Kayla, 15, presents to urgent care one afternoon accompanied by her aunty, June. Kayla tells you she has come to see you because she has a heavy discharge. She’s anxious and worried because she’s recently split with her boyfriend, Brendan. She found out he had cheated on her, and she’s terrified she might have an STI. She’s come to the Urgent Treatment Centre as she was scared to go to the GP as her stepmother works in reception there and she didn’t want her dad to find out she’d been to the doctors.
Vaginal discharge is a common presentation to primary care and to GU clinics. Frustratingly, it is frequently a taboo subject and the range of normal physiological secretions are rarely discussed openly. This means teenagers (and their parents) are often unaware of what is normal versus what might be pathological. As a clinician, it is all too easy to assume that all discharge is thrush (it’s not) or to feel anxious about taking swabs or discussing sexual histories to make an assessment of the likely causes.
What to ask
- Is this discharge new or different to usual for this person?
- When did it start?
- What colour is the discharge?
- Is there blood or just discharge?
- Is the discharge smelly?
- Is there any pain associated with the discharge?
- Is it itchy?
- Is there any associated dyspareunia?
- Are they/could they be pregnant?
- How many sexual partners have they had in the last 3 months?
- What do they think might be the problem?
- Have they tried any treatment – home remedies or over the counter?
- Have they had any gynaecological procedures recently?
(Discharge after a termination of pregnancy (TOP), miscarriage, delivery or cryotherapy treatment for a cervical ectropion will need managing differently)
Kayla tells you the discharge started 5 days ago. It is watery and “smells bad, like fish”. There’s no bleeding and minimal pain though she feels a bit sore generally in the vulval area. She says she hasn’t had sex for 3 weeks and had her period on time 2 weeks ago. When she found out Brendan was cheating on her she started adding Dettol to her bathwater as she’d heard this could reduce infections. She has not had any irregular bleeding. Brendan and she had been together for 5 months, she had one sexual partner before him. She almost always used condoms when having sex with Brendan.
There are a wide number of differential diagnoses for vaginal discharge especially in someone who is or has been sexually active. Having a sense of the probability of each of the causes, based largely on history can really help to identify the causes.
Should we swab everyone presenting with a discharge?
The British Association for Sexual Health and HIV (BASHH) suggest that routinely doing swabs, especially high vaginal swabs in all patients with a PV discharge, risks over investigation and is unlikely to result in better treatment outcomes if patients are presenting with uncomplicated symptoms of thrush or BV. When consulting with teenagers, it is worth remembering the high prevalence of chlamydia (symptomatically or asymptomatically) in this age group. NICE CKS (Clinical Knowledge Summaries) recommend a swab for chlamydia annually in all sexually active women aged under 25 and a swab with every change of partner. It seems logical therefore to offer a NAAT (Nucleic Acid Amplification Test – basically the swab for chlamydia) to every sexually active teenager presenting with vaginal discharge. It is possible to give a NAAT swab to the patient to do a self-taken lower vaginal swab. These have good enough pick up rates to be an alternative to formal examination and triple swabs if there is a good reason that a speculum and swabs are not going to be an option. It is optimal to offer screening for HIV and Hepatitis B as well though in practice in an A&E/UTC setting this is unlikely to be practical.
You examine Kayla using a small speculum and note a thin watery discharge adherent to the vaginal walls. You take triple swabs and explain the results will be sent to her GP in the next 3-4 days. She and her aunty say they would be OK with ringing the surgery to get the results after you explain the duty of confidentiality held by all NHS staff and that her stepmother should not have any access to her medical records.
You opt to treat Kayla for Bacterial Vaginosis with oral metronidazole and she reassures you that she never drinks alcohol when you discuss the disulfiram reaction side effect profile. You explain that changes to the vaginal pH are often caused by scented bath products and you discourage her from using these on her genital area and suggest she does not add Dettol to the bathwater in future. You reassure her that BV is not an STI and supply her with condoms and encourage her to consider regular STI screening. You also give her a leaflet discussing contraceptive options for ongoing more reliable contraception.
It is helpful to have to hand details of your local Contraception and Sexual Health (CASH)/GUM service and especially if they have an app or web-based service for young people. It is usually possible for young people in the UK to access free condoms via such a service. It is also always worth using any interaction with a teenager which includes a sexual health component as an opportunity for health promotions including STI detection and avoidance and contraception.
References
BASHH National guideline for Management of Vulvovaginal Candidiasis (2019), Bacterial Vaginosis (2012), Chlamydia Trachomatis (2015)
https://cks.nice.org.uk/topics/chlamydia-uncomplicated-genital/background-information/risk-factors/
