Management of Vaginal Discharge in Women

Diagnostic Criteria

The American College of Obstetricians and Gynecologists recommends measuring vaginal pH to differentiate between bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis, with pH >4.5 indicating bacterial vaginosis or trichomoniasis, and pH ≤4.5 suggesting vulvovaginal candidiasis 1, 2
The Centers for Disease Control and Prevention suggests using narrow-range pH paper applied directly to vaginal secretions to measure pH 1
A saline wet mount can identify motile trichomonads (trichomoniasis) or clue cells (bacterial vaginosis), and a KOH preparation can identify yeast or pseudohyphae (candidiasis) 1, 2
A positive whiff test (fishy odor immediately after KOH application) confirms bacterial vaginosis or trichomoniasis 3, 1

The American College of Obstetricians and Gynecologists recommends metronidazole 500 mg orally twice daily for 7 days as the preferred regimen for bacterial vaginosis, with a 95% cure rate 2, 4
The Centers for Disease Control and Prevention suggests fluconazole 150 mg orally as a single dose as the standard treatment for vulvovaginal candidiasis, with a 55% therapeutic cure rate 2
The American College of Obstetricians and Gynecologists recommends metronidazole single 2-gram dose as the standard treatment for trichomoniasis 2

The American College of Obstetricians and Gynecologists recommends using only 7-day topical treatments for bacterial vaginosis and candidiasis in pregnant women 5
The Centers for Disease Control and Prevention suggests treating HIV-infected women with the same regimens as non-HIV-infected women 5

The American College of Obstetricians and Gynecologists recommends returning only if symptoms persist or recur within 2 months, with routine test-of-cure not necessary if symptoms resolve 2, 5
Recurrence of bacterial vaginosis is common (50-80% within one year) but does not change initial management 4

The Centers for Disease Control and Prevention recommends that treating male sexual partners does not prevent recurrence of bacterial vaginosis and is not recommended 6
The American Academy of Family Physicians suggests that alternative treatment for bacterial vaginosis includes Clindamycin cream intravaginally 7
The American Academy of Family Physicians recommends that for uncomplicated vulvovaginal candidiasis, fluconazole 150 mg orally as a single dose is the standard treatment with a 55% therapeutic cure rate 7
The American Academy of Family Physicians suggests that maintenance therapy for complicated or recurrent vulvovaginal candidiasis includes fluconazole 150 mg weekly for 6 months to maintain clinical and mycologic control 7
The American Academy of Family Physicians recommends that for trichomoniasis, metronidazole 2 grams orally as a single dose has a 90-95% cure rate 7
The Centers for Disease Control and Prevention recommends that sexual partners of patients with trichomoniasis must be treated simultaneously to prevent reinfection 7
The American Academy of Family Physicians suggests that HIV-infected women receive identical treatment regimens as non-HIV-infected women for all three conditions 7
The Centers for Disease Control and Prevention recommends that partners should not be treated for bacterial vaginosis or candidiasis, only trichomoniasis requires partner treatment 6, 7