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Vaginal Discharge in Adults β€” Primary-Care Assessment & Initial Management Based on BASHH, NICE, UKHSA/MHRA and local antimicrobial guidance Β· local sexual-health, microbiology, safeguarding and obstetric pathways take precedence Β· adults aged β‰₯16
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⚑ Snapshot. The whole pathway on one page: act now, triage, classify, treat today and safety-net. The Steps tab holds the detail.

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1
Safety

Red Flags β€” Exclude serious / systemic infection and malignancy

Scope: primary-care summary for adults aged β‰₯16 years; children and young people require separate pathways. Local sexual-health, microbiology, safeguarding and obstetric guidance takes precedence.

Vaginal discharge is usually benign, but these presentations require urgent action before routine management.

Sepsis features Suspected sepsis (assess with NEWS2), haemodynamic instability, altered mental state, poor perfusion, severe systemic illness or peritonism β†’ follow the local sepsis pathway (NICE NG253); emergency hospital assessment / 999 where indicated (e.g. septic abortion, post-procedure infection)
Retained tampon / toxic shock features Fever, rash, vomiting or diarrhoea, hypotension, dizziness or confusion with a tampon, menstrual cup or other foreign body in place, or after recent use β†’ remove it if easily accessible; 999 / emergency hospital assessment (toxic shock syndrome is a medical emergency).
Pelvic inflammatory disease (PID) Consider and treat empirically with pelvic/lower abdominal pain plus cervical motion, uterine or adnexal tenderness, after excluding ectopic pregnancy and other important differentials. β†’ Admission / same-day gynaecology if sepsis or significant systemic illness, severe pain/peritonism or suspected tubo-ovarian abscess, pregnancy, diagnostic uncertainty/possible surgical abdomen, inability to tolerate or adhere to oral treatment, or no improvement after 72 hours of outpatient therapy.
Post-surgical / post-procedure Discharge after hysteroscopy, IUD insertion, caesarean section, termination β†’ Retained products? Endometritis? β†’ Same-day gynae
Pregnancy with concerning features Assess gestation, rupture of membranes, bleeding, contractions, fever, uterine tenderness and fetal concerns β†’ discuss promptly with maternity services if suspected intra-amniotic infection, PPROM, significant bleeding or maternal/fetal compromise (999 if unstable)
Blood-stained offensive discharge (non-menstrual) Unexplained postmenopausal bleeding β†’ suspected cancer pathway; suspicious cervical lesion β†’ urgent gynaecology referral; age 55+ with unexplained discharge (first presentation, or with thrombocytosis or haematuria) β†’ consider urgent direct-access USS (NICE NG12). Persistent unexplained discharge after a normal initial assessment β†’ review and escalate rather than repeat empirical treatment. Premenopausal + haematuria: possible fistula.
Immunocompromised patient HIV, diabetes, corticosteroids, immunosuppressants + severe/atypical discharge β†’ Lower threshold for admission + specialist review. Offer HIV testing per routine opt-out and STI-risk practice (recurrent candidiasis may add rationale).
Child / adolescent In prepubertal children, consider vulvovaginitis, foreign body, pinworms, dermatological disease, infection and possible sexual abuse. Undertake safeguarding assessment where clinically indicated and follow local safeguarding/paediatric pathways. Do not perform an internal examination in primary care.
Allergy or hypersensitivity reaction Angioedema, severe rash, anaphylaxis following treatment β†’ 999. Document and avoid causative agent.
Delayed or inadequately treated PID increases the risk of long-term sequelae (infertility, ectopic pregnancy, chronic pelvic pain). Intra-amniotic infection is an important cause of preterm birth and neonatal morbidity. Prepubertal vaginal discharge has different aetiology (physiological vs infection vs foreign body vs abuse) and requires a completely different approach β€” vaginal candidiasis is rare before puberty, and its presence in a child should prompt safeguarding consideration.
2
Diagnose

Characterise the Discharge β€” Clinical history

Discharge characteristics are suggestive, not diagnostic β€” colour and odour alone do not reliably distinguish BV, trichomoniasis, gonorrhoea and cervicitis. Take a focused but comprehensive history.

Colour & consistency
White/thick/curdy β†’ Candida. Thin/grey/homogenous β†’ BV. Yellow/green/frothy β†’ Trichomonas or gonorrhoea. Clear/watery β†’ physiological or chlamydia. Blood-stained β†’ endocervical pathology, malignancy.
Smell
Fishy odour (especially post-coital, post-menstrual) β†’ BV (amine production). Offensive/putrid β†’ foreign body, necrotic tumour, fistula. No odour β†’ candida or physiological.
Itching / irritation
Intense external pruritus + erythema β†’ Candida. Mild or none β†’ BV or Trichomonas. Internal dyspareunia β†’ PID/cervicitis.
Sexual history
New partner in last 3 months, number of partners (concurrent), condom use, overseas travel (gonorrhoea resistance), male partner symptoms β†’ drives STI risk assessment
Timing
Post-coital smell β†’ BV. Mid-cycle β†’ physiological (cervical mucus). Perimenopausal β†’ atrophic. Following antibiotic use β†’ Candida (oral/topical antibiotic-induced)
Pregnancy status
Establish pregnancy status in anyone who could be pregnant before prescribing medicines for which pregnancy changes management; Urine Ξ²hCG where clinically indicated or the history is uncertain. Changes management of BV (standard-dose metronidazole can be used in pregnancy; avoid the 2 g stat high-dose regimen β€” BASHH BV 2012, SPC) and of STIs (antibiotic choice).
Current contraception
IUD/IUS β†’ actinomyces, BV risk. Spermicides β†’ disrupts vaginal flora. No contraception + STI risk β†’ offer EC if relevant.
Previous episodes
Recurrent candida (β‰₯4/year, at least two microbiologically confirmed) β†’ confirm with culture/speciation; consider HbA1c, HIV per risk, antibiotic history; treat partners only if symptomatic. Recurrent BV β†’ confirm diagnosis, review irritants and reinfection risk; suppressive metronidazole gel only with counselling and local/specialist guidance.
Other history
Menstrual and menopausal status. Intravaginal products, douching, soaps, lubricants, antiseptics. Recent sexual assault or coercion. Recent procedures, retained tampon or foreign body. Vulval skin symptoms and dermatological history. Systemic symptoms and pelvic pain. Medication β€” recent antibiotics, corticosteroids, SGLT2 inhibitors. Previous treatment response and microbiological results.
Clinical diagnosis of vaginal discharge is only 50–60% accurate based on history and examination alone β€” the "rule of three" (BV: fishy, thin, grey/white; Candida: itchy, thick, white; Trichomonas: frothy, yellow, itchy) helps but has significant overlap. BASHH guidelines recommend point-of-care testing where available. Pregnancy changes antibiotic choice significantly β€” BASHH (BV 2012) notes meta-analyses show no teratogenicity from metronidazole, including in the first trimester; the metronidazole SPC advises against high-dose (2 g stat) regimens in pregnancy, so use the 5–7 day course or vaginal gel.
3
Diagnose

Classify the Cause β€” Diagnostic framework

Bacterial Vaginosis (BV)
Most common cause (40–50% of cases). Gardnerella vaginalis overgrowth, reduced lactobacilli. Amsel criteria: β‰₯3 of β€” thin grey/white discharge, fishy odour + KOH (whiff test), vaginal pH >4.5, clue cells on wet mount.
Vulvovaginal Candidiasis
Second most common (20–30%). Candida albicans 85–90%, non-albicans 10–15%. Thick white curdy discharge, vulval pruritus, erythema, satellite lesions. pH normal (≀4.5). Spores/hyphae on wet mount.
Trichomonas vaginalis
STI β€” frothy yellow-green discharge, offensive odour, vulvovaginal irritation, strawberry cervix on colposcopy. pH >4.5. Motile flagellated organisms on wet mount. NAAT more sensitive than microscopy.
Chlamydia trachomatis
Most common bacterial STI (UK). Often asymptomatic. When discharge present: mucopurulent yellow endocervical discharge, IMB, PCB, dysuria. NAAT swab β€” vulvovaginal most sensitive.
Neisseria gonorrhoeae
Often asymptomatic in women. Yellow/green purulent cervical discharge, dysuria, PID symptoms, contact tracing essential. If NAAT-positive or strongly suspected: culture from relevant sites before treatment where feasible (do not delay treatment); specialist sexual-health management.
Physiological
Clear/white, no odour, no itching, cyclical variation. Increased mid-cycle (cervical mucus), in pregnancy, on COCP. Normal pH ≀4.5. Diagnosis of exclusion β€” reassure after excluding pathology.
Atrophic vaginitis
Postmenopausal / oestrogen-deficient. Watery yellow discharge, dryness, dyspareunia. Pale, thin, dry vaginal epithelium on speculum. pH >5. Treat with topical oestrogen.
Cervicitis
Endocervical mucopurulent discharge + friable cervix. STI until proven otherwise. Screen for chlamydia + gonorrhoea. Test for Mycoplasma genitalium only if persistent/recurrent cervicitis, PID (per local sexual-health guidance) or contact of confirmed infection.
Other differentials
Aerobic vaginitis Β· desquamative inflammatory vaginitis Β· irritant/allergic contact dermatitis Β· lichen sclerosus and lichen planus Β· genitourinary syndrome of menopause Β· retained tampon/foreign body Β· cervical ectropion, polyp and malignancy Β· fistula Β· cytolytic vaginosis where appropriate (IUSTI/BASHH).
Point-of-care testing (POCT) for vaginal pH is available via pH paper strips (simple, inexpensive) and has high clinical utility β€” BV and Trichomonas characteristically have pH >4.5 while Candida does not. Amsel criteria (clinical) remain valid for BV diagnosis in primary care without microscopy, with sensitivity ~90%. Mycoplasma genitalium is increasingly recognised as a cause of cervicitis and PID but is not routinely tested in primary care β€” consider referral to sexual health if persistent cervicitis despite standard STI treatment.
4
Diagnose

Targeted Examination β€” With chaperone documented

Vital signs
Temperature, HR, BP, RR, mental state β€” calculate NEWS2 if systemic illness is possible; follow the local sepsis pathway if concerned.
Vulval inspection
Erythema, excoriation, satellite lesions (Candida), vulval ulceration (herpes, primary syphilis, behçet's), labial adhesions, skin changes (lichen sclerosus)
Speculum exam
Where appropriate and acceptable, with consent and chaperone documented. Quantity, colour, consistency, origin of discharge (vaginal walls vs endocervix). Cervical appearance: ectropion, friability (STI, malignancy), contact bleeding. Foreign body.
Vaginal pH
pH paper on lateral vaginal wall (avoid discharge). BV/Trichomonas: >4.5. Candida/physiological: ≀4.5. Simple, inexpensive, highly discriminating test.
Bimanual exam
If pelvic pain/PID is possible: cervical excitation, uterine tenderness, adnexal mass/tenderness. CMT (cervical motion tenderness) + lower abdominal pain β†’ consider PID after excluding ectopic pregnancy and surgical causes.
Inguinal nodes
Lymphadenopathy β†’ possible syphilis, LGV, herpetic ulceration, malignancy. Bilateral tender inguinal nodes + genital ulcers β†’ STI screen + refer sexual health
Cervical motion tenderness (CMT) on bimanual examination is a key sign of PID β€” it should be performed whenever PID is possible. The threshold for PID treatment should be low (BASHH 2019): clinical diagnosis is appropriate and delay risks tubal damage. Vulval inspection is frequently omitted but critical β€” lichen sclerosus, herpes, and primary syphilis may present with "discharge" symptoms but require entirely different management. Always offer and document chaperone.
5
Diagnose

Investigations β€” Targeted swabs and tests

Self-taken vulvovaginal swab
NAAT (nucleic acid amplification test) β€” gold standard for chlamydia + gonorrhoea. Self-taken swab equally sensitive as clinician-taken. Can be done without speculum. Offer to all <25 or new partner. Urine is generally less sensitive than a vaginal swab in women. Include pharyngeal/rectal sites according to sexual exposure.
Vaginal swab β€” microscopy / culture
Do not request routine culture for Gardnerella vaginalis. BV: clinical assessment plus vaginal pH/Amsel criteria (where microscopy available), Gram-stain (Nugent or Hay–Ison) or locally validated molecular tests. Candida: microscopy preferred for acute VVC; culture/speciation for recurrent VVC, treatment failure, suspected non-albicans or azole resistance. Trichomonas: wet mount has limited sensitivity (must be prompt; negative does not exclude) β€” use NAAT where available.
Gonorrhoea culture
If gonorrhoea is detected by NAAT or strongly suspected: culture from relevant sites (endocervical, pharyngeal, rectal according to exposure) before treatment where feasible β€” do not delay treatment; arrange specialist sexual-health management and partner notification. Sampling follows the laboratory/sexual-health pathway.
Pregnancy test
Where pregnancy status is uncertain and management would change β€” e.g. antibiotic choices (tetracyclines such as doxycycline are avoided; fluoroquinolones need consideration; avoid high-dose 2 g stat metronidazole).
HbA1c
Recurrent or difficult-to-treat candidiasis β€” reasonable, especially with diabetes symptoms or risk factors. Offer HIV testing per routine opt-out and STI-risk practice (recurrent candidiasis alone is not an urgent HIV indication, though it adds rationale).
Syphilis serology
Treponemal antibody screen (EIA/CLIA) with RPR β€” HIV and syphilis testing according to STI risk and patient preference. Genital ulcers β†’ dark field microscopy and serology (if available).
Do NOT order
CA-125 for discharge alone. Routine urine culture for vaginal discharge (urinary tract separate from vaginal pathology unless UTI symptoms co-exist). HVS for asymptomatic women. Routine Gardnerella culture. Mycoplasma hominis or Ureaplasma testing. Routine Mycoplasma genitalium testing in all discharge/cervicitis.
Self-taken vulvovaginal NAAT swabs have equivalent sensitivity to clinician-taken endocervical swabs for chlamydia (96–99%) and gonorrhoea (>95%) β€” they remove the barrier of speculum examination, increasing uptake particularly in younger women. BASHH 2019 guidance recommends offering self-swabs. Gonorrhoea culture before treatment (where feasible, without delaying treatment) allows antibiotic sensitivity testing β€” multi-resistant gonorrhoea (MRNG) is increasingly prevalent in the UK, particularly following international travel. Never treat gonorrhoea with azithromycin monotherapy β€” ceftriaxone 1 g IM is first-line (BASHH 2025).
6
Refer

Referral Criteria

999 / A&E
Suspected sepsis with instability (NEWS2 / local sepsis pathway). Haemodynamically unstable. Suspected ruptured TOA (tubo-ovarian abscess). Peritonism. Suspected toxic shock syndrome (retained tampon or foreign body).
Same-day Gynae
PID with sepsis/significant systemic illness, severe pain or peritonism, suspected TOA, pregnancy, diagnostic uncertainty/possible surgical abdomen, inability to tolerate or adhere to oral treatment, or no improvement after 72 hours. Post-procedure discharge + fever. Pregnancy with concerning features β†’ maternity services. Suspected foreign body in child β†’ local paediatric pathway.
Suspected cancer: Gynaecology
Unexplained postmenopausal bleeding β†’ suspected cancer pathway. Suspicious cervical lesion β†’ urgent gynaecology/cervical-cancer referral. Discharge alone is not automatically a suspected-cancer referral. Β· NICE NG12 (updated April 2026): age 55 and over with unexplained vaginal discharge that is a first presentation, or with thrombocytosis, or with reported haematuria β†’ consider urgent direct-access ultrasound (endometrial)
Sexual Health Clinic
Confirmed gonorrhoea (specialist management, contact tracing, culture sensitivity). Recurrent BV/candidiasis not responding. Possible LGV, syphilis, Mycoplasma genitalium. Partner tracing services.
Gynaecology routine
Recurrent candidiasis not responding to extended therapy. Lichen sclerosus / vulval dermatosis requiring biopsy. Suspected fistula.
GP manages
Uncomplicated BV, Candida, non-complicated chlamydia (if trained for contact tracing notification). Physiological discharge after reassurance. Atrophic vaginitis. Persistent unexplained discharge after normal assessment β†’ review and escalate rather than repeat empirical treatment.
Gonorrhoea should be managed by sexual health services where possible β€” contact tracing, follow-up test of cure (TOC), sensitivity testing, and escalating resistance make specialist involvement preferable. BASHH 2025: take culture before treatment for sensitivity testing where feasible, without delaying treatment. PID should have a low threshold for hospital admission: women who are pregnant, have suspected TOA, fail to respond to oral antibiotics in 72 hours, or have severe PID require IV antibiotics. Contact tracing (partner notification) is a key public health and ethical responsibility in STIs β€” sexual health services have specialist advisors to manage this.
7
Treat

Treatment β€” Diagnosis-specific antibiotic pathways

Bacterial Vaginosis
Metronidazole First-line
BASHH BV 2012: 400mg BD Γ— 5–7 days, OR metronidazole 0.75% vaginal gel nocte Γ— 5 nights, OR clindamycin 2% vaginal cream Γ— 7 nights (can weaken latex condoms/diaphragms during and after treatment β€” see SPC). Alcohol advice per current SPC/local formulary. Routine male partner treatment is not recommended.
Vulvovaginal Candidiasis
Fluconazole or Clotrimazole
Intravaginal: clotrimazole 500mg pessary stat or 200mg Γ— 3 nights. Oral: fluconazole 150mg stat (not in pregnancy). External vulval symptoms: clotrimazole 2% cream as an adjunct (not equivalent to a pessary). Pregnancy: topical imidazole for 7 days; avoid oral fluconazole. Treat partners only if symptomatic. Recurrent/atypical: consider diabetes, immunosuppression and dermatological diagnoses.
Trichomonas vaginalis
Metronidazole
400–500mg BD Γ— 7 days (BASHH TV 2021; preferred over 2 g stat for higher cure rate in women). Treat current sexual partners; abstain until treatment is completed and partners treated. Offer a full STI screen. Follow-up generally unnecessary if asymptomatic β€” retest if symptoms persist or recur (any routine retest is local sexual-health policy). Contact trace.
Chlamydia
Doxycycline First-line
100mg BD Γ— 7 days (non-pregnant adults). Doxycycline is not recommended in pregnancy β€” use the current BASHH/local sexual-health pregnancy regimen. (Pregnancy, BASHH 2026: azithromycin 1 g then 500 mg daily for 2 days preferred; 1 g single dose, erythromycin or amoxicillin are alternatives. Test of cure no earlier than 3 weeks after treatment.) Abstain until treatment completed and partners treated. Test of cure not routine except pregnancy/selected cases; retest for reinfection at about 3 months, especially in younger patients. Notify CCHP / contact tracing.
Gonorrhoea
Ceftriaxone 1g IM Specialist-led
Ceftriaxone 1g IM stat alone (BASHH 2025) when gonorrhoea is confirmed or strongly suspected β€” co-infections are investigated and treated separately. Specialist-led or discussed with local sexual health (resistance, site-specific sampling, contact tracing); test-of-cure strategy set by sexual health. Refer sexual health urgently.

PID (empirical β€” cover chlamydia, gonorrhoea, anaerobes):

OutpatientIM Ceftriaxone 1g stat + Doxycycline 100mg BD + Metronidazole 400mg BD, both oral drugs for 14 days (BASHH 2019 first-line). No routine GP fluoroquinolone alternative β€” fluoroquinolone regimens are exceptional and specialist/microbiology-directed (MHRA January 2024: only when other recommended antibiotics are inappropriate). Start same day β€” do not delay for swab results. Exclude ectopic pregnancy and surgical causes. Review at 72 hours; admit or seek same-day gynaecology advice if systemically unwell, pregnant, unable to tolerate oral medication, suspected TOA, significant diagnostic uncertainty or no improvement.
InpatientIV Ceftriaxone 2g once daily + Doxycycline 100mg BD (oral doxycycline may be used), then oral doxycycline 100mg BD + metronidazole 400mg BD to complete 14 days total.

Special situations:

Recurrent BV (β‰₯3/year; no agreed threshold)
Confirm the diagnosis rather than repeatedly treating symptoms; review intravaginal irritants and reinfection risk. Suppressive metronidazole 0.75% vaginal gel (e.g. twice weekly Γ— 16 weeks, BASHH BV 2012) only with counselling and local/specialist guidance. Probiotics/lactic acid products are not established treatments. Boric acid is not for routine primary care β€” toxic if ingested, not for use in pregnancy, variable quality and licensing; specialist sexual-health/gynaecology supervision and local protocol only.
Recurrent Candida (β‰₯4/year)
Confirm the diagnosis (culture; speciation and susceptibility if treatment failure); exclude pregnancy; review medication interactions, liver disease and QT risk where relevant. Induction fluconazole 150mg every 72hr Γ— 3 doses, then 150mg weekly Γ— 6 months. Specialist advice for non-albicans or azole-resistant infection. Consider HbA1c; HIV per risk. Treat partner only if symptomatic.
Atrophic vaginitis
Vagifem pessary 10Β΅g OD Γ— 2 weeks β†’ twice weekly long-term. Or Ovestin cream. Safe long-term. Lubricants (Replens) for symptomatic relief.

Next steps: see Bacterial vaginosis Β· Recurrent thrush Β· Trichomoniasis Β· Chlamydia Β· Gonorrhoea Β· Pelvic inflammatory disease

BASHH updated gonorrhoea guidance in 2019 to remove routine azithromycin from dual therapy following evidence of increasing azithromycin resistance β€” ceftriaxone 1g IM monotherapy is now first-line for uncomplicated gonorrhoea where sensitivity testing is not yet available. PID empirical treatment must cover gonorrhoea, chlamydia, and anaerobes β€” using incomplete regimens (e.g. doxycycline alone) risks treatment failure and long-term sequelae. Evidence for probiotics and lactic acid preparations is insufficiently consistent to recommend them as BV treatment (BASHH BV 2012).
8
Lifestyle

Non-Pharmacological Measures & Prevention

Avoid douching Vaginal douching disrupts normal lactobacilli-dominant flora β†’ strongly predisposes to BV recurrence. Advise explicitly: "no soap, shower gels, or douches inside the vagina." External washing with water only.
Condom use Consistent condom use reduces STI transmission and also reduces BV recurrence rates (protective against semen alkalinisation of vaginal pH). Discuss dual protection β€” contraception + condoms.
Underwear and clothing Breathable cotton underwear and avoiding tight clothing may be offered as comfort advice β€” low-evidence and not proven to prevent Candida.
Antibiotic stewardship Broad-spectrum antibiotics for non-vaginal indications cause candida recurrence. Avoid unnecessary broad-spectrum antibiotics. If recurrent antibiotic-associated VVC is clearly documented, consider an individualised plan after confirming the diagnosis and reviewing risk factors β€” no routine fluconazole prophylaxis (interactions, hepatotoxicity, QT effects, resistance, pregnancy).
Cervical screening Check cervical screening is up to date; screening is not a diagnostic test β€” blood-stained or persistent discharge, a suspicious cervix or postcoital/intermenstrual bleeding needs a cervical examination whatever the last result.
Partner treatment for STIs Contact tracing and partner treatment is essential for chlamydia, gonorrhoea, and trichomonas. Re-infection is the main driver of recurrence. Sexual Health clinics provide partner notification services. Expedited partner therapy (EPT) where appropriate.
Probiotics Probiotics are not first-line treatment; evidence for prevention of recurrent BV or VVC is limited and inconsistent, and products are not equivalent.
Glucose control in diabetes Elevated blood glucose β†’ altered vaginal glycogen β†’ Candida proliferation. Optimise glycaemic control against an individualised target according to diabetes treatment and risk profile.
Smoking cessation Smoking alters vaginal microbiome composition and reduces immunity β€” associated with BV and HPV persistence. Refer to NHS Stop Smoking Service.
Vaginal douching is the single most modifiable risk factor for recurrent BV β€” douching is consistently associated with BV. This advice is counterintuitive to many patients (who associate cleanliness with douching) and requires emphatic, non-judgmental communication. Partner treatment for trichomonas prevents re-infection β€” it is clinically essential, not optional. Glucose control (with individualised targets) is part of managing recurrent vulvovaginal candidiasis in people with diabetes.
9
Safety

Follow-Up, Test of Cure & Safety-Netting

BV / Candida
No routine follow-up needed if symptoms resolve. Retest if symptoms recur. If recurrent (BV β‰₯3/year; candida β‰₯4/year): scheduled review at 3 and 6 months. Culture to identify non-albicans Candida species if treatment failure.
Chlamydia TOC
Test of cure is not routine in non-pregnant adults. In pregnancy, a test of cure is needed no earlier than 3 weeks after finishing treatment. Consider it with persistent symptoms, suspected non-adherence, rectal infection, azithromycin treatment, treatment failure or re-exposure; avoid testing too early because of residual nucleic acid. Retest for reinfection at about 3 months.
Gonorrhoea TOC
Sexual-health follow-up β€” specialist sexual-health follow-up is required; the service determines the test-of-cure strategy based on site, treatment, symptoms and local resistance advice (not a GP-managed NAAT at 2 weeks).
Trichomonas TOC
No universal test of cure β€” retest if symptoms persist or recur, or where required by specialist/local policy. Confirm partner treatment.
PID review
Review at 72 hours β€” assess response. If no improvement: consider IV antibiotics (admit), repeat swabs for resistance. Full 14-day course mandatory. Further review for symptom resolution, adherence, partner management and complications (fertility counselling if severe). Persistent pain after treatment β†’ consider tubo-ovarian abscess, alternative diagnosis, resistant infection or incorrect diagnosis.
999 safety-net
Worsening fever + pelvic pain after starting antibiotics (TOA? Sepsis?). Haemodynamic compromise. Severe abdominal pain / peritonism. Swelling of the face, lips or tongue, difficulty breathing or a severe rash after treatment (anaphylaxis). Fever, rash, vomiting or feeling faint with a tampon or other item in the vagina (toxic shock).
Same-day safety-net
Pelvic or lower abdominal pain with fever. Feeling systemically unwell. No improvement in PID at 72 hours. New fever developing on oral antibiotics for BV/discharge. Blood-stained discharge developing. Any concern re: pregnancy complication. Vomiting or inability to take medication. New bleeding. Persistent/recurrent discharge despite treatment β†’ reassess.
Test of cure for gonorrhoea is directed by sexual-health services β€” multi-drug resistant gonorrhoea (MDRNG) is increasing in the UK (UKHSA annual gonorrhoea surveillance shows increasing ceftriaxone MIC creep) and treatment failure must be identified promptly to prevent onward transmission. BASHH 2019 moved away from routine chlamydia TOC in uncomplicated cases because NAAT remains positive for up to 3 weeks post-treatment due to residual DNA β€” premature testing leads to false positives and unnecessary re-treatment. PID 72-hour review (BASHH) identifies the women who have not improved on oral treatment and need IV therapy or admission.
Educational use only. Primary-care summary; local sexual-health, microbiology, safeguarding and obstetric guidance takes precedence. Pathway based on: IUSTI/BASHH European guideline on vaginal discharge (2018, minor revision 2023); BASHH guidelines β€” STI testing summary guidance 2023, BV 2012, vulvovaginal candidiasis 2019, Trichomonas vaginalis 2021, PID 2019 interim update, chlamydia 2026, gonorrhoea 2025; NICE NG253 Suspected sepsis; local antimicrobial guidelines (current version β€” principal prescribing reference); NICE NG12 Suspected cancer; NICE NG201 Antenatal care; MHRA fluoroquinolone safety update (January 2024); UKHSA STI surveillance and guidance; NICE NG23 (menopause β€” urogenital atrophy only); current SPCs for medicines listed. Always adapt to local resistance patterns and formulary.