EVALUATION OF 2 CLINICAL PROTOCOLS FOR THE MANAGEMENT OF WOMEN WITH VAGINAL DISCHARGE IN SOUTHERN THAILAND

Objectives: (1) To compare the effectiveness of two clinical protocols for the management of vaginal discharge in the situations where no la boratory facilities are available but speculum examination is possible and where basic laboratory facilities are available. (2) To determine clinical and simple laboratory indicators for diagnosis of patients w ith vaginal discharge in the local setting. Design: Alternate allocati on of subjects to one of two management protocols. Subjects: Women pre senting to university gynaecology outpatients department with a compla int of vaginal discharge. Methods: Subjects were alternately allocated management according to one of two protocols: one without (group A) a nd one with (group B) immediate access to results of basic laboratory tests. Full clinical assessment including speculum examination and mic robiological assessment for infection with gonorrhoea, chlamydia, cand ida, trichomonas, and bacterial vaginosis was performed on all women. Follow up assessment of clinical and microbiological response was perf ormed 1-2 weeks later. Results: At initial assessment, both groups wer e similar in all respects except that more group B women had inflammat ion of the vulva. The prevalences of various conditions were: candidia sis 22%, bacterial vaginosis 38%, trichomoniasis 4%, chlamydia 4%, gon orrhoea 0.4%. There was no association between any demographic charact eristic and diagnosis of cause of the discharge. Both protocols result ed in clinically and statistically significant improvements for women with candidiasis, bacterial vaginosis, and trichomoniasis. There were no clinically important differences in outcomes between the two protoc ols. The sensitivities and specificities of various indicators were: c urd-like vaginal discharge for candidiasis, 72% and 100%; homogeneous vaginal discharge for bacterial vaginosis or trichomoniasis, 94% and 8 8%; absent or scanty lactobacilli for bacterial vaginosis, 99% and 68% ; > 20% clue cells for bacterial vaginosis, 81% and 99%; visible endoc ervical mucopus for chlamydia or gonorrhoea, 36% and 86%; microscopic endocervical mucopus for chlamydia or gonorrhoea, 64% and 69%. Conclus ions: Both protocols were equally effective in managing women with abn ormal vaginal discharge. Simple clinical indicators for candidiasis, b acterial vaginosis, or trichomonas as in protocol A are sufficiently s ensitive and specific for use in situations with no laboratory support . A modification to protocol A could increase detection of bacterial v aginosis at basic health service level. Further work is needed to iden tify appropriate indicators for infection with chlamydia or gonorrhoea .