Sexual Health · Full case

Vaginal Discharge & STI Screen

BASHH / NICE CKSBV · candida · STI · PIDCervical red flags

Discharge ≠ STIThe two commonest causes of vaginal discharge — bacterial vaginosis and candida — are NOT sexually transmitted. But discharge can also signal chlamydia, gonorrhoea, trichomonas or PID, so a sexual history and risk assessment are essential before assuming it's "just thrush"

BV = fishy, thin, greyBacterial vaginosis: thin grey-white homogeneous discharge with a fishy odour, raised vaginal pH (>4.5), no itch/soreness. Overgrowth of anaerobes; not an STI. Treat with metronidazole; often recurs

Candida = itch, white, curdyVulvovaginal candidiasis: thick white "cottage cheese" discharge with vulval itch and soreness, normal pH. Treat with an azole (clotrimazole pessary/cream or oral fluconazole). Recurrent (≥4/yr) → induction + maintenance and check for diabetes

Test of choice: NAATChlamydia and gonorrhoea are diagnosed by nucleic acid amplification test (NAAT) — a vulvovaginal self-swab is the recommended sample in women. Offer a full STI screen (incl. HIV and syphilis serology) where there is risk

Chlamydia = commonest STIChlamydia is the most common bacterial STI in the UK and is often asymptomatic; untreated it can cause PID, ectopic pregnancy and tubal infertility. Treat with doxycycline (azithromycin in pregnancy); partner notification is essential

PID = treat on clinical suspicionPelvic inflammatory disease (pelvic/lower abdominal pain, deep dyspareunia, abnormal bleeding/discharge, adnexal/cervical motion tenderness) — have a low threshold and treat empirically; delay risks infertility. Exclude/cover ectopic and pregnancy

Bleeding = examine the cervixPost-coital or intermenstrual bleeding, or discharge with a suspicious-looking cervix, must not be assumed infective — examine the cervix; a clinically suspicious cervix warrants urgent referral for suspected cervical cancer (NICE NG12), regardless of smear history

Safeguarding alwaysIn anyone under 16 (or 16–17 with power imbalance), assess competence (Fraser), capacity to consent to sex, and child sexual exploitation/abuse. Document consent, partner age and circumstances; involve safeguarding leads where there is concern

📋 Clinical Stem — Vaginal Discharge & STI Screen

A 24-year-old woman with three weeks of altered vaginal discharge and one episode of bleeding after sex, who "just wants some thrush treatment" and is reluctant to be examined

Aisha Rahman, 24, attends asking for thrush treatment. She has had three weeks of increased vaginal discharge, which she describes as different from her usual thrush — more watery, and she's noticed a smell. On direct, sensitive questioning she mentions one episode of light bleeding after sex last week. She has a new partner over the past two months and they have not consistently used condoms; her last cervical screening was normal a year ago. She is keen to be given thrush treatment and leave, and is hesitant about an examination or swabs. She is otherwise well, with no fever or severe pain.

This stem tests the ability to: take a non-judgmental sexual history and risk assessment; recognise that "different from usual thrush" plus odour and a new partner shifts the differential toward BV and STIs rather than candida; offer appropriate testing (self-taken vulvovaginal NAAT for chlamydia/gonorrhoea, and a full STI screen) and explain why; recognise post-coital bleeding as a feature that mandates examining the cervix and considering the NICE NG12 cervical cancer pathway if the cervix looks suspicious (not simply reassuring on the basis of a recent normal smear); manage PID risk; and handle partner notification, safeguarding and the patient's reluctance to be examined with sensitivity. The SCA challenge is balancing her wish for a quick fix against the need to test and examine.

Scenario A — Bacterial vaginosis Thin grey discharge, fishy odour, no itch, raised pH. Metronidazole; advise on recurrence triggers (douching, etc.); not an STI but consider STI risk.

Scenario B — Vulvovaginal candidiasis Thick white discharge, vulval itch/soreness, normal pH. Azole treatment; if recurrent (≥4/yr) induction + maintenance and screen for diabetes.

Scenario C — STI (chlamydia/gonorrhoea/trichomonas) New partner, inconsistent condoms, altered discharge ± dysuria/bleeding. NAAT self-swab + full STI screen; treat; partner notification; test of cure where indicated.

Scenario D — Pelvic inflammatory disease Lower abdominal/pelvic pain, deep dyspareunia, abnormal bleeding, cervical motion/adnexal tenderness. Treat empirically; exclude ectopic/pregnancy; safety-net; partner treatment.

Scenario E — Cervical red flag Post-coital or intermenstrual bleeding; a friable/irregular cervix on examination. Examine the cervix; urgent referral for suspected cervical cancer (NG12) if suspicious — a recent normal smear does not exclude it.

Key variables to adapt for Symptom character (BV vs candida vs STI); sexual history & risk (new/multiple partners, condoms, MSM partner, sex work); bleeding (PCB/IMB → examine cervix; NG12); pregnancy (drug choice, ectopic, screen); age & safeguarding (<16, 16–17, exploitation); recurrence; systemic features/PID; partner notification; the patient's reluctance and need for confidentiality.

Steps:

Step 1

History — Characterise the Discharge · Sexual History · Bleeding · Safeguarding · ICE

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The history has three jobs: characterise the discharge (which points toward BV, candida or an STI), take a sensitive sexual history and risk assessment (because discharge is not always benign), and pick up the features that change everything — abnormal bleeding (cervical red flag), pelvic pain (PID), pregnancy, and safeguarding concerns. Aisha's "different from usual thrush," the odour, the new partner and the post-coital bleeding are exactly the threads that move this away from a simple thrush prescription.

🎓 SCA framing — confidentiality, non-judgment, and a reason to test

"Everything we discuss is confidential. To give you the right treatment rather than guessing, I'd like to ask a few questions about your sexual health and, ideally, do some simple tests — including one you can do yourself. Is that okay?"

Aisha wants thrush treatment and is reluctant to be examined. The skill is to create a confidential, non-judgmental space, explain why testing matters (right treatment, the bleeding, partner health), and offer a self-taken swab to lower the barrier — without pressuring her.

1A — Characterise discharge, bleeding and pain

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Tell me about the discharge — what it's like, when it started, and what made you come in now."	The character of the discharge narrows the cause. Thin grey + fishy odour, no itch → BV. Thick white + itch/soreness → candida. Watery/altered with odour, ± dysuria or bleeding, especially with a new partner → think STI. Aisha's "watery, with a smell, different from my usual thrush" already argues against simple candida.In SCA: capturing colour, consistency, odour, itch AND the patient's own comparison ("different from usual") is what distinguishes a real assessment from a reflex thrush prescription.	Fishy/grey → BV; itchy/white → candida; altered + risk → STI
Associated symptoms"Any itch or soreness, pain passing urine, pain low down or during sex?"	Itch/soreness favours candida; dysuria can occur with STIs (and urethritis); lower abdominal/pelvic pain and deep dyspareunia raise PID — which needs a low threshold to treat. Their presence or absence reshapes the differential and urgency.	Itch → candida; dysuria → STI/urethritis; pelvic pain + dyspareunia → PID.	PID features → empirical treatment
🚩 Abnormal bleeding"You mentioned bleeding after sex — has that happened more than once? Any bleeding between periods?"	A pivotal safety thread. Post-coital and intermenstrual bleeding can be caused by chlamydia/cervicitis — but they are also red flags for cervical pathology. They mandate examining the cervix; a suspicious-looking cervix warrants urgent referral for suspected cervical cancer (NG12), and a recent normal smear does NOT exclude it.	PCB/IMB → examine cervix; infective cause treated; suspicious cervix → NG12 urgent referral.	Suspicious cervix → 2WW (NG12)
Sexual history & risk"Can I ask about partners — when you last had sex, whether partners are male or female, condom use, and any new partners recently?"	Risk assessment guides testing: new/multiple partners, inconsistent condoms, a partner from a high-prevalence group, MSM partner, or sex work raise STI probability and the scope of the screen (e.g. extra-genital swabs, HIV/syphilis serology). Aisha's new partner and inconsistent condoms place her at risk.	Risk present → full STI screen (NAAT + HIV/syphilis); consider extra-genital sites by exposure.	Full STI screen by risk/sites
Pregnancy & contraception"Is there any chance you could be pregnant? What contraception are you using?"	Pregnancy changes drug choice (avoid some agents), raises the stakes of an STI (vertical transmission), and — with pain/bleeding — must prompt exclusion of ectopic. Contraception need is an opportunity (e.g. emergency contraception, LARC).	Pregnancy → altered drugs, exclude ectopic, screen. Contraception need → address.	Pregnancy alters treatment
🛡️ Age & safeguarding"How old is your partner? Do you feel safe and in control of what happens in the relationship?"	In anyone under 16 (or 16–17 with a power imbalance), assess Fraser competence, capacity to consent, partner age/circumstances and any signs of child sexual exploitation or abuse. Coercion, age disparity, or grooming markers require safeguarding action. This is mandatory, not optional, in sexual-health consultations with young people.	Under-16 / coercion / exploitation markers → safeguarding assessment and referral.	Safeguarding pathway if concern

1B — Red flags

🚨

Red Flags — when discharge is not "just thrush"

Red flag	Why dangerous	Action
Post-coital / intermenstrual bleeding, or a suspicious-looking cervix	Can be infective (cervicitis) but is a recognised presentation of cervical cancer. A normal smear does not exclude cancer. The cervix must be visualised; a friable, irregular or contact-bleeding cervix needs urgent referral.	Examine cervix; urgent suspected cervical cancer referral (NICE NG12) if appearance suspicious
PID — pelvic pain, deep dyspareunia, abnormal bleeding, cervical motion/adnexal tenderness	Delayed treatment risks tubal infertility, ectopic pregnancy and chronic pain. Have a low threshold to treat empirically.	Empirical PID antibiotics; exclude ectopic/pregnancy; partner treatment; safety-net
Pregnancy with pain/bleeding	Ectopic pregnancy is life-threatening and can mimic PID/STI symptoms; never attribute pain/bleeding in a possibly pregnant woman to infection without excluding ectopic.	Pregnancy test; urgent assessment / EPU if ectopic possible
Systemic sepsis / tubo-ovarian abscess	Severe PID with fever, severe pain, peritonism or a pelvic mass can become life-threatening.	Same-day admission; IV antibiotics; gynaecology
Safeguarding — under 16, coercion, exploitation, FGM, abuse	Sexual-health presentations in young or vulnerable people may be the only window onto abuse or exploitation; missing it has lifelong consequences.	Safeguarding assessment; involve safeguarding lead; document; refer as indicated
Possible disseminated/complicated gonococcal or syphilis	Untreated gonorrhoea/syphilis can disseminate; resistant gonorrhoea needs specialist management and culture for sensitivities.	GUM referral; culture for gonorrhoea sensitivities; treat per BASHH

1C — ICE

💭 Ideas

"What do you think is causing it — and what's made you feel it's thrush?"

Aisha has self-diagnosed thrush. Engaging her idea lets you gently introduce that the features she describes (odour, watery, different from usual, bleeding after sex) don't all fit thrush — opening the door to testing without making her feel doubted or judged.

😟 Concerns

"Is there anything you've been worried it might be?"

She may be quietly worried about an STI (given the new partner) but reluctant to say so, or embarrassed about examination. Naming the worry, and reassuring on confidentiality and non-judgment, often unlocks an honest history and consent to testing.

🎯 Expectations

"You were hoping for thrush treatment — can I explain why I'd like to check a couple of things first?"

Her expectation is a quick prescription. Naming it lets you offer a better deal: the right treatment based on a self-taken test, addressing the bleeding properly, and protecting her future fertility — framed as being on her side, not obstructing her.

1D — Psychosocial context

Vaginal symptoms and sexual-health questions carry stigma and embarrassment, and many people present hoping for a quick, private fix — "just some thrush cream." A consultation that simply hands over the cream misses BV, STIs, PID and, occasionally, cervical pathology; one that interrogates or judges drives the patient away and damages trust. The work is to create a confidential, non-judgmental, unhurried space, explain why a few questions and a simple (often self-taken) test give the right answer, and respect autonomy if she declines — while being clear about the bleeding that does need looking at.

🔒 Confidentiality

Explicit reassurance about confidentiality (and its limits in safeguarding) is the foundation of an honest sexual history — especially for young people.

"Everything we talk about here is confidential. The only time I'd ever need to share anything is if I were worried about your safety — and I'd talk to you first."

🙅 Reluctance to be examined

Offer the self-taken vulvovaginal swab to lower the barrier; explain when an examination is genuinely needed (the bleeding) and let her retain control.

"For the infection tests you can take the swab yourself — it's just like inserting a tampon. The one thing I would like to look at, because of the bleeding after sex, is your cervix — but we can talk that through and you're always in control."

💬 Non-judgmental partner notification

Framing partner notification as routine and blame-free (and offered via the clinic/GUM) makes it acceptable and protects others.

"If a test is positive, we'd want to let recent partners know so they can be treated too — that can be done completely anonymously through the sexual-health service. It's routine and nobody is blamed."

🩺 Future fertility framing

Linking testing to protecting her future fertility (untreated chlamydia → PID → tubal damage) gives a positive, personal reason to test.

"One reason I'm keen to test rather than guess is that some infections, if missed, can quietly affect fertility later — testing now is the best way to protect that."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Has the bleeding after sex happened more than once? Any bleeding between periods?" — opens the cervical red-flag door.

"Everything's confidential — can I ask a few questions about your sexual health so I treat the right thing?" — enables the history.

"For the infection tests you can take the swab yourself." — lowers the barrier, respects autonomy.

Deductions

Prescribing thrush treatment without a sexual history or considering STI/BV
Ignoring post-coital bleeding / not examining the cervix
Omitting safeguarding assessment in a young person
Judgmental or rushed manner that shuts down the history

🔴 Red

Thrush treatment given blindly; no sexual history; PCB ignored; no safeguarding; judgmental manner

🟠 Amber

Discharge characterised; some sexual history; STI testing mentioned but not arranged; bleeding noted but cervix not examined; ICE partial

🟢 Green

Discharge characterised; full sexual history & risk; NAAT/STI screen offered (self-swab); PCB → examine cervix + NG12 awareness; safeguarding considered; confidentiality & non-judgment; ICE all three

Step 2

Triage — Emergency · Urgent (PID / Cervical / Safeguarding) · Routine

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Most discharge is managed in a single primary-care or sexual-health contact. The triage task is to pull out ectopic/sepsis, the PID that needs prompt empirical treatment, the abnormal bleeding that needs the cervix examined (and possibly an NG12 referral), and the safeguarding concern.

🔴 Emergency

Same day / 999

Immediate action

Possible ectopic pregnancyPain/bleeding + positive/possible pregnancy → urgent EPU/gynae
Severe PID / tubo-ovarian abscess / sepsisFever, severe pain, peritonism, mass → admit
Acute safeguarding riskExploitation/abuse with immediate risk → safeguarding emergency pathway

🟠 Urgent / Refer

Days–2 weeks

Prompt action

Suspicious cervix / persistent PCB-IMBUrgent suspected cervical cancer referral (NICE NG12)
PID (clinical)Empirical antibiotics now; partner treatment; review
Safeguarding concern (non-acute)Safeguarding lead; document; refer

🟢 Routine

GP / sexual health

Primary care first-line

BV / candidaTreat per features; advice on recurrence
STI screen (asymptomatic risk / discharge)NAAT self-swab + HIV/syphilis; treat + partner notification
Uncomplicated chlamydiaDoxycycline; partner notification; test of cure if indicated

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"The infection itself we can sort here, but because you've had bleeding after sex I do want to look at the cervix — and if anything looks unusual I'd refer you promptly, separately from treating any infection."

Deductions

Missing ectopic in a possibly pregnant woman with pain/bleeding
Not recognising PID needs prompt empirical treatment
Reassuring on PCB because of a recent normal smear

Step 3

Examination — When & How · Speculum · Bimanual · The Cervix

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Not every discharge needs an examination — a confident clinical picture of candida or BV in a low-risk woman can be managed on history. But abnormal bleeding, pelvic pain, treatment failure, pregnancy, or diagnostic uncertainty all require examination — and post-coital bleeding specifically requires the cervix to be visualised. Always with a chaperone and informed consent.

🩺 When to examine

Trigger	Why
Abnormal bleeding (PCB/IMB)	Visualise the cervix — exclude/identify a suspicious cervix (NG12) and cervicitis.
Pelvic pain / ?PID	Bimanual for cervical motion and adnexal tenderness; assess for mass.
Treatment failure / recurrence / uncertainty	Confirm the diagnosis; take swabs.
Pregnancy / atypical features	Assess and exclude complications.

🔬 What to do at examination

Step	Detail
Inspect vulva	Excoriation (candida), ulcers (herpes/syphilis), warts, FGM.
Speculum	Discharge character; cervix appearance (friable/contact bleeding/irregular = suspicious); take swabs.
Swabs / tests	Vulvovaginal NAAT (chlamydia/gonorrhoea); high vaginal swab (candida/BV/trichomonas) if uncertain; endocervical culture if gonorrhoea likely (sensitivities); vaginal pH.
Bimanual	Cervical motion tenderness, adnexal tenderness/mass → PID/ectopic.
Chaperone & consent	Always; document; respect autonomy and dignity.

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Narration that scores

"Because of the bleeding after sex I'd like to do an internal examination with a speculum to look at the cervix and take some swabs, with a chaperone present — is that okay? You can stop at any point."

Deductions

Not examining the cervix despite post-coital bleeding
No chaperone / consent not documented
Reflex examination when self-swab would suffice for a low-risk candida/BV picture

Step 4

Investigations — NAAT · Full STI Screen · Microscopy/pH · Pregnancy

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Testing turns guesswork into the right treatment and protects partners and future fertility. The core test is a vulvovaginal NAAT for chlamydia and gonorrhoea; where there is risk, offer a full STI screen including HIV and syphilis serology. BV and candida are largely clinical but swabs/pH help when uncertain or recurrent.

🧪 Tests

Test	When / why
Vulvovaginal NAAT (self-taken)	Chlamydia & gonorrhoea — recommended first-line sample in women; lowers the barrier to testing.
Full STI screen	HIV and syphilis serology (± hepatitis B/C by risk) where there is risk; extra-genital (rectal/pharyngeal) swabs by exposure.
Endocervical culture (gonorrhoea)	If gonorrhoea likely/positive NAAT — for antimicrobial sensitivities (resistance).
High vaginal swab / pH / microscopy	If uncertain or recurrent: BV (clue cells, pH >4.5), candida, trichomonas.
Pregnancy test	If any chance of pregnancy — alters drugs and excludes ectopic.
Glucose/HbA1c	Recurrent candida — screen for diabetes.

🤝 Partner notification & follow-up

Positive STI → partner notification (often via GUM, can be anonymous) is essential to prevent reinfection and onward transmission.

Advise abstinence until both partners treated; arrange test of cure where indicated (e.g. gonorrhoea, pregnancy, persistent symptoms).

Offer onward referral to sexual-health services for full screening, contact tracing and complex cases.

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"I'd like you to do a self-swab for chlamydia and gonorrhoea, and given the new relationship I'd offer a full check including HIV and syphilis blood tests — all confidential. If anything's positive we'll treat it and let partners know discreetly."

Deductions

Treating empirically for an STI without NAAT testing
Not offering HIV/syphilis in an at-risk patient
Forgetting partner notification / test of cure

Step 5

Diagnosis — BV · Candida · STIs · PID · The Cervical Red Flag

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Name the cause from the discharge character, the risk assessment and the tests — and consciously separate the infective causes from the bleeding that needs the cervix examined.

Diagnosis	Discriminating features	STI?
Bacterial vaginosis	Thin grey homogeneous discharge, fishy odour, pH >4.5, no itch; clue cells. Metronidazole.	No
Vulvovaginal candidiasis	Thick white "curdy" discharge, vulval itch/soreness, normal pH. Azole; recurrent → maintenance + diabetes screen.	No
Chlamydia	Often asymptomatic; altered discharge, dysuria, PCB/IMB; commonest STI. Doxycycline; partner notification.	Yes
Gonorrhoea	Purulent discharge ± dysuria; culture for sensitivities; ceftriaxone per BASHH; GUM.	Yes
Trichomoniasis	Frothy yellow-green discharge, odour, vulvovaginitis, "strawberry cervix". Metronidazole; partner treatment.	Yes
PID	Pelvic pain, deep dyspareunia, abnormal bleeding, cervical motion/adnexal tenderness. Treat empirically.	Often
🚩 Cervical pathology	PCB/IMB, suspicious cervix on examination → urgent referral (NG12); normal smear does not exclude.	2WW

🚩 The discipline — treat the infection, but examine the bleeding

The trap is to find an infective cause (BV or chlamydia), treat it, and attribute the post-coital bleeding to that — without ever looking at the cervix. Cervical cancer is repeatedly missed this way. For Aisha, the formulation is: characterise and test the discharge (likely BV ± STI given the risk), AND examine the cervix because of the post-coital bleeding — referring urgently under NG12 if it looks suspicious, independent of her recent normal smear.

🎓 SCA Checkpoint — Step 5Tasks

Explaining it plainly

"The discharge could be a couple of things, so I've tested for them and we'll treat what shows up. Separately, the bleeding after sex means I want to look at your cervix to be safe — even though your smear was normal, that's the careful thing to do."

Deductions

Attributing PCB to infection without examining the cervix
Reassuring purely on a recent normal smear

Step 6

Referral — GUM · Gynaecology · 2WW Cervical · Safeguarding

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Much is managed in primary care or sexual-health services. Referral is for complex/recurrent STIs and contact tracing (GUM), the suspicious cervix (2WW), PID or ectopic concerns (gynaecology), and any safeguarding concern.

Referral	Who / when	Urgency
🟣 Suspected cervical cancer	Clinically suspicious cervix on examination (friable/irregular/contact bleeding), or unexplained persistent PCB/IMB — regardless of smear history.	2WW · NICE NG12
Sexual health / GUM	Confirmed/complex STI, gonorrhoea, contact tracing, full screening, recurrent infection, or patient preference.	Routine / soon
Gynaecology	PID not responding, tubo-ovarian abscess, or possible ectopic (urgent/EPU).	Urgent by severity
Safeguarding	Under-16, coercion, exploitation, abuse, FGM concerns.	Per local pathway
🔴 Acute admission	Ectopic, severe PID/sepsis, tubo-ovarian abscess.	Same day

🎓 SCA Checkpoint — Step 6Tasks

Stating the threshold

"If the cervix looks at all unusual when I examine it, I'll refer you on a two-week pathway to gynaecology — that's standard for bleeding after sex with an abnormal-looking cervix, even with a normal smear."

Deductions

Not knowing/actioning the NG12 cervical pathway
Missing the need for GUM contact tracing in confirmed STI

Step 7

Management — Treat the Cause · Partner Notification · Safety-Net · Prevention

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Management treats the specific cause, notifies and treats partners where relevant, addresses prevention and contraception, and safety-nets — while keeping any cervical red flag on its own urgent track.

7A — Treat by cause

💊 Specific treatment

Cause	Treatment
Bacterial vaginosis	Metronidazole (oral or vaginal); avoid douching; manage recurrence; not an STI.
Candida	Azole (clotrimazole pessary/cream or oral fluconazole — not in pregnancy); recurrent → induction + maintenance; diabetes screen.
Chlamydia	Doxycycline 100mg BD 7 days (azithromycin in pregnancy); partner notification; abstain until treated; test of cure if pregnant/persistent.
Gonorrhoea	Ceftriaxone IM per BASHH (culture for sensitivities); GUM; partner notification; test of cure.
Trichomonas	Metronidazole; treat partner; STI screen.
PID	Empirical antibiotics (e.g. ceftriaxone + doxycycline + metronidazole per local/BASHH); partner treatment; review 72h; safety-net.

🛡️ Beyond the prescription

Element	Detail
Partner notification	Via GUM (can be anonymous); abstain until both treated; prevents reinfection.
Prevention	Condoms; STI risk-reduction advice; HPV vaccination status; consider PrEP discussion/referral by risk.
Contraception	Address need (LARC, emergency contraception); pregnancy intentions.
Safety-net	"Return urgently if you develop pelvic pain, fever, or heavier bleeding"; PID and ectopic warning.
Follow-up	Results, test of cure where indicated, the cervical referral if made, recurrence review.

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"Here's the plan: a self-swab and a full sexual-health check today, treatment for whatever shows up, partners notified discreetly if needed, a look at your cervix because of the bleeding, and a safety-net for pelvic pain or fever. Everything stays confidential."

Deductions

Treating without testing; no partner notification
Ignoring the cervical red flag; no safety-net for PID/ectopic
Missing contraception/prevention opportunity

"Hi — I think I've got thrush again. Could I just get some treatment for it? I'm in a bit of a rush, to be honest."

Who you are

Aisha Rahman, 24, office worker. Three weeks of increased vaginal discharge — but it's "different from my usual thrush": more watery and there's a smell. You assumed it's thrush and want treatment so you can get on with your day. You feel a bit awkward talking about it. You've had a new partner for about two months and you haven't always used condoms. If asked sensitively, you'll admit you had some light bleeding after sex once last week, which you found a bit embarrassing and didn't want to bring up. Your last smear a year ago was normal. You're well otherwise — no fever, no bad pain. You're hesitant about being examined and would rather just take a tablet/cream and go.

Hidden concerns (reveal if explored)

STI worry (main, unspoken): deep down you're worried it might be an infection from the new partner, but you're embarrassed to say so. If the doctor is non-judgmental and confidential, you open up.

The bleeding: you didn't want to mention it; if asked directly and gently, you'll admit it. If the doctor explains why they want to look, you'll agree to an exam.

Privacy: you're worried about confidentiality. Reassurance helps a lot.

Clinical details if asked

Discharge: watery, greyish, with an odour; no real itch; "not like my usual thrush"
One episode of light post-coital bleeding last week; no bleeding between periods otherwise
New partner ~2 months; inconsistent condom use; male partner; no other recent partners
No fever, no severe pelvic pain; mild discomfort only
Last menstrual period ~2 weeks ago; on the pill (sometimes misses one); could you be pregnant? unlikely but not certain
Smear normal a year ago; up to date with HPV vaccine; no past STIs that you know of
You feel safe in the relationship; partner is a similar age

Reactions at key moments

On being asked about sex: initially a bit guarded; opens up if the doctor is warm and non-judgmental.
On the self-swab: relieved you can do it yourself; happy to.
On examination for the bleeding: hesitant, but agree if it's explained and you're reassured you're in control.
Challenge line: "Can't you just give me the cream? I don't really want all these tests and an examination."

"Honestly, I just wanted some thrush treatment — do we really need to do swabs and an examination? It's a bit embarrassing."

Resolution: Aisha is satisfied if the GP: (1) creates a confidential, non-judgmental space and takes a sexual history; (2) recognises the picture isn't simple thrush and offers a self-taken NAAT + full STI screen, explaining why; (3) gently elicits and acts on the post-coital bleeding — examining the cervix and explaining the NG12 pathway if it looks suspicious, not reassuring on the normal smear alone; (4) handles partner notification and prevention sensitively; (5) safety-nets for PID/ectopic. She disengages if she feels judged, rushed, or is simply handed thrush cream with the bleeding ignored.

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Clinic Quick Reference

Vaginal Discharge & STI — Clinical Decision Framework

BASHH/CKS · BV · candida · STI · PID · Cervical red flag (NG12)

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🚦 1 — Triage first

Vaginal discharge

▼

🔴 Same-day

Possible ectopic (pain/bleeding + ?pregnant)
Severe PID / sepsis / TOA
Acute safeguarding risk

Admit / urgent

🟠 Urgent

Suspicious cervix / persistent PCB-IMB → NG12
PID (clinical) → empirical Rx
Safeguarding concern

2WW / treat

🟢 Routine

BV / candida
STI screen & treat

GP / GUM

🔍 2 — Diagnose & treat

Not an STI

BV: thin grey, fishy, pH>4.5 → metronidazole. Candida: white, itchy, normal pH → azole; recurrent → maintenance + diabetes screen.

STI / PID

NAAT self-swab + HIV/syphilis by risk. Chlamydia → doxycycline; gonorrhoea → ceftriaxone (culture); trichomonas → metronidazole. PID → empirical antibiotics, low threshold. Partner notification + test of cure. PCB/suspicious cervix → examine + NG12.

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SCA Quick Reference

Vaginal Discharge & STI — Consultation Playbook

Confidentiality · test don't guess · examine the bleeding · safeguard

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🎯 The three pivots that pass this case

1 · The red flag

Post-coital/intermenstrual bleeding → examine the cervix. A suspicious cervix → NG12 2WW, even with a normal smear.

2 · Test, don't guess

"Different from usual thrush" + new partner → sexual history + vulvovaginal NAAT + full STI screen, not reflex thrush cream.

3 · The wraparound

Partner notification, safeguarding, confidentiality, prevention/contraception — and a PID/ectopic safety-net.

⛔ Don't reflex-prescribe thrush treatment without a sexual history · Don't attribute post-coital bleeding to infection without examining the cervix · Don't reassure on a normal smear alone · Don't forget partner notification, safeguarding and confidentiality · Have a low threshold to treat PID and exclude ectopic

Vaginal Discharge & STI Screen · GP Clinical Reasoning Framework v2 · BASHH guidelines · NICE CKS (vaginal discharge, BV, candida, chlamydia, PID) · NICE NG12 Suspected cancer (cervical) · FSRH · local safeguarding policy

BV (fishy, grey, pH>4.5) and candida (white, itchy) are not STIs — but discharge can be chlamydia/gonorrhoea/trichomonas/PID · Vulvovaginal NAAT is the test of choice; offer full STI screen (HIV/syphilis) by risk · Post-coital/intermenstrual bleeding → examine the cervix; suspicious cervix → NG12 urgent referral regardless of smear · Low threshold to treat PID; exclude ectopic in pregnancy · Partner notification, safeguarding, confidentiality and prevention are integral

Teaching clinicians why each step matters — not just what to do · Always consult current BASHH, NICE CKS and NG12 guidance · Clinical judgement takes precedence over any framework

Vaginal Discharge & STI Screen

Red Flags — when discharge is not "just thrush"

🔒 Confidentiality

🙅 Reluctance to be examined

💬 Non-judgmental partner notification

🩺 Future fertility framing

Same day / 999

Days–2 weeks

GP / sexual health

🚩 The discipline — treat the infection, but examine the bleeding

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments