory disease	Ceftriaxone 500 mg intramuscularly once, doxycycline 100 mg twice daily, and metronidazole 400–500 mg twice daily, for 14 days; admit if unwell, pregnant, or no improvement
Atrophic vaginitis (after menopause)	Vaginal moisturiser or low-dose vaginal oestrogen; exclude other causes of bleeding

Syndromic management (national programme): when tests are not possible, treat vaginal discharge for bacterial vaginosis, trichomoniasis, and candidiasis, and add treatment for cervicitis where risk is high (kits and drugs are provided under the programme)

STEP 4 · SPECIAL SITUATIONS — pregnancy, children, and the menopause

🧭 SPECIAL GROUPS

Group	Points
Pregnancy	Bacterial vaginosis and trichomoniasis are linked to preterm birth: test and treat with oral metronidazole (safe in all trimesters); candidiasis: use vaginal azoles for 7 days, not oral fluconazole; chlamydia: azithromycin 1 g, not doxycycline
Postmenopausal women	Atrophic vaginitis is common, but any blood-stained or persistent discharge needs examination, ultrasound, and biopsy if needed
Girls before puberty	Poor hygiene, worms, foreign body, and infection are common; blood-stained discharge or repeated infection needs a paediatric or gynaecology review; think of sexual abuse and involve a senior and child protection services
Women with an intrauterine device	Check for infection and the position of the device; do not remove it automatically unless severe infection
Women with HIV or diabetes	More frequent and persistent candidiasis and cervical disease; control glucose and screen the cervix
After delivery or abortion	Foul discharge with fever suggests retained products or endometritis; admit

STEP 5 · PREVENT AND FOLLOW UP — counsel, test, and review

🛡️ COUNSELLING AND PREVENTION

Topic	Advice
Hygiene	Wash the vulva with water only; no douching, scented soaps, wipes, or sprays; cotton underwear; wipe front to back; change out of wet clothes
Safer sex	Condoms with new or multiple partners; partner treatment and no sex until both are treated
Test and screen	Offer HIV, syphilis, and hepatitis B tests; cervical screening at the right age and human papillomavirus vaccine for girls
Take the medicine fully	Finish the course; avoid alcohol while on metronidazole and for 24 hours after it
Follow up	Review if symptoms persist after treatment or return within 3 months; retest for chlamydia, gonorrhoea, and trichomonas after about 3 months
Do not	Treat every itch with an antifungal-steroid cream; use leftover antibiotics

⚠️ COMMON PITFALLS

Treating by colour or smell alone without a speculum examination or pH test

Treating every discharge as candidiasis, especially with steroid combination creams

Forgetting to treat the partner in trichomoniasis, gonorrhoea, and chlamydia

Missing pelvic inflammatory disease because the pain is mild

Missing cancer in blood-stained or persistent discharge, or in postmenopausal women

Not testing for pregnancy, HIV, and syphilis

Using doxycycline or fluconazole in pregnancy

Memory Aid

SWAB

Four steps for every woman with vaginal discharge.

S

Speculum — look at the vulva, vagina and cervix

W

Whiff and wet mount — smell test and microscopy

A

Acidity — vaginal pH above or below 4.5

B

Bugs and barriers — test for chlamydia, gonorrhoea and trichomonas; treat the partner; use condoms

Remember: look, test, treat the cause, treat the partner when needed, and review.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary drawn from memory of Centers for Disease Control and Prevention (CDC) sexually transmitted infection treatment guidelines, British Association for Sexual Health and HIV (BASHH), Royal College of Obstetricians and Gynaecologists (RCOG), and World Health Organization (WHO) guidance; no source was read for this sheet. No Government of India document was read: the national syndromic management kits and regimens are recalled from memory, so check the National AIDS Control Organisation guidelines. Drug doses and durations vary between guidelines; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior doctor in any high-risk case.