The article on chronic vaginal discharge (O&G Magazine Vol 16 No 3 Spring 2014 p47) gives an extensive list of possible infective causes, while under-reporting the non-infective causes. The cases discussed are not representative of the true case mix of aetiologies seen by gynaecologists and women’s health GPs in urban Australia.1 The medical literature on this topic is confusing, and the reader needs wide clinical experience in order to accurately interpret it.
We are concerned regarding the information offered on vaginal candidiasis. It describes only acute vaginal candidiasis, which is not a cause chronic vaginal discharge. There is no mention of recurrent and chronic vulvovaginal candidiasis.2 These are common causes of chronic vaginal discharge and have specific diagnostic and therapeutic features.
The article asserts that the diagnosis of candidiasis ‘is based on clinical symptoms’, while describing examination and low-sensitivity microscopy. The statement ‘primary culture is rarely indicated’ suggests that the clinician does not need to perform a vaginal culture on the initial presentation. In Australia, any patient can obtain antifungal medication from a pharmacist without a diagnostic test and this frequently precedes a visit to a doctor. Once patients self-medicate, swabs become as insensitive as microscopy. A patient who has recurrent candidiasis with a negative swab as a result of treatment (a very common scenario) is difficult to differentiate from a patient with non-infective vaginitis. We therefore advocate vaginal culture at the earliest opportunity.
The very small section on non-infective discharge does not reflect the real world of office gynaecology in urban Australia. Space is given to cervical polyps, fistulae and malignancies, while neglecting to mention far less rare causes of abnormal discharge, such as desquamative inflammatory vaginitis3 and lichen planus.4 Vulval dermatoses, especially psoriasis, produce what may be mistaken for discharge because of weeping and desquamation from the skin surface. The author quotes a paper from Mumbai, describing increased vaginal discharge in the context of psychosocial distress. Psoriasis may flare with stress, but we have never been convinced that heavy discharge is caused directly by stress.
The most important omission however, is a discussion of the process of differentiating a normal from an abnormal vaginal discharge. Every women’s health practitioner will be familiar with the (often young) woman who presents with the complaint of a chronic heavy discharge, but without other abnormal symptoms, and with an entirely normal examination and testing. The young woman is often distressed and keen for a ‘solution’, and the practitioner must therefore be very certain that she can tell normal from abnormal.
We hope these comments will lead to a better understanding of the topic.
- Fischer G, Bradford J, Persistent Vaginitis, BMJ 2011;343:d7314.
- Hong E, Dixit S, Fidel P, Bradford J, Fischer G, Vulvovaginal Candidiasis as a Chronic Condition: Diagnostic Criteria and Definition. J Low Genit Tract Dis, 2013 doi: 10.1097.
- Bradford J, Fischer G, Inflammatory vaginitis: differential diagnosis and alternate diagnostic criteria. JLGTD Vol 14, no 4, 2010.
- Bradford J, Fischer G, Management of Vulvo-vaginal Lichen Planus: a New Approach J Low Genit Tract Dis, 2013. 17(1): p.28-32.