In operational settings, most women complaining of vaginal discharge will have no other associated symptoms (pain, bleeding, fever, vulvar lesions, etc.) You can solve 95% of these vaginal discharge complaints by asking two questions:

• Does it itch?
• Does it have a bad odor?

If it itches, give the patient Monistat (or other antifungal medication). If there is a bad odor, give Flagyl. If it itches and has a bad odor, give both Monistat and Flagyl. You will solve most of the vaginal discharge problems and will miss nothing important for very long.

Those women whose symptoms persist despite this expedient treatment will need a more thorough evaluation. For those, the diagnosis of vaginal discharge is based on a History, Physical Exam, and a few simple diagnostic tests.

History

Ask the patient about itching, odor, color of discharge, painful intercourse, or spotting after intercourse.

• Yeast causes intense itching with a cheesy, dry discharge.
• Gardnerella causes a foul-smelling, thin white discharge.
• Trichomonas gives irritation and frothy white discharge.
• Foreign body (lost tampon) causes a foul-smelling black discharge.
• Cervicitis causes a nondescript discharge with deep dyspareunia
• Chlamydia may cause a purulent vaginal discharge, post-coital spotting, and deep dyspareunia.
• Gonorrhea may cause a purulent vaginal discharge and deep dyspareunia.
• Cervical ectropion causes a mucous, asymptomatic discharge.

Treatment

In addition to specific treatment of any organism identified by culture or other test...

• Any patient complaining of an itchy vaginal discharge should probably be treated with an antifungal agent (Monistat, Lotrimin, etc.) because of the high likelihood that yeast is present, and
   

• Any patient complaining of a bad-smelling vaginal discharge should probably be treated with Flagyl (or other reasonable substitute) because of the high likelihood that Gardnerella is present.

Ectropion, Erosion or Eversion

This harmless condition is frequently mistaken for cervicitis.

Ectropion, erosion or eversion (all synonyms) occurs when the normal squamo-columnar junction is extended outward from the its; normal position at the opening of the cervix.

Grossly, the cervix has a red, friable ring of tissue around the os. Careful inspection with magnification (6-10x) will reveal that this red tissue is the normal tissue of the cervical canal, which has grown out onto the surface of the cervix.

Cervical ectropion is very common, particularly in younger women and those taking BCPs. It usually causes no symptoms and need not be treated. If it is symptomatic, producing a more or less constant, annoying, mucous discharge, cervical cauterization will usually eliminate the problem.

When faced with a fiery red button of tissue surrounding the cervical os, chlamydia culture (in high-risk populations) and Pap smear should be performed. If these are negative and the patient has no symptoms, this cervical ectropion should be ignored.

Cervicitis

Inflammation or irritation of the cervix is rarely the cause of significant morbidity. It is mainly a nuisance to the patient and a possible symptom of underlying disease (gonorrhea, chlamydia).

Some patients with cervicitis note a purulent vaginal discharge, deep dyspareunia, and spotting after intercourse, while others may be symptom-free. The cervix is red, slightly tender, bleeds easily, and a mucopurulent cervical discharge from the os is usually seen.

A Pap smear rules out malignancy. Chlamydia culture and gonorrhea culture (for gram negative diplococci) are routinely performed.

No treatment is necessary if the patient is asymptomatic, the Pap smear is normal, and cultures are negative. Antibiotics specific to the organism are temporarily effective and may be curative. Cervical cautery may be needed to achieve permanent cure.