Evaluation of vaginal discharge

Diseases

Summary

Vaginal discharge is a common symptom seen by clinicians. It may be physiologic or pathologic.

Physiologic vaginal discharge

Normal vaginal discharge in a reproductive-aged woman, also called physiologic discharge, usually consists of 1-4 mL per 24 hours. It is typically transparent, odorless (but can also be slightly malodorous), mucousy, and white-to-yellowish.

The character of physiologic discharge can vary over the menstrual cycle and in the different reproductive stages. For instance, it becomes more noticeable with higher estrogen states (e.g., during pregnancy, when using estrogen-progestin contraceptives, or at ovulation). Lactobacilli in the normal vaginal flora maintain vaginal acidity by producing hydrogen peroxide and lactic acid. The acidic pH of the vagina in reproductive women (4.0-4.5) creates a hostile environment for pathogens. In premenarchal and postmenopausal women with low estrogen states, vaginal pH may be 4.7 or more.

Epidemiology

Vulvovaginal symptoms are prevalent in both premenopausal and postmenopausal women.[1] However, the true prevalence of pathologic vaginal discharge is uncertain because vaginitis, which encompasses the symptom vaginal discharge, is often asymptomatic, self-diagnosed, and self-treated.[2]

Abnormal vaginal discharge was reported by 14.5% of 3000 women (ages 18-50 years) who were randomly sampled from a population in Goa, India, in one community-based survey.[3] Within one US community-practice setting, abnormal vaginal discharge was reported by 68% of women presenting with symptoms of vaginitis.[4]

Most women will experience more vaginal discharge during pregnancy.[5] The prevalence of pathologic vaginal discharge during pregnancy has been reported to be 40% to 50%.[6] [7] [8]

Library

Photomicrograph revealing bacteria adhering to vaginal epithelial cells, known as clue cells
Phase contrast wet mount micrograph of a vaginal discharge revealing the presence of Trichomonas vaginalis protozoa
Trichomonas vaginitis with copious purulent discharge emanating from the cervical os
Vaginal smear identifying Candida albicans using Gram stain technique
Vaginal smear identifying Candida albicans using a wet mount technique
McCoy cell monolayer micrograph revealing intracellular Chlamydia trachomatis inclusion bodies; magnified 50x
Micrograph of polymorphonuclear leukocytes and diplococci on a cervical smear
Cervicitis and vaginal discharge due to gonorrhea
Cervicitis due to herpes simplex virus; erosive inflammation with accompanying paracervical purulency is seen
Presence of herpes simplex virus in a Tzanck test specimen
Enterobius vermicularis egg (human pinworm)

Citations

Key Articles

Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. Jul 2021 [internet publication].[Full Text]
Sherrard J, Wilson J, Donders G, et al. 2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge. Int J STD AIDS. 2018 Nov;29(13):1258-72.[Abstract]
Workowski KA, Bachmann LH, Chan PA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.[Abstract][Full Text]
Miller JM, Binnicker MJ, Campbell S, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2018 update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis. 2018 Aug 31;67(6):e1-94.[Abstract][Full Text]

Other Online Resources

British Association for Sexual Health and HIV (BASHH) guidelines

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