How should I approach the investigation of a patient with recurrent vaginal discharge?

When investigating a patient presenting with recurrent vaginal discharge, start with a detailed clinical history and examination to identify associated symptoms such as itching, soreness, unpleasant odour, or dysuria, which may indicate infection requiring further investigation ¹.

Consider vaginal swabs to identify causative organisms, especially if the discharge is symptomatic or recurrent, to differentiate between common causes such as bacterial vaginosis, candidiasis, or sexually transmitted infections (STIs) ¹ (Sherrard et al., 2011).

In pregnant women, vaginal discharge is common, but if accompanied by symptoms, vaginal swabs should be performed to guide treatment, with topical imidazoles for candidiasis and antibiotics for bacterial vaginosis as per antimicrobial stewardship principles ¹.

Assess risk factors for STIs and consider appropriate testing if suspected, including chlamydia and gonorrhoea screening, as recurrent discharge may be due to untreated or persistent infections (Sherrard et al., 2011).

Exclude malignancy in women aged 55 and over or those with unexplained discharge accompanied by thrombocytosis or haematuria by considering direct access ultrasound to assess for endometrial pathology, as recommended by NICE for suspected cancer pathways ².

Referral to secondary care should be considered if there are suspicious findings on examination such as cervical abnormalities, vaginal masses, or if discharge is unexplained and persistent despite treatment ².

Additional investigations may include microscopy, culture, and sensitivity of vaginal secretions, pH testing, and possibly PCR-based tests for specific pathogens, aligning with European guidelines emphasizing targeted diagnosis to guide therapy (Sherrard et al., 2011).

Management should be tailored based on identified cause, with follow-up to ensure resolution and to reassess if symptoms persist or recur, considering alternative diagnoses or referral for specialist assessment ¹ (Sherrard et al., 2011).