2018 European IUSTI/WHO guideline on the management of vaginal discharge

Abstract

Four common pathological conditions are associated with vaginal discharge: bacterial vaginosis, aerobic vaginitis, candidosis, and the sexually transmitted infection, trichomoniasis. Chlamydial or gonococcal cervical infection may result in vaginal discharge. Vaginal discharge may be caused by a range of other physiological and pathological conditions including atrophic vaginitis, desquamative inflammatory vaginitis, cervicitis, and mucoid ectopy. Psychosexual problems may present with recurrent episodes of vaginal discharge and vulval burning. These need to be considered if tests for specific infections are negative. Many of the symptoms and signs are non-specific and a number of women may have other conditions such as vulval dermatoses or allergic and irritant reactions.

The Guidelines Group recommends that the current best test to diagnose bacterial vaginosis in women is microscopy using the Hay-Ison criteria, best test to diagnose aerobic vaginitis and Candida is microscopy, best tests to diagnose trichomoniasis are nucleic acid amplification tests.

The Guidelines Group recommends that 5–7 days of topical or oral metronidazole or 7 days of intravaginal clindamycin can be considered first line for uncomplicated bacterial vaginosis; best treatment for persistent and recurrent bacterial vaginosis is intravaginal metronidazole; best treatment for uncomplicated aerobic vaginitis is clindamycin cream; best treatment for uncomplicated Candida is a single-dose azole (oral or vaginal); best treatment for persistent and recurrent Candida is a three-day induction course of an azole followed by long-term maintenance suppressive regimen for at least 6 months; best treatment for uncomplicated trichomoniasis are nitroimidazoles (metronidazole or tinidazole); best treatment for persistent and recurrent trichomoniasis is repeated course of nitroimidazole at a higher dose. Best treatment in pregnant women for trichomoniasis is metronidazole; for bacterial vaginosis is clindamycin; for Candida are topical azole preparations.