Section 4-8: Canadian Guidelines on Sexually Transmitted Infections – Management and treatment of specific syndromes – Vaginal discharge

The 2016 Updates Summary, the 2014 Supplementary Statement and the Laboratory Diagnosis of Sexually Transmitted Infections chapter, revised in 2016, contain important information pertaining to this chapter. They should be used in conjunction with this 2010 chapter to ensure that you are implementing the most current recommendations in your practice.

Section 4 - Management and Treatment of Specific Syndromes

Vaginal Discharge (Bacterial Vaginosis, Vulvovaginal Candidiasis, Trichomoniasis)

Etiology

  • The three infections most commonly associated with vaginal discharge in adult women are:
    • Bacterial vaginosis (BV)
    • Vulvovaginal candidiasis (VVC)
    • Trichomoniasis
  • On occasion, vaginal discharge may be seen in cervicitis caused by Neisseria gonorrhoeae or Chlamydia trachomatis.
  • Non-infectious causes of vaginal discharge include the following:
    • Excessive physiologic secretions
    • Desquamative inflammatory vaginitis
    • Atrophic vaginitis (scant discharge)
    • Foreign bodies
  • Non-infectious causes of vulvovaginal pruritus without discharge should also be considered:
    • Irritant or allergic dermatitis (e.g., latex, soaps, perfumes)
    • Skin disorders, such as the following:
      • Lichen sclerosus (may increase the risk of vulvar cancer)
      • Squamous cell hyperplasia
      • Lichen planus
      • Psoriasis
Bacterial vaginosis
  • Most common cause of vaginal discharge.
  • Characterized by an overgrowth of genital tract organisms (e.g., Gardenerella, Prevotella, Mobiluncus spp.) and a depletion of lactobacilli.
  • Not usually considered sexually transmitted.
Vulvovaginal candidiasis
  • Approximately 90% of cases caused by Candida albicans;remainder caused by other Candida spp. (e.g., C. glabrata) or Saccharomyces cerevisiae.
  • Not usually considered sexually transmitted.
Trichomoniasis
  • Caused by Trichomonas vaginalis, a protozoa.
  • Sexually transmitted.

Epidemiology

  • Vaginal complaints are common in primary care and are among the most common reasons for gynecological consultation.
Bacterial vaginosis
  • Prevalence has been estimated at 10–30% of pregnant women and 10% of family practice patients.Footnote 1,Footnote 2
  • BV during pregnancy is associated with premature rupture of the membranes, chorioamnionitis, preterm labour, preterm birth and post-cesarean delivery endometritis.Footnote 3
  • The presence of BV during an invasive procedure, such as placement of an intrauterine device (IUD), endometrial biopsy or uterine curettage, has been associated with post-procedure pelvic inflammatory disease and vaginal cuff cellulitis.Footnote 4,Footnote 5
  • Presence of BV is associated with increased acquisition of HIV.Footnote 6,Footnote 7
Vulvovaginal candidiasis
  • Approximately 75% of women will experience at least one episode of VVC during their lifetime, and 5–10% have more than one episode.Footnote 8
  • The incidence of recurrent VVC (four or more symptomatic episodes of VVC a year) has been estimated at 5% of women of reproductive age.Footnote 8
  • Among HIV-positive women, lower CD4 counts and high viral loads are associated with persistent Candida colonization and an increased incidence of VVC.Footnote 9Footnote 12
Trichomoniasis
  • The prevalence of trichomoniasis has not been well determined. In one study in a US sexually transmitted infection (STI) clinic, the prevalence was estimated to range from 10–35%; however, these data are not likely to be generalizable.Footnote 13 Among men attending STI clinics, the prevalence has been estimated at 3–20%.Footnote 13
  • Trichomoniasis is associated with an increased risk of HIV acquisition and transmission in women.Footnote 13Footnote 15

Prevention and Control

  • Predisposing factors for BV and VVC are listed in Table 1.
  • Trichomoniasis is sexually transmitted and can be prevented by practising safer sex.

Manifestations and Diagnosis

  • The symptoms and signs associated with these infections are not specific (see Table 1).
  • Definitive diagnosis is based on laboratory testing.Footnote 16
Table 1. Diagnostic features and laboratory diagnosis
Bacterial vaginosis Candidiasis Trichomoniasis
intrauterine device
polymorphonuclear leukocytes
*Clue cells are vaginal epithelial cells covered with numerous coccobacilli.
Culture is more sensitive than microscopy for T. vaginalis.
Sexual transmission
  • Not usually considered sexually transmitted
  • Not usually considered sexually transmitted
  • Sexually transmitted
Predisposing factors
  • Often absent
  • More common if sexually active
  • New sexual partner
  • IUD use
  • Often absent
  • More common if sexually active
  • Current or recent antibiotic use
  • Pregnancy
  • Corticosteroids
  • Poorly controlled diabetes
  • Immuno-compromised
  • Multiple partners
Symptoms
  • Vaginal discharge
  • Fishy odour
  • 50% asymptomatic
  • Vaginal discharge
  • Itch
  • External dysuria
  • Superficial dyspareunia
  • Up to 20% asymptomatic
  • Vaginal discharge
  • Itch
  • Dysuria
  • 10–50% asymptomatic
Signs
  • White or grey, thin, copious discharge
  • White, clumpy, curdy discharge
  • Erythema and edema of vagina and vulva
  • Off-white or yellow, frothy discharge
  • Erythema of vulva and cervix (“strawberry cervix”)
Vaginal pH
  • >4.5
  • <4.5
  • >4.5
Wet mount
  • Budding yeast
  • Pseudohyphae
Gram stain
  • Clue cellsTable 1 - Footnote *
  • Decreased normal flora
  • Predominant Gram-negative curved bacilli and coccobacilli
  • PMNs
  • Budding yeast
  • Pseudohyphae
  • PMNs
  • Trichomonads
Whiff test
  • Positive
  • Negative
  • Negative
Preferred treatment (see Tables 3Table 9)
  • Metronidazole
  • Clindamycin
  • Antifungals
  • Metronidazole
  • Treat partner
Specimen collection
  • Speculum examination.
  • Rule out cervicitis.
  • Collect a sample of the discharge from the vaginal wall for microscopy (if microscopy is not available on-site, see Figure 1 for syndromic management).
  • Although not a sensitive test, Gram stain may be helpful in diagnosing mucopurulent cervicitis (MPC) and gonorrhea in symptomatic females.
  • A negative wet mount does not rule out an infectious cause of vaginitis.
  • Culture is rarely needed in acute cases of vaginitis.
Table 2. Specimen collection
Test Procedure Normal result
*While KOH destroys cellular debris and allows one to more clearly detect yeast cells and hyphae, it also destroys the epithelial cells in clue cells needed to diagnose BV and lyses trichomonads. Therefore, for vaginitis, saline is necessary.
Clue cells are vaginal epithelial cells covered with numerous coccobacilli
pH test
  • Use narrow-range pH paper
pH ≤4.5
Wet mount
  • Place a drop of vaginal discharge on a slide; mix with a drop of 0.9% salineTable 2 - Footnote *; apply a cover slip; examine immediately under a microscope at low and high power
  • Examine for leukocytes, clue cellsTable 2 - Footnote , lactobacilli, yeast and trichomonads
Epithelial cells and rare white blood cells
Whiff test/ KOH slide (optional)
  • Place a drop of discharge on a slide; mix with a drop of 10% KOH; an amine (fishy) odour after applying the KOH is a positive test; apply a cover slip; examine under a microscope at low and high power
  • Examine for yeast
Negative
Gram stain   Predominantly large Gram-positive bacilli

Figure 1. Syndromic management of vaginal discharge

For situations where on-site microscopy is not available, the World Health Organization has developed an algorithm for management of vaginal discharge.Footnote 17

Figure 1
Text Equivalent - Figure 1

Figure 1 is an algorithm developed by the World Health Organization in 2003 to guide syndromic management of a patient who is presenting with vaginal discharge in a location where on-site microscopy is not readily available.
Two scenarios are presented, based on the history physical examination findings.

Scenario 1 provides guidance for the syndromic management of a patient whose history suggests that she is at risk of an STI or has a partner who is symptomatic; OR whose physical examination demonstrates that she has fever or lower abdominal tenderness.

In this case, treat for chlamydia plus or minus gonorrhea, Trichomonas vaginalis AND bacterial vaginosis;

THEN

Provide education and counselling AND promote condom use, if appropriate.

Scenario 2 provides guidance for the syndromic management of a patient whose history does not suggest that she is at risk of an STI nor has a partner who is symptomatic; AND whose physical examination does not reveal evidence of fever or lower abdominal tenderness.

In this case, treat for Trichomonas vaginalis, bacterial vaginosis, AND vulvovaginal candidiasis;

THEN

Provide education and counselling AND promote condom use, if appropriate.

BV
bacterial vaginosis
STI
sexually transmitted infection
VVC
vulvovaginal candidiasis

Consideration for Other STIs

  • In a case of trichomoniasis, other STIs need to be considered. If appropriate, based on the patient’s and partner’s risk factors (and immunization status in the case of hepatitis B), specimens can be taken for the following:
    • Gonorrhea and chlamydia
    • Syphilis
    • HIV
    • Hepatitis B
  • Discuss HPV vaccine with women as per the recommendations outlined in the Canada Communicable Disease Report, Volume 33 ACS-2, (2007) National Advisory Committee on Immunization (NACI) statement on Human papillomavirus vaccine.

Bacterial Vaginosis

Management and Treatment

Table 3. Treatment of bacterial vaginosis

Asymptomatic

Treatment is unnecessary except in cases of:

  • High-risk pregnancy (history of preterm delivery)
  • Prior to IUD insertion
  • Prior to gynecologic surgery, therapeutic abortion or upper tract instrumentation

Symptomatic

Preferred

  • Metronidazole 500 mg PO bid for 7 days
  • Metronidazole gel 0.75%, one applicator (5 g) once a day intravaginally for 5 days
  • Clindamycin cream 2%, one applicator (5 g) intravaginally once a day for 7 days

Alternatives

  • Metronidazole 2 g PO in a single dose
  • Clindamycin 300 mg PO bid for 7 days
  • For therapy with metronidazole, a 7 day oral course and a 5 day course of gel are equally efficacious (cure rate 75–85%).Footnote 18Footnote 20 A single oral dose also has a cure rate of 85% but a higher relapse rate at 1 month (35–50% vs. 20–33%) [A-l]Footnote 21
  • In one study, clindamycin cream was equivalent to both metronidazole regimens (cure rate of 75–86%) [A-l]Footnote 20
IUD
intrauterine device

Notes:

  • Patients should not drink alcohol during and for 24 hours after oral therapy with metronidazole because of a possible disulfiram (antabuse) reaction.
  • Clindamycin cream is oil-based and may cause latex condoms or diaphragms to fail.
Recurrent bacterial vaginosis
  • 15–30% of patients develop a recurrence in the first 1–3 months after treatment.Footnote 22
  • Reconfirm diagnosis.

Table 4. Treatment of recurrent bacterial vaginosis

  • Metronidazole 500 mg PO bid for 10–14 days [B-lll]Footnote 22,Footnote 23
  • Metronidazole gel 0.75%, one applicator (5 g) once a day intravaginally for 10 days, followed by suppressive therapy of metronidazole gel twice a week for 4–6 months [B-lll]Footnote 24

Note:

  • Patients should not drink alcohol during and for 24 hours after oral therapy with metronidazole because of a possible disulfiram (antabuse) reaction.
Reporting and Partner Notification
  • Bacterial vaginosis is not a reportable disease.
  • Treatment of male sexual partners is not indicated and does not prevent recurrence.
Follow-up
  • No follow-up is necessary unless the patient is pregnant or symptoms recur.
Special Considerations
Pregnancy
  • BV during pregnancy is associated with premature rupture of the membranes, chorioamnionitis, preterm labour, preterm birth and post-cesarean delivery endometritis.
  • Routine screening for BV during pregnancy is not recommended, although evidence is available to support screening and treatment at 12–16 weeks in high-risk pregnancies (see Pregnancy chapter). However, symptomatic women should be tested and treated.
  • Treatment of asymptomatic BV in women with a previous preterm birth may reduce the risk of preterm prelabour rupture of the membranes and low birth weight [B-l].Footnote 25,Footnote 26 Treat with oral antibiotics: oral metronidazole and clindamycin are not contraindicated during pregnancy or breastfeeding.Footnote 26Footnote 31 Topical antibiotics have no effect on preterm birth, though topical clindamycin treatment has been associated with adverse outcomes in the newborn when used in pregnancy (see Pregnancy chapter).
  • Testing should be repeated after 1 month to ensure that therapy was effective.
HIV
  • The same therapy is recommended for HIV-positive as for HIV-negative patients.

Vulvovaginal Candidiasis

Management and Treatment
Uncomplicated vulvovaginal candidiasis

Table 5. Treatment of uncomplicated vulvovaginal candidiasis

Asymptomatic

Treatment is unnecessary

Symptomatic

  • Intravaginal, over-the-counter azole ovules and creams (e.g., clotrimazole, miconazole)
  • Fluconazole 150 mg PO in a single dose. (Contraindicated in pregnancy)
  • Topical and oral azoles are equally effective [A-l].Footnote 32 Efficacy estimated at 80–90%Footnote 32
  • In most cases, expect resolution of symptoms in 2–3 days

Note:

  • Oil-based ovules and creams may cause latex condoms or diaphragms to fail.
Complicated vulvovaginal candidiasis
  • Defined as recurrent VVC, severe VVC, a non-albicans species or occurring in a compromised host.

Recurrent VVC (RVVC)

  • Four or more episodes of VVC in a 12-month period.
  • Confirm the diagnosis of RVVC by obtaining a vaginal culture and full identification of the isolated species, which should be used to guide therapy. Non-albicans Candida species are found in 10–20% of patients with RVVC.Footnote 33 Conventional antifungal therapy is not as effective against some of these species (see Table 8).
  • Treatment requires induction, usually followed by a 6-month maintenance regimen (see Table 6).
  • For patients prone to RVVC who require a course of antibiotics, prophylactic topical or oral azoles, such as fluconazole 150 mg PO, can be given at the start of the antibiotic course and once a week during the duration of the course [B-lll].Footnote 8

Table 6. Treatment of recurrent vulvovaginal candidiasis (RVVC)

Induction treatment

  • Fluconazole 150 mg PO once every 72 hours for three doses [A-l].Footnote 34 Efficacy 92%. Contraindicated in pregnancy
  • Topical azole for 10–14 days [B-ll]Footnote 35Footnote 38
  • Boric acid 300–600 mg gelatin capsule intravaginally once a day for 14 days [B-ll]Footnote 39,Footnote 40 Less mucosal irritation experienced when 300 mg used.Footnote 40 Efficacy approximately 80%.Footnote 40 Contraindicated in pregnancy

Notes:

  • Each individual episode of RVVC caused by C. albicans usually responds to a course of oral or topical azoles, with a longer course usually more effective than a shorter one.Footnote 36
  • Without maintenance therapy, VVC recurs in 50% of patients within 3 months.
  • Start maintenance therapy as soon as initial treatment has been completed.

Maintenance treatment

  • Fluconazole 150 mg PO once a week [A-l].Footnote 34 Recurrence occurred in 10% while receiving therapy
  • Ketoconazole 100 mg PO once a day [A-l].Footnote 41 Recurrence occurred in 5% while receiving therapy. Patients receiving long-term ketoconazole should be monitored for hepatotoxicity (incidence one in 12,000)
  • Itraconazole 200–400 mg PO once a month [A-l].Footnote 42,Footnote 43 Recurrence occurred in 36% while receiving therapyFootnote 43
  • Clotrimazole 500 mg intravaginally once a month [A-l]Footnote 44
  • Boric acid 300 mg capsule intravaginally for 5 days each month beginning the first day of the menstrual cycle [B-ll].Footnote 40 Recurrence occurred in 30% while receiving therapyFootnote 40

Notes:

  • Duration of maintenance therapy is a minimum of 6 months. After 6 months, discontinue therapy and observe.
  • Relapse rate is high, with approximately 60% of women relapsing within 1–2 months of discontinuing maintenance therapy.Footnote 8,Footnote 36
  • If recurrence occurs, treat the episode and then reintroduce a maintenance regimen.
  • Fluconazole and boric acid are contraindicated in pregnancy.
  • Oil-based ovules and creams may cause latex condoms or diaphragms to fail.
RVVC
recurrent vulvovaginal candidiasis
VVC
vulvovaginal candidiasis
Severe VVC
  • Extensive vulvar erythema, edema, excoriation or fissure formation.

Table 7. Treatment of severe vulvovaginal candidiasis

Note:

  • Oil-based ovules and creams may cause latex condoms or diaphragms to fail.

Non-albicans VVC

  • Most commonly due to C. glabrata, which is 10- to 100-fold less susceptible to azoles than C. albicans.Footnote 8

Table 8. Treatment of non-albicans vulvovaginal candidiasis

Initial treatment

  • Boric acid 600 mg capsule intravaginally once a day for 14 days [B-ll].Footnote 38,Footnote 39,Footnote 45,Footnote 46 Efficacy 64–81%. Vaginal burning reported in <10%
  • Flucytosine cream 5 g intravaginally once a day for 14 days [B-ll].Footnote 46,Footnote 47 Efficacy 90%
  • Amphotericin B 50 mg suppository intravaginally once a day for 14 days [B-lll].Footnote 48 Efficacy 80% (10 patients). Mild external irritation reported in 10%
  • Flucytosine 1 g PLUS amphotericin B 100 mg (combined in a lubricating jelly) administered intravaginally once a day for 14 days [B-lll].Footnote 49,Footnote 50 Efficacy 100% (in 4 patients)

If symptoms recur

  • Retreat with boric acid 600 mg capsule intravaginally once a day for 14 days FOLLOWED BY: alternate-day boric acid for several weeks or 100,000 units of nystatin vaginal suppositories once a day for 3-6 months [B-lll] Footnote 8

Note:

  • No safety data available for long-term use of boric acid.Footnote 51

Compromised host

  • Corticosteroids, uncontrolled diabetes.
  • C. glabrata and other non-albicans species are isolated more frequently in women with diabetes than in those without.
  • Treat with a longer (10–14 day) course of an intravaginal azole [B-lll] OR boric acid 600 mg capsule intravaginally once a day for 14 days [B-ll].Footnote 37,Footnote 38
Reporting and Partner Notification
  • Vulvovaginal candidiasis is not a reportable disease.
  • Routine screening and treatment of male partners is not indicated.Footnote 52Footnote 54 However, male sexual partners should be treated if Candida balanitis is present. Use a topical azole cream twice a day for 7 days.
Follow-up
  • No follow-up necessary unless symptoms persist or recur.
  • Consider culture and sensitivity of yeast if not responding to appropriate therapy or if infection recurs.
Special Considerations
Pregnancy
  • Only topical azoles are recommended for treatment of vulvovaginal candidiasis during pregnancy. Treatment for 7 days may be necessary.Footnote 55
HIV
  • The treatment of candidiasis is the same in HIV-positive as it is in HIV-negative individuals.
  • Vaginal candidiasis is often recurrent and more severe in HIV-positive women and, in some cases, will require more aggressive and long-term therapy.

Trichomoniasis

Management and Treatment

Table 9. Treatment of trichomoniasis

  • Metronidazole 2 g PO in a single dose [A-l]Footnote 56
  • Metronidazole 500 mg PO bid for 7 days [A-l]Footnote 56

  • Efficacy 82–88% for both regimens; increases to 95% if partner also treatedFootnote 56
  • Intravaginal metronidazole gel is not effective

Note:

  • Patients should not drink alcohol during and for 24 hours after oral therapy with metronidazole because of a possible disulfiram (antabuse) reaction.
Reporting and Partner Notification
  • Trichomoniasis is a reportable disease in some jurisdictions.
  • Current partners should be treated for trichomoniasis, regardless of symptoms (it is not necessary to screen partners for trichomonas). The majority of men infected with T. vaginalis are asymptomatic, but some may have mild urethritis. Treat sexual partners with the same therapy as recommended for the case.
Follow-up
  • No follow-up necessary unless symptoms recur; usually due to reinfection.
  • Prevalence of metronidazole-resistant T. vaginalis estimated at 5%. Usually responds to high-dose metronidazole.Footnote 57
Special Considerations
Pregnancy
  • Trichomoniasis may be associated with premature rupture of the membranes, preterm birth and low birth weight.
  • Symptomatic pregnant women should be treated with metronidazole 2 g PO in a single dose for symptom relief [A-l]. An alternative treatment is metronidazole 500 mg PO bid for 7 days [A-l]. It is not known whether treatment will improve pregnancy outcomes.Footnote 58,Footnote 59
  • It is not recommended that asymptomatic pregnant women be treated [D-l].Footnote 60
  • Metronidazole is not contraindicated during pregnancy or breastfeeding.Footnote 26Footnote 31
HIV
  • The same therapy is recommended for HIV-positive as for HIV-negative patients.
The Use of Live Lactobacilli to Restore Normal Vaginal Flora
  • Lactobacilli preparations are commonly used in the treatment of BV and VVC. One small randomized trial in healthy women showed that the use of oral Lactobacilli was safe and resulted in increased vaginal Lactobacilli and decreased yeast as compared to the placebo group.Footnote 61 However, in a more recent, well-conducted randomized, controlled trial of 278 women, oral and vaginal L. rhamnosus was ineffective in the prevention of post-antibiotic VVC.Footnote 62
  • Two randomized, controlled trials have studied the use of a topical L. acidophilus–low dose estriol combination, one in the management of BV, the other for several infections (BV, VVC, trichomoniasis).Footnote 63,Footnote 64 Both showed a statistically significant greater reduction in symptoms and microscopic restoration of normal flora than the placebo group.

References

Report a problem or mistake on this page
Please select all that apply:

Privacy statement

Thank you for your help!

You will not receive a reply. For enquiries, contact us.

Date modified: