Clinical Guides
Vaginal Discharge
An India-focused, evidence-bound approach to distinguishing physiological vaginal discharge from vaginitis, cervicitis and serious pelvic disease, with diagnostic, syndromic and treatment safety guidance.
MedNext Academy | 17 min read
Vaginal Discharge
An India-focused, evidence-bound approach to distinguishing physiological vaginal discharge from vaginitis, cervicitis and serious pelvic disease, with diagnostic, syndromic and treatment safety guidance.
Summary
Vaginal discharge is a symptom, not a diagnosis. Normal secretions vary with puberty, the menstrual cycle, pregnancy, sexual activity and hormonal contraception. Physiological discharge is generally clear to white, minimally odorous and not accompanied by itch, pain, dysuria, bleeding or pelvic tenderness. Discharge becomes clinically concerning when it represents a change from the person's usual pattern in amount, colour, smell or consistency, or is associated with vulval irritation, dyspareunia, urinary symptoms, pelvic pain, fever, bleeding or pregnancy complications.
The common vaginal causes are bacterial vaginosis, vulvovaginal candidiasis and trichomoniasis. Cervicitis from infections such as chlamydia or gonorrhoea may present with discharge and can progress to pelvic inflammatory disease, yet vaginal symptoms alone correlate poorly with cervical infection. Non-infectious causes include irritant or allergic vulvovaginitis, a retained foreign body, genitourinary syndrome of menopause, dermatological disease, desquamative inflammatory vaginitis, fistula and neoplasia. More than one condition may coexist. Neither colour nor a remote history alone is accurate enough to separate these diagnoses.
A safe assessment combines confidential sexual, menstrual, pregnancy, hygiene and medicine history with examination and targeted testing when available. Vaginal pH, saline and potassium-hydroxide microscopy, amine testing, Gram stain, nucleic-acid amplification tests and yeast culture answer different questions. In settings without examination or laboratory access, WHO and NACO support syndromic management, but the limitations must be understood: syndromic treatment can relieve common vaginitis while over-treating some patients and missing asymptomatic or poorly correlated cervicitis. Persistent, recurrent, pregnant, postmenopausal or atypical presentations need diagnostic review rather than repeated empirical kits. This guide is educational and not a patient-specific prescription; current Indian guidance, pregnancy status, allergies, interactions and local test availability must be checked by a registered clinician.
How Common Is It?
Vaginal discharge is one of the most frequent reasons for gynaecology and sexual-health consultation, but a single prevalence number is misleading. Physiological discharge is normal, many vaginal microbiome changes are asymptomatic, and studies use different case definitions, tests and populations. Clinic samples over-represent people with distressing symptoms, pregnancy or STI risk. The NACO 2024 guideline notes substantial heterogeneity in India's STI and reproductive-tract infection statistics and treats vaginal discharge as a syndrome whose common causes include Candida, bacterial vaginosis and Trichomonas vaginalis. That programme context does not mean every discharge is an STI.
The relative frequency also changes by age and setting. Bacterial vaginosis is a common cause of malodorous discharge in reproductive-age populations. Vulvovaginal candidiasis commonly causes itch and soreness, although Candida can colonise without causing disease. Trichomoniasis prevalence follows sexual networks and access to testing. Cervicitis may be asymptomatic, and discharge alone is an insensitive predictor. Before puberty, a foreign body, hygiene-related irritation, pinworms, dermatological disease or safeguarding concern may be more relevant. After menopause, low-oestrogen tissue change, dermatoses, malignancy and fistula move higher in the differential.
Burden is better measured by consequences than attendance counts. Persistent symptoms disrupt sleep, sex, work and well-being; cervical infection or PID can affect fertility; pregnancy changes the urgency of selected infections; stigma can delay care. NACO provides Designated STI/RTI Clinics, also known as Suraksha Clinics, across district hospitals and medical colleges, with laboratory reference support. Clinicians should offer confidential, non-judgemental assessment rather than assuming sexual transmission, poor hygiene or infidelity. For public education, the useful message is that normal discharge needs no antimicrobial treatment, while a new symptomatic pattern deserves an accurate diagnosis and safety screen.
Risk Factors
Risk depends on the cause. Bacterial vaginosis is associated with disruption of lactobacillus-predominant vaginal ecology; new or multiple partners, condomless sex and vaginal douching or insertion practices are associated factors, but BV is not simply classified as a conventional STI. Trichomoniasis and cervicitis are sexually transmitted, so partner exposure, inconsistent barrier use and previous STI matter. Vulvovaginal candidiasis can follow antibiotic exposure and is more difficult in poorly controlled diabetes, pregnancy, immunosuppression or corticosteroid use, although many otherwise healthy patients have no identifiable trigger.
Local practices and products deserve neutral questions. Douching, antiseptics, deodorants, fragranced washes, lubricants, spermicides, detergents, sanitary products, intravaginal herbs and repeated over-the-counter antifungals can alter symptoms, pH or microscopy and may cause irritant dermatitis. A retained tampon, condom or other foreign body can produce offensive discharge. Recent intercourse, semen, menstruation, intravaginal medicine and antibiotics can affect bedside tests. Hormonal state changes secretions: ovulation and pregnancy can increase physiological discharge, while menopause and lactation can produce low-oestrogen dryness, burning and secondary inflammation.
Cervical infection risk is not determined by discharge colour. Age, local epidemiology, a new partner, multiple partners, a partner with an STI, inconsistent condoms and previous STI inform testing, but they should not be used to deny testing outside a stereotype. Sexual history should include the sites and types of contact, partners of any gender and possibility of coercion. Pregnancy possibility affects both the differential and medicine selection.
Recurrence after treatment raises other risks: an incorrect initial diagnosis, non-adherence, reinfection in trichomoniasis or cervicitis, resistant or non-albicans Candida, uncontrolled diabetes, immunodeficiency, a foreign body or non-infectious disease. Repeated empirical combinations can themselves disrupt flora and obscure the diagnosis. Risk assessment should therefore guide tests and safety, not become a moral judgement or a substitute for examination.
Diagnosis
First decide whether the discharge is physiological, vaginitis, cervicitis, upper-genital-tract infection or non-infectious disease. CDC and WHO both emphasise that history alone is insufficient for reliable vaginitis diagnosis. Offer privacy, consent, a chaperone and trauma-informed examination; defer non-urgent internal examination when the patient declines while arranging a safe alternative.
History
Ask what changed from baseline: onset, amount, colour, consistency and odour, and whether itch, burning, external dysuria, deep or superficial dyspareunia, lower abdominal pain, fever, bleeding, ulcers or urinary symptoms are present. Record last menstrual period, pregnancy possibility, postpartum status, menopause, contraception, recent antibiotics, diabetes, immunosuppression, products and intravaginal practices. Take a confidential sexual history covering new partners, barrier use, oral, vaginal and anal exposure, partner symptoms, previous STI and assault risk. Ask about self-treatment because antifungals and antibiotics alter findings. Recurrent episodes require dates, test results and response, not simply the label thrush.
Examination
Assess vital signs and abdominal tenderness if pain, fever, pregnancy or systemic illness is possible. Inspect the vulva for erythema, oedema, fissures, excoriation, ulcers, dermatosis or trauma. With consent, speculum examination identifies discharge origin and character, retained material, vaginal inflammation, cervical friability, mucopus, contact bleeding, polyps or a lesion. Bimanual examination is indicated for lower abdominal pain or suspected PID to assess cervical motion, uterine and adnexal tenderness. A normal examination does not exclude chlamydia, gonorrhoea or trichomoniasis.
Investigations
Bedside vaginal pH and microscopy can rapidly separate patterns. BV commonly raises pH above 4.5 and meets Amsel or Gram-stain Nugent criteria. Trichomonads may be seen on saline microscopy, but wet-mount sensitivity is limited and falls with delay; NAAT is preferable where available. Candida is suggested by budding yeast, hyphae or pseudohyphae on potassium-hydroxide microscopy with usually normal pH; culture or a validated molecular test is useful when microscopy is negative despite symptoms or disease is complicated or recurrent. Obtain NAAT for chlamydia and gonorrhoea when cervicitis or STI risk is present and test for HIV, syphilis and other infections according to risk and national guidance. Pregnancy testing, urinalysis, glucose or HbA1c and culture are targeted. Biopsy, ultrasound or specialist testing belongs to persistent bleeding, a lesion, mass, fistula suspicion or unexplained inflammation.
Differential Diagnosis
Physiological leucorrhoea is clear or white, non-offensive and not associated with pain, itch, dysuria or bleeding. It may increase around ovulation, in pregnancy or with oestrogen exposure. Bacterial vaginosis typically produces thin homogeneous discharge and a fishy odour, with pH above 4.5, clue cells and a positive amine test contributing to Amsel diagnosis. Vulvovaginal candidiasis more often causes intense itch, soreness, vulval erythema, fissures, external dysuria and thick discharge; pH is usually below 4.5. Trichomoniasis can cause diffuse inflammation, malodorous yellow-green discharge, dysuria or a strawberry cervix, but presentation is variable and NAAT is more sensitive than wet mount.
Cervicitis should be considered with endocervical mucopus, friability, postcoital bleeding or STI exposure; chlamydia and gonorrhoea can be present without these signs. Lower abdominal pain, cervical-motion, uterine or adnexal tenderness, fever or dyspareunia raises concern for PID. Genital ulcers change the syndrome entirely. A discharge algorithm that treats only BV and Candida must not miss cervicitis, trichomoniasis, PID or pregnancy.
Non-infectious differentials are common in persistent cases. Irritant or allergic contact vulvitis can follow soaps, antiseptics, pads, lubricants or topical medicines. Genitourinary syndrome of menopause causes dryness, burning, dyspareunia, urinary symptoms and sometimes watery or yellow discharge with elevated pH. Lichen sclerosus, lichen planus, eczema and psoriasis cause vulval symptoms and need visual diagnosis, sometimes biopsy. Desquamative inflammatory vaginitis or aerobic vaginitis can produce purulent discharge, raised pH and inflammation after common infections are excluded.
Retained foreign material often causes offensive or blood-stained discharge. Urinary or faecal fistula causes continuous leakage rather than episodic secretion. Cervical or endometrial polyps and malignancy can cause watery, offensive or blood-stained discharge, especially after menopause. In children, consider nonspecific vulvovaginitis, a foreign body, threadworms, dermatoses and safeguarding issues; do not perform or interpret the adult syndromic pathway mechanically. Mixed infection exists, but multiple positive molecular results must still be interpreted with symptoms and validated assays.
Management
Explain the working diagnosis and whether it is sexually transmitted. Physiological discharge needs reassurance, avoidance of irritants and no antimicrobial. Encourage external washing with water or a mild non-perfumed cleanser if desired; the vagina does not need internal cleansing. Stop douching, antiseptics and unnecessary intravaginal products. Use a cause-specific regimen when examination and testing are available: antibacterial treatment for symptomatic BV, antifungal treatment for confirmed or strongly supported candidiasis, antiprotozoal treatment plus partner management for trichomoniasis, and national regimens with partner services for cervicitis.
Where diagnostics are not available and loss to follow-up is likely, NACO 2024 and WHO 2021 support syndromic or enhanced syndromic management. Apply the national vaginal-discharge algorithm rather than inventing a combination. Assess cervicitis risk, lower abdominal pain, pregnancy and red flags separately. Tell the patient what the kit covers and does not cover, likely adverse effects, whether a partner needs evaluation and when to return. Syndromic care is a pragmatic access strategy, not proof that all treated organisms were present. Where point-of-care or laboratory tests are accessible, use them to improve precision and antimicrobial stewardship.
For suspected BV, candidiasis or trichomoniasis, the organism-specific guides provide treatment details. Avoid treating asymptomatic Candida colonisation. Do not repeatedly prescribe fluconazole for every itch, or antibiotics for physiological discharge. For cervical infection, follow NACO testing and treatment, offer HIV and syphilis services and ensure partner notification is voluntary, confidential and safe. PID requires prompt broad treatment; waiting for a perfect test can increase reproductive harm. Pregnancy requires pregnancy-safe regimens and obstetric coordination when symptoms, bleeding or pain are significant.
Address comfort without masking serious disease: cool compresses, avoidance of friction and a bland emollient externally may help selected irritant symptoms, but topical steroids, boric acid or combination creams should not be improvised without diagnosis. Review if symptoms persist, recur soon, or tests conflict with the clinical picture. At review, reconsider foreign body, dermatosis, non-albicans yeast, resistance, cervicitis, PID, diabetes and malignancy. Document consent, tests, medicines, counselling, partner plan and a specific safety net.
Prescribing Information
Prescribe to an identified diagnosis or a recognised national syndrome. The 2024 NACO guideline is the India-specific authority for enhanced syndromic algorithms and colour-coded STI/RTI kits. Confirm the current kit contents locally because programme formulations can change. Ask about pregnancy and breastfeeding, allergies, liver and renal disease, alcohol use where clinically relevant, anticoagulants and interacting medicines. Verify whether oral and intravaginal products affect latex barrier contraception and explain the treatment interval.
For BV, WHO 2024 suggests oral metronidazole 400 or 500 mg twice daily for seven days for adults and adolescents, including pregnant patients. Alternatives depend on availability, adherence and preference and include metronidazole vaginal gel, clindamycin oral or vaginal therapy, secnidazole, or tinidazole outside pregnancy. For uncomplicated Candida albicans infection, WHO options include a single oral fluconazole 150 to 200 mg dose or several intravaginal azoles. In pregnancy, use the recommended topical course such as clotrimazole for seven days or nystatin, not oral fluconazole. Trichomoniasis requires an effective nitroimidazole regimen and partner treatment; use the current NACO or WHO recommendation rather than assuming BV treatment and partner rules are identical.
These examples are not a licence for a universal metronidazole-fluconazole combination. Symptoms alone have limited specificity, oral azoles have interactions and rare hepatic toxicity, and nitroimidazoles can cause gastrointestinal effects and metallic taste. Intravaginal azole or clindamycin preparations may be oil-based and weaken latex products temporarily. Check current labels. Avoid boric acid in pregnancy and never use orally; specialist-supervised use belongs to selected recurrent non-albicans candidiasis after confirmation, not routine discharge.
Cervicitis treatment should follow current Indian antimicrobial guidance and local resistance or test information. Do not copy an outdated gonorrhoea regimen from memory. Provide adherence instructions, abstinence or barrier advice until relevant STI treatment and partner management are complete, and retesting when national guidance recommends it. If treatment fails, do not automatically extend the same drug. Confirm adherence, re-exposure, diagnosis, microscopy or NAAT limitations, culture and susceptibility where relevant. Persistent discharge with negative infection tests needs non-infectious assessment rather than escalating antimicrobials.
When to Refer
Refer urgently for haemodynamic instability, severe lower abdominal pain, peritonism, fever with systemic toxicity, pregnancy with pain or bleeding, suspected ectopic pregnancy, tubo-ovarian abscess, sepsis or inability to tolerate oral treatment. PID is a clinical diagnosis and should not be delayed when cervical-motion, uterine or adnexal tenderness and compatible risk are present. Acute urinary retention, rapidly spreading vulval swelling or severe drug reaction also requires urgent care.
Use an urgent gynaecology or cancer pathway for postmenopausal bleeding, persistent blood-stained or watery discharge, a suspicious cervical or vulval lesion, pelvic mass, unexplained weight loss, offensive discharge with tissue necrosis or symptoms that persist despite adequate infection assessment. Suspected fistula, retained foreign body that cannot be safely removed, genital trauma or significant prolapse needs appropriate specialist care. Children with discharge, bleeding, a foreign body or possible abuse require paediatric and safeguarding expertise; do not apply an adult internal examination or partner pathway.
Refer to a sexual-health, dermatology or gynaecology service for recurrent or treatment-resistant symptoms, uncertain microscopy, non-albicans Candida, suspected desquamative inflammatory or aerobic vaginitis, lichen sclerosus or lichen planus, severe vulval pain, immunosuppression, poorly controlled diabetes or complex pregnancy. Repeated positive tests without matching symptoms, or repeated symptoms without a positive test, both warrant diagnostic review.
NACO's Designated STI/RTI Clinics provide an India-specific referral option for etiological testing, partner services, HIV and syphilis care and treatment failure. Refer when the needed test is unavailable locally, when a current national regimen cannot be safely delivered or when confidentiality and safeguarding require a specialist setting. Give first-dose or emergency treatment only when indicated, share results securely and state the urgency. A vague referral without a bleeding, pain, pregnancy or infection safety plan is incomplete.
Red Flags
Lower abdominal pain with fever, cervical-motion tenderness, uterine or adnexal tenderness, vomiting or systemic illness may indicate PID or tubo-ovarian abscess. In pregnancy, pain, bleeding, dizziness or shoulder-tip pain requires urgent ectopic-pregnancy assessment. Postpartum or post-procedure offensive discharge with fever may indicate endometritis or retained products. Do not label these presentations simple vaginitis because discharge is prominent.
Bleeding changes urgency. Postmenopausal bleeding, persistent postcoital or intermenstrual bleeding, contact bleeding from a cervical lesion, blood-stained watery discharge or unexplained anaemia requires directed evaluation. A visible ulcer, mass, pigment change, architectural loss, non-healing fissure or vulval lesion needs specialist examination and sometimes biopsy. Urine or faeces continuously leaking through the vagina suggests fistula. An offensive discharge with a missing tampon or other item suggests a retained foreign body.
Systemic or treatment red flags include syncope, hypotension, severe dehydration, jaundice, widespread rash, mucosal blistering, facial swelling, breathing difficulty, focal neurological symptoms or suspected severe drug interaction. Severe vulval oedema, necrosis or rapidly spreading pain is not routine Candida. Persistent fever, weight loss, lymphadenopathy or immunosuppression should broaden the differential.
Safeguarding red flags include discharge or an STI in a child, disclosure or signs of sexual assault, reproductive coercion, trafficking, intimate-partner violence or inability to consult privately. Follow local legal, forensic and child-protection pathways while preserving dignity and avoiding repeated examinations. Finally, recurrence itself can be a red flag when symptoms return within weeks, remain culture-positive, repeatedly follow intercourse, or never matched the original diagnosis. Stop serial empirical treatment, obtain appropriate specimens and reconsider cervicitis, trichomoniasis, resistant or non-albicans yeast, dermatosis, foreign body, diabetes and neoplasia.
Indian Clinical Context
The National Technical Guidelines on STI and RTI 2024 from NACO are the primary Indian programme source. They distinguish physiological from abnormal discharge, identify Candida albicans, bacterial vaginosis and Trichomonas vaginalis as common vaginal causes, and use enhanced syndromic case management when immediate treatment is needed. The guidelines also promote laboratory diagnosis where possible to improve precision and antimicrobial stewardship. NACO supports Designated STI/RTI or Suraksha Clinics, regional reference laboratories and partner and HIV services.
India's care settings range from subcentres without microscopy to tertiary clinics with NAAT and culture. At a low-resource first contact, assess pregnancy, pain, bleeding, fever and cervicitis risk before applying the national flowchart. At a laboratory-capable site, do not ignore available tests merely because a kit exists. Syndromic management of vaginal discharge has lower specificity for cervical infection than some other STI syndromes; document the uncertainty and arrange testing or follow-up. A patient should not be told she has three infections simply because a combination was dispensed.
Use non-stigmatising language in the patient's preferred language. BV and candidiasis are not proof of sexual transmission or partner infidelity. Take sexual history privately, include partners of any gender, and obtain consent before partner notification. Offer HIV and syphilis testing according to national guidance without coercion. Provide pregnancy-safe treatment and involve antenatal care when appropriate. Avoid advice to douche, steam or insert antiseptics, herbs or commercial washes; these practices can worsen irritation and alter vaginal ecology.
Prescribe generically and confirm current NACO kit composition, Indian label and supply rather than repeating an old colour or brand. Ensure referral information includes the nearest functional Suraksha Clinic or gynaecology service, not only a tertiary centre the patient cannot reach. Teleconsultation can support counselling and results but is limited when microscopy, speculum examination or pelvic assessment is necessary. A high-quality plan balances prompt access with diagnostic accuracy: treat a recognised syndrome when needed, collect tests before antimicrobials when feasible, and insist on review for persistence, recurrence or red flags.
NMC Competency Mapping
The NMC Competency Based Medical Education Curriculum 2024 makes vaginal discharge a specific undergraduate topic. OG22.1 requires recognition of physiological vaginal discharge. Learners should describe normal clear-to-white, minimally odorous secretion, its variation with the cycle and pregnancy, and the absence of itch, pain, dysuria or bleeding. Reassurance and avoidance of unnecessary antimicrobial therapy are clinical skills, not omissions.
OG22.2 requires aetiology with emphasis on Candida, Trichomonas vaginalis and bacterial vaginosis; clinical characteristics, diagnosis, investigations, genital hygiene, management of common causes and syndromic management. A competent answer contrasts pH, odour, inflammation and microscopy patterns without pretending any one feature is diagnostic. It separates vaginitis from cervicitis and PID, explains when NAAT or culture is needed and gives hygiene advice that avoids douching and irritants.
DR10.10 requires diagnosis and management of vaginal discharge according to syndromic case-management guidance. MI8.3 addresses the concept and utility of syndromic STI management, while MI8.1 and MI8.2 support organism and laboratory knowledge. OG35.5 requires examination, differential diagnosis and management of a discharge case. Together, these competencies mean the learner must do more than recall a colour-coded kit: obtain consent, take a private sexual and pregnancy history, examine appropriately, collect valid specimens, identify red flags, prescribe safely, counsel partners when the cause requires it and arrange follow-up.
For OSCE performance, introduce yourself, ensure privacy and a chaperone, ask the patient's preferred language, characterise the change from baseline, screen for pain, fever, pregnancy and bleeding, and explain the examination. State which samples are vaginal and which are cervical. Interpret vaginal pH and microscopy in context. Finish with diagnosis or honest uncertainty, medicine instructions, genital-care advice, STI testing or partner plan and specific safety-netting. Stigma, coercive testing and unnecessary internal cleansing advice should lose marks because they are clinically harmful.
Key Exam Pearls for NEET PG
Physiological discharge is clear or white, minimally odorous and not associated with itch, pain or bleeding. History alone cannot reliably distinguish vaginitis causes. BV usually has thin homogeneous discharge, pH above 4.5, clue cells and a positive amine test; three of four Amsel criteria support diagnosis. Candida commonly causes pruritus, vulval erythema, fissures and thick discharge with pH usually below 4.5; demonstrate budding yeast, hyphae or pseudohyphae, or use culture when needed. Trichomoniasis often raises pH and may cause malodorous discharge and a strawberry cervix, but NAAT is more sensitive than wet mount.
Cervicitis is not the same as vaginitis. Think of mucopurulent endocervical discharge, friability or postcoital bleeding, and test for chlamydia and gonorrhoea according to risk. Pelvic pain plus cervical-motion, uterine or adnexal tenderness suggests PID and merits prompt treatment. Wet mount sensitivity is limited: a negative result does not reliably exclude trichomoniasis or Candida. Candida colonisation without symptoms is not an indication to treat.
Use NACO enhanced syndromic management when diagnostics are not available and immediate programme care is appropriate, but know its limitations. Partner treatment is cause-specific: required for trichomoniasis and relevant bacterial STIs, not routinely for BV or uncomplicated candidiasis. Oral fluconazole is avoided in pregnancy; use a recommended topical azole course. Metronidazole treats BV and trichomoniasis but the regimen and partner plan differ.
Red flags override the discharge algorithm: pregnancy with pain or bleeding, fever and lower abdominal tenderness, postmenopausal or postcoital bleeding, a cervical or vulval lesion, retained foreign body, fistula, child safeguarding concerns or systemic toxicity. For exam answers, use the sequence physiological versus pathological, vaginitis versus cervicitis or PID, pH and microscopy or NAAT, organism-specific versus syndromic treatment, partner and STI services, and safety-netting.
Frequently Asked Questions
How can normal vaginal discharge be distinguished from infection?
Normal discharge is usually clear or white, has little odour and is not accompanied by itch, soreness, dysuria, bleeding or pelvic pain. Its amount and texture can change with ovulation, pregnancy and hormonal contraception. Infection is more likely when there is a new odour, colour or consistency plus symptoms, but appearance alone is not diagnostic. A careful history, examination and targeted pH, microscopy or molecular testing are safer than treating every white discharge as Candida.
Is every episode of vaginal discharge a sexually transmitted infection?
No. Physiological secretion is normal, while bacterial vaginosis and vulvovaginal candidiasis are not classified as conventional STIs. Trichomoniasis, chlamydia and gonorrhoea are sexually transmitted and require appropriate partner and STI management. Irritants, menopause, dermatoses, a retained foreign body and malignancy are other possibilities. Clinicians should take a confidential sexual history without implying infidelity and use examination and tests to distinguish vaginitis from cervicitis and upper-genital-tract disease.
Why should recurrent vaginal discharge not receive repeated empirical treatment?
Recurrence may mean the original diagnosis was wrong, the organism was not covered, a partner-related STI caused reinfection, Candida is non-albicans or resistant, diabetes or immunosuppression is relevant, or a non-infectious disorder is present. Repeated antibiotic and antifungal combinations can disrupt flora, cause adverse effects and delay diagnosis of dermatosis, foreign body, cervicitis or neoplasia. Persistent or early recurrent symptoms warrant examination and appropriate microscopy, NAAT or culture before another course.
Which symptoms with vaginal discharge require urgent medical assessment?
Urgent assessment is needed for severe lower abdominal pain, fever, vomiting, fainting, pregnancy with pain or bleeding, cervical-motion or adnexal tenderness, postmenopausal bleeding, a suspicious genital lesion, rapidly increasing vulval swelling or systemic illness. Offensive postpartum or post-procedure discharge may indicate serious infection. A child with discharge or any concern for assault requires specialist safeguarding care. These presentations should not wait for routine self-treatment or be labelled simple thrush.
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