Canadian Guidelines on Sexually Transmitted Infections

Supplementary statement for recommendations related to the diagnosis, management, and follow-up of Vaginal Discharge: March 2014

Key Issue

The Gonococcal Infections chapter has been revised in response to emerging antimicrobial resistance. As a result, the 2010 print and online versions of the Vaginal Discharge chapter of the Canadian Guidelines on Sexually Transmitted Infections also require updates.

This statement is intended to inform clinicians of key changes in the management of vaginal discharge until such time as the full chapter revision is available.

Diagnosis

  • On occasion, cervicitis caused by N. gonorrhoeae or C. trachomatis may be associated with vaginal discharge.
  • Patient examination should include:
    • An external genital exam for vulvar edema/erythema or excoriations;
    • A speculum exam to visualize the cervix and the vaginal walls;
    • A bimanual exam to rule out lower abdominal tenderness or cervical motion tenderness.
  • If there is clinical evidence of cervicitis:
    • Although not a sensitive test, Gram stain may be helpful in diagnosing mucopurulent cervicitis (MPC) and gonorrhea in symptomatic females.
    • Testing for both gonorrhea and chlamydia is recommended.
    • Depending on the clinical situation, consideration should be given to collection of samples for N. gonorrhoeae using both culture and NAAT.

Treatment

  • In patients presenting with vaginal discharge who have a suspected or confirmed gonococcal infection, treatment should include combination therapy in response to increasing antimicrobial resistance.
    • Combination therapy using medications with two different mechanisms of action is thought to improve treatment efficacy as well as to potentially delay the emergence of cephalosporin-resistant gonorrhea.
    • This combination therapy also includes effective treatment for concomitant chlamydia infection, which occurs frequently.
  • Refer to Table 7 in the Gonococcal Infections chapter for treatment recommendations and to the Follow-up section for test of cure recommendations.
  • Figure 1 in the current Vaginal Discharge chapter is out of date and should not be used to guide treatment decisions.
  • In patients where there is no identified risk for gonococcal infection AND patient follow-up can be assured, treatment of vaginal discharge should be based on clinical findings and test results according to the recommendations in the appropriate section of the current Vaginal Discharge chapter.

Follow-up

  • Patients treated for bacterial vaginosis, candidiasis or trichomoniasis do not generally require follow-up post-treatment except if there are recurrent or persistent symptoms. Refer to the appropriate section of the current Vaginal Discharge chapter for follow-up and management recommendations for these patients.
  • Those who have confirmed gonococcal infection should be reported to local public health and followed up as per the recommendations in the Partner notification and Follow-up sections of the Gonococcal Infections chapter.
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