Good general practice management of women with vaginal discharge and sexually transmitted infections can make an important difference to their health. It may prevent the potentially devastating consequences of undiagnosed or inadequately treated cervical chlamydia infection. It can also help to reduce the discomfort, embarrassment, and anxiety often associated with genitourinary problems.

Not every woman needs investigation. If a woman in a long-term stable relationship develops symptoms of thrush after a course of antibiotics, blind treatment is perfectly reasonable. But in young women with abnormal vaginal discharge or suspected sexually transmitted infection, microbiological tests, especially for chlamydia and gonorrhoea, are essential for accurate diagnosis and management. It is totally unacceptable to reassure a woman that she has no serious infection merely on the basis of a normal high vaginal swab. This chapter covers common genital and sexually transmitted infections seen in general practice, excluding human immunodeficiency virus infection.

Prevalence

Vaginal discharge is a common problem in general practice. The 1991 – 92 National Morbidity Survey found there were 421 general practice consultations annually for inflammatory disease of the cervix, vagina, or vulva per 10 000 women aged 16 – 44. Figure Number of diagnoses of acute sexually transmitted infections and of all episodes seen in genitourinary clinics in England and Wales, 1989 – 98 shows the increase in diagnoses of sexually transmitted diseases seen in English and Welsh genitourinary clinics over the past decade. Between 1996 and 2001, diagnoses of genital chlamydia infection increased by 108% and of gonorrhoea by 87%. Although the rise in diagnoses of chlamydial infection partly reflects an increase in testing, it is likely that the overall rise in sexually transmitted infections is associated with increasing unsafe sexual behaviour, particularly among teenagers.

Number of diagnoses of acute sexually transmitted infections

Number of diagnoses of acute sexually transmitted infections

Figure Number of diagnoses of acute sexually transmitted infections and of all episodes seen in genitourinary clinics in England and Wales, 1989 – 98.

Causes of vaginal discharge

Vaginal discharge may be physiological or pathological. Physiological vaginal discharge is white, becoming yellow on contact with air due to oxidation. The amount of discharge produced varies considerably between women. It may increase at ovulation, premenstrually, or when using oral contraception or an IUCD. What matters is that a woman is complaining of a change in her normal discharge.

Abnormal discharge is usually due to infection. Table Organisms identified in 386 women aged 15 – 65 years shows the organisms isolated from 386 consecutive women (mainly social classes 3 and 4) who presented with vaginal discharge, soreness, or vulval irritation in a suburban general practice in Cardiff. Bacterial vaginosis and Candida albicans are the commonest infections. They are relatively harmless and not generally regarded as sexually transmitted. The most important causes of vaginal discharge are Chlamydia trachomatis and Neisseria gonorrhoeae, since these sexually transmitted infections can cause pelvic inflammatory disease leading to tubal infertility, ectopic pregnancy, or chronic pelvic pain. Trichomonas vaginalis is also a vaginal pathogen. Its main significance is that it is sexually transmitted and a marker for other sexually transmitted diseases. Streptococcus, Staphylococcus aureus and Haemophilus species may be commensals in the vagina but should be treated if causing symptoms. Streptococci should always be treated in pregnant women near term or after delivery because of the risks of neonatal infection or post-partum endometritis. Herpes and genital warts are sexually transmitted viral infections, which can be distressing for the patient. Unfortunately, treatment for these infections is only suppressive and not curative.

Table Organisms identified in 386 women aged 15 – 65 years presenting in general practice with lower genital tract symptoms

Organism Women infected (%)
Bacterial vaginosis 56.5
Candida albicans 34.5
Chlamydia trachomatis 6.5
Trichomonas vaginalis 2.3
Streptococcus milleri 1.8
Haemophilus species 1.0
Staphylococcus aureus 0.5
Neisseria gonorrhoeae 0.3
Herpes virus 0.3
Note: some women had more than one infection.
No organism was identified in a third of women.

Non-infective causes of vaginal discharge are usually diagnosed on clinical examination. They include cervical ectropion, polyp or carcinoma, retained products, and foreign bodies in the vagina, notably a “lost” tampon. The latter should be disposed of in a self-sealing plastic bag before the smell in the surgery becomes intolerable. Fortunately, toxic shock syndrome is rare. Vulvovaginitis may also be due to dermatological problems such as eczema, or associated with irritants.

Diagnosis of vaginal discharge

History

Most causes of vaginal discharge will be elucidated by clinical examination and tests. However, if possible, a brief sexual history should be taken (Box Taking a sexual history in general practice). Finally, check if the patient has already treated herself unsuccessfully with an over-the-counter preparation such as clotrimazole cream or oral fluconazole.

Box Taking a sexual history in general practice

Lifestyle

  • Are you in a relationship at the moment?
  • When did you last have sex?
  • When did you last have sex with someone other than your partner?

Symptoms

  • When did you first notice this problem?
  • Have you had it before?
  • Do you know if your partner has any symptoms?
  • Have you any idea what you think this might be?

If clinical history and prior knowledge of the patient suggest a sexually transmitted infection is likely, and the local genitourinary clinic is easily accessible and if the patient agrees to attend, it may be simpler to give the patient a letter and clinic leaflet and send her straight there. Otherwise appropriate swabs should be taken.

Examination

The vulva should be examined for genital warts or herpetic ulcers. A bimanual examination may reveal adnexal tenderness or cervical motion pain suggestive of pelvic inflammatory disease. It is preferable to use warm water as a lubricant as other substances may interfere with cultures. A speculum should be passed and the appearance of the cervix and any discharge should be noted. However, as with symptoms, physical signs are not reliable in making a diagnosis.

Tests

If these are to be done at all, they should be done properly. Although specimens taken will depend on arrangements with the local laboratory, minimum tests should include:

  • Cervical swab for culture in Stuart’s transport medium. The swab should be inserted in the endocervix to sample pus and discharge for gonorrhoea. This will also usually pick up vaginal infections such as bacterial vaginosis, candidiasis, and trichomoniasis.
  • Opportunistic cervical smear if the patient has not had a normal routine smear, or there is some clinical indication.
  • Endocervical swab for chlamydia.

Chlamydiae are intracellular bacteria, so specimens for chlamydia should contain cells from the endocervix or an ectropion if present, not pus or discharge. Sampling should be done at the end of a speculum examination after cleaning the cervix. (In practice, if a cervical smear or other swabs have been taken first, cleaning may not be necessary.) A cotton-tipped swab is rotated gently in the endocervix for at least 10 seconds to collect as much material as possible. Then it is placed in transport medium for ligase or polymerase chain reaction assay or enzyme immunoassay. Exact details will depend on the local laboratory. In future general practitioners will have access to urine screening.

If vulval or cervical ulcers are seen, a special viral swab should be taken for herpes simplex culture.

Box Basic investigations of a sexually active young woman complaining of abnormal vaginal discharge

  • Endocervical swab for Neisseria gonorrhoeae in Stuart’s medium. May also diagnose Candida albicans, bacterial vaginosis, or Trichomonas vaginalis
  • Cervical smear if not recently done
  • Endocervical swab for Chlamydia trachomatis after cleaning the cervix

Management

Ideally the patient should be asked to come back in a week when all the swab results will be available and appropriate treatment can be given. However, if she requests treatment for symptoms of possible thrush or bacterial vaginosis, it is not unreasonable to treat blind provided she returns for follow-up. Similarly, if pelvic inflammatory disease is suspected clinically, she should be given a 2-week course of doxycycline and metronidazole on the understanding that it is essential she returns for the swab results in case additional treatment or contact tracing is required. Detailed management in line with UK national guidelines (http://www.mssvd.org.uk) will be discussed under the section for each infection and is summarized in Table Diagnosis and management of infective causes of vaginal discharge.

Infective Causes Of Vaginal Discharge

Bacterial Vaginosis And Adverse Pregnancy Outcome

Viral Sexually Transmitted Infections

Sexual health promotion

Strategies to reduce the incidence of sexually transmitted infections include encouraging safer sex, increasing screening, and improving treatment and contact tracing among people found to be infected. For primary prevention, increasing condom use in women with multiple partners is likely to be beneficial. However, since barrier methods are unreliable in preventing pregnancy, the pill should also be used (“the double Dutch method”).

Condom promotion schemes have been widely piloted in UK general practice. However, there is no clear evidence of their effectiveness. In the only randomized controlled trial of condom promotion in primary care, 37% of women with two or more partners in the previous year reported that their partner used a condom at the last sexual intercourse. But there was no difference between intervention and control groups. Despite this, it would seem sensible to consider offering opportunistic advice about how to avoid sexually transmitted infections to all sexually active young women, especially when they attend for speculum examinations.

Secondary prevention of sexually transmitted diseases and their consequences is also important. Screening has been shown to reduce the prevalence of both chlamydial infection and pelvic inflammatory disease. General practitioners and practice nurses have a vital role to play in screening women at risk of sexually transmitted infections, and ensuring that those found to be infected are managed appropriately.

Key points

  • All general practitioners and practice nurses performing speculum examinations should have appropriate equipment available and know how to take endocervical swabs for chlamydia and gonorrhoea.
  • Women with chlamydia, gonorrhoea or a first attack of genital herpes or warts need:
    • appropriate treatment;
    • partner notification and no sex until both have been treated;
    • screening for other sexually transmitted infections;
    • referral to a genitourinary clinic.
  • Good relationships with local genitourinary physicians are very helpful. The practice should have a supply of genitourinary clinic leaflets to hand to patients including the
  • The important bacterial causes of vaginal discharge which should not be missed are chlamydia and gonorrhoea because of their potential sequelae of pelvic inflammatory disease, tubal infertility, and ectopic pregnancy.
  • All sexually transmitted infections can be asymptomatic.
  • Opportunistic chlamydial testing on the basis of risk factors should be offered to sexually active young women who:
    • request termination of pregnancy;
    • are age <25, especially teenagers;
    • had two or more sexual partners in the previous year;
    • have mucopurulent cervicitis or a friable cervix.

Genital Herpes: 10-Minute Consultation

Sexually Transmitted Disease: Frequently Asked Questions

Information for patients

There is an excellent series of booklets on sexually transmitted infections published by the former Health Education Authority and available from health promotion units and genitourinary clinics. These include: “Vaginal infections”, “Thrush”, “Chlamydia and NSU”, “Genital herpes”, “Genital warts”, and “Guide to a healthy sex life”.

Practices should also have available a supply of local genitourinary clinic leaflets and the telephone number of the clinic health advisers.

There is an active self-help group for herpes sufferers: The Herpes Viruses Association, SPHERE, 42 North Rd, London N7 9DP; Tel 0207 6099061; website: http://www.herpes.org.uk. For reliable information on all health topics including STDs and women’s health, contact: http://www.nlm.nih.gov. Select health topics. This website is also accessible via http://www.claphamhealth.org.uk.

Clinical effectiveness guidelines on the medical management of STDs are available from the Medical Society for the Study of Venereal Diseases: http://www.mssvd.org.uk/ceg.htm.

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