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Abnormal vaginal discharge is a common problem which can usually be managed syndromically in non-specialist services.1 Common pathological causes include bacterial vaginosis (BV), candidiasis and Trichomoniasis (TV). Some women fail to improve with syndromic treatment, or present with additional symptoms such as severe dyspareunia or purulent discharge. This article focuses on a practical approach to investigating and managing such a presentation in a specialist setting where near-patient microscopy is available. It needs to be read in conjunction with guidelines, such as the 2011 European (IUSTI/WHO) Guideline on Management of Vaginal Discharge.2
Overgrowth conditions of the vagina
Normal vaginal health in adult women is maintained by acid-secreting lactobacilli. In overgrowth conditions such as BV these healthy lactobacilli are disrupted, although the underlying cause for this remains unclear. In all these conditions vaginal pH rises and there is usually an increased discharge.
BV presents with a painless but unpleasant, odorous discharge. There is overgrowth of anaerobic organisms, such as Gardnerella vaginalis, Mobiluncus spp., BV-associated bacteria 1–3 and Atopobium spp. causing a rise in vaginal pH, discharge, and smell, but little inflammation. Once BV is established, biofilm formation may explain the high recurrence rate.3
Aerobic vaginitis (AV) presents with a more purulent discharge with significant inflammation and epithelial disruption. Patients may also report burning, stinging and dyspareunia. There is predominance of aerobic flora such as Escherichia coli, group B streptococci, Staphylococcus aureus and evidence of local cytokine-mediated inflammation.4
Desquamative inflammatory vaginitis (DIV), is a chronic condition of unknown aetiology with vaginal rash and purulent discharge. Patients present with profuse discharge, vestibulovaginal irritation, dyspareunia and vaginal inflammation or erythema. Many patients have long-standing symptoms for 12 months or …