Case Studies

Case 1: Vaginal discharge

A 24-year-old woman attends your SH clinic complaining of a 10-day history of vaginal discharge. She says the discharge smells and is copious. She has no dysuria or pelvic pain; however, she says that her vulva is uncomfortable and feels irritated. Her LMP was 2 weeks ago and was normal. She is using the Cu-IUD for contraception and does not use condoms. She is a para 0+1 (STOP 2 years ago). She has a regular male partner who she has been with for 2 months. She last had sexual intercourse with him 5 days ago. She has had ‘thrush’ in the past and her GP prescribed her some antifungal cream last week but this hasn’t helped her symptoms.

• 1. What is the initial management of this case?

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  Correct answer:

  Once the history is complete, an examination is indicated as she has had failed syndromic treatment. A chaperone should be present and you should explain the purpose of the examination and investigations you will be undertaking. The woman should verbally consent to the examination. You should carefully examine the external genitalia, looking for the colour and consistency of any discharge, and noting any swelling, erythema or lesions, e.g. blisters, ulcers or fissures. A speculum examination should be undertaken, looking for signs of vaginitis, the consistency, colour, odour and quantity of the discharge and any foreign bodies. There are no factors in the history suggestive of upper reproductive tract pathology therefore a bimanual examination is not required (unless examination findings suggest otherwise).

The examination reveals the following: The vulva is moist with discharge and slightly erythematous, but there are is no swelling, and no lesions. There is a thin white discharge seen on parting the labia. No foreign bodies are seen on speculum examination. There are no signs of vaginitis or cervicitis. The Cu-IUD threads are seen. Copious white discharge is seen ‘pooling’ in the speculum.

• 2. Given these examination findings what is the most likely diagnosis? Which test would be useful to undertake if you did not have on-site microscopy facilities?

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  Correct answer:The symptoms and signs are in keeping with bacterial vaginosis. A vaginal pH can be done in most healthcare settings and discriminates between the two most common causes of abnormal vaginal discharge (BV and candida)

• 3. What investigations would you recommend?

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  Correct answer:

  • vaginal pH (in specialist and non-specialist settings)
  • endocervical swab for gonorrhoea and chlamydia NAAT test
  • serology for HIV and syphilis
  • vaginal smear for wet mount and Gram stain
  • endocervical swab for Gram stain, culture and sensitivity if GC is suspected

Investigations 1–3 can be carried out in non-specialist settings. An STI screen is recommended as she has had SI with a new partner (without a barrier method of contraception). Tests 4 and 5 utilize near patient microscopy; however, an air-dried slide can be transported to the laboratory if this is not available. The vaginal pH is 5.0 and clue cells are seen on the Gram stain. A diagnosis of BV is made. The woman is informed of the diagnosis.

• 4. She asks what the treatment is and is there anything else she can do to prevent BV recurring?

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  Correct answer:

  • BV is treated with metronidazole 400 mg b.d. orally for 5–7 days or in a 2-g single oral dose
  • General genital hygiene advice should be given e.g. no douching, avoid scented feminine products and bubble bath, etc.
  • Some women find vaginal acidifying gels useful (although the evidence is limited)
  • BV is more common in users of the Cu-IUD but this method is extremely efficacious therefore changing to an alternative method on the basis of a single episode of BV would not usually be recommended (if she is otherwise happy with the method)