1. In patients with recurrent symptoms of vaginal discharge and/or perineal itching, have a broad differential diagnosis (e.g., lichen sclerosus et atrophicus, vulvar cancer, contact dermatitis, colovaginal fistula), take a detailed history, and perform a careful physical examination to ensure appropriate investigation or treatment. (Do not assume that the symptoms indicate just a yeast infection.)
  2. In patients with recurrent vaginal discharge, no worrisome features on history or physical examination, and negative tests, make a positive diagnosis of physiologic discharge and communicate it to the patient to avoid recurrent consultation, inappropriate treatment, and investigation in the future.
  3. When bacterial vaginosis and candidal infections are identified through routine vaginal swab or Pap testing, ask about symptoms and provide treatment only when it is appropriate.
  4. In a child with a vaginal discharge, rule out sexually transmitted infections and foreign bodies. (Do not assume that the child has a yeast infection.)
  5. In a child with a candidal infection, look for underlying illness (e.g., immunocompromise, diabetes).


  • Infectious vaginal discharge
    • Bacterial vaginosis (most common cause of vaginal discharge 30%)
    • Candida vulvovaginitis
    • Trichomonas vaginalis (STI)
    • Cervicitis (Gono/Chlam)
  • Non-infectious vaginal discharge
    • Physiologic
    • Atrophic vaginitis (scant discharge)
    • Foreign body
  • Non-infectious vulvovaginal pruritus without discharge
    • Irritant or allergic contact dermatitis (latex, soaps, perfumes)
    • Lichen planus
    • Lichen sclerosus
    • Vulvar cancer
    • Psoriasis
    • Colovaginal fistula

Bacterial Vaginosis

  • Diagnosis
    • Clinical (Amsel's), require 3 of 4
      • Adherent and homogenous vaginal discharge (smoothly coats vaginal walls)
      • Vaginal pH >4.5
      • Clue cells on saline wet mount
      • Positive whiff-amine test
        • Fishy amine odour (before or) after addition of 10% KOH
    • Other
      • Gram stain vagina smear with Nugent scoring system (gold standard)
      • Commercial test DNA probe (eg. Affirm VP III)
    • Note: Vaginal culture positive for G. vaginalis is not diagnostic due to low specificity (cultured in >50% of healthy asymptomatic women)
  • Treatment
    • Oral: Metronidazole 500mg PO BID or Clindamycin 300mg PO BID x 7-14d
      • Preferred in pregnancy as they have been shown to reduce preterm birth
    • Topical: Metronidazole gel 0.75% one applicator (5g) PV daily x 5d
    • Longer courses if multiple recurrences
      • Consider Metronidazole gel 0.75% one applicator (5g) PV daily x10d then two times per week for 3-6 months
  • Alternatives:
    • Vaginal metronidazole gel
    • Oral or vaginal clindamycin cream

Trichomonas vaginalis

  • Diagnosis
    • Malodorous, green/yellow frothy discharge, pruritus, dyspareunia, petechiae - strawberry cervix
    • Motile trichomonads on wet mount microscopy, NAAT PCR vaginal swabs, culture
  • Treatment
    • Metronidazole 2g PO x1 or Metronidazole 500mg PO BID x7d
    • High-dose therapy may be needed for resistance
    • Partner treatment enhances cure rates
    • Abstain from intercourse until both patients treated and asymptomatic

Candida vulvovaginitis

  • Diagnosis
    • Erythema, edema of vulvovaginal tissues with thick, white clumped vaginal discharge, pH<4.5
    • Budding yeast and pseudohyphae on wet mount microscopy (negative in 50%)
    • Consider culture in negative microscopy or persistent/recurrent symptoms after treatment
  • Treatment
    • Uncomplicated (Sporadic, infrequent ≤3/y, healthy, immunocompetent, nonpregannt)
      • Fluconazole 150mg PO x1 or topical intravaginal/suppository (clotrimazole, miconazole)
        • Topical antifungal azoles may require longer courses, but are first-line in pregnancy
          • eg. Clotrimazole Combi Pak (Canesten 500mg vag tab/1% cream) or cream 10% x 1
    • Complicated
      • Fluconazole 150mg PO x3 doses 72h apart (day 1, 4, 7)
        • Consider maintenance with Fluconazole 150mg PO weekly x 6 months
        • Monitor for hepatotoxicity with long-term use and drug interactions
  • Non-albicans species may not respond to fluconazole
    • For C glabrata, consider vaginal boric acid capsules at compounding pharmacist (avoid in pregnancy)
    • For C krusei, consider topical clotrimazole

Prepubescent Vaginal Discharge

  • Mucoid white vaginal discharge normal in neonates, decreases by 3 months old


  • Non-specific (most common)
    • Causal factors
      • Thin vaginal mucosa
      • Moisture (tight clothing)
      • Irritants (soap, bubble bath, prolonged contact with urine/feces)
  • Bacterial
    • Group A beta-hemolytic strep
    • H. influenzae
    • E. coli
    • Candida (unusual)
  • Dermatologic
    • Lichen sclerosis
    • Psoriasis
    • Atopic dermatitis
  • Foreign body, usually toilet paper (recurrent symptoms or bloody discharge)
    • Flush with sterile saline or refer to gyne for vaginoscopy
  • Pinworms (nocturnal perineal pruritus)
    • Treat with mebendazole
  • Systemic infection (varicella, measles, rubella, diphtheria, shigella)
  • Rule out STIs and sexual abuse, especially in recurrent cases


  • Introital (not vaginal) swab if profuse discharge
    • Bacterial culture (GAS, Haemophilus influenzae, Gardnerella)
      • If positive bacterial culture, can treat with antibiotics
    • Candida unusual, consider if immunosuppression


  • Treat underlying cause
  • If non specific,
    • Reassurance
    • Hygiene (wipe front to back)
    • Avoid causal factors (soaps, baby wipes, tight-fitting clothing, wet bathing suits, bubble bath, scented detergents)
    • Warm soaks, gentle drying
    • Sleep without underwear
    • Gentle emollients and barrier creams