Original Title: Pertes vaginales : mesures diagnostiques et traitement pharmacologique

Authors' objectives: In primary care settings, vaginal discharge is among the most common reasons for gynecological consultation. Unusual vaginal discharge can have different infectious causes. Bacterial vaginosis, vulvovaginal candidiasis and trichomoniasis are reported as the most common infectious causes of unusual vaginal discharge. Indeed, nearly 75% of women will experience at least one episode of vulvovaginal candidiasis during their lifetime, and 5% to 10% will experience more than one episode. Chlamydia trachomatis infection is the most frequently reported sexually transmitted infection (STI) in Québec, and it can cause unusual vaginal discharge, as can Neisseria gonorrhoeae infection and Mycoplasma genitalium infection. The involvement of all qualified professionals in the management of unusual vaginal discharge, including nurses, is important because it is relatively common and sometimes results from an STI. Consequently, to support clinicians, the Ministère de la Santé et des Services sociaux (MSSS) asked the Institut national d’excellence en santé et en services sociaux (INESSS) to carry out work aimed at updating the Québec’s national medical protocol (NMP) and the collective prescription (CP) template with regard to diagnostic measures and pharmacological treatment in a person with unusual vaginal discharge. These two items were last updated in 2018.

Authors' results and conclusions: Upon completion of the analysis of all the gathered data and the iterative process with the advisory committee’s members, the following key findings and messages were considered to have the potential to support the harmonization of clinical practice and to facilitate the management of persons with unusual vaginal discharge. (#1 THE NATIONAL MEDICAL PROTOCOL APPLIES TO PERSONS AGED 14 YEARS AND OLDER WITH UNUSUAL VAGINAL DISCHARGE, BUT ALSO, FOR CERTAIN STIS, THEIR ASYMPTOMATIC SEXUAL PARTNERS): The protocol applies to persons with unusual vaginal discharge and to asymptomatic individuals identified as sexual partners of a person with a syndrome consistent with a C. trachomatis or N. gonorrhoeae infection or of a person who has a laboratory-confirmed C. trachomatis or N. gonorrhoeae infection. It also applies to asymptomatic individuals identified as the current sexual partners of a person with a laboratory-confirmed Trichomonas vaginalis or M. genitalium infection. It does not cover individuals under the age of 14 years. The previous version of the protocol applied only to persons with unusual vaginal discharge and to asymptomatic sexual partners of a person with a laboratory-confirmed T. vaginalis infection. The update has therefore broadened the scope of the NMP. (#2 THE PERSON’S HEALTH STATUS MUST BE ASSESSED TO HELP DETERMINE THE POSSIBLE ETIOLOGY OF THE UNUSUAL VAGINAL DISCHARGE AND TO IDENTIFY COMPLICATED INFECTIONS.): The signs and symptoms, health history and medication history are the first elements to be examined in a person with unusual vaginal discharge. If possible, a physical examination should be performed. It should always be performed if a sexually transmitted and blood-borne infection (STBBI) cannot be ruled out after assessing the STBBI risk factors. Among other things, the physical examination serves to describe the appearance of the vaginal secretions and to identify signs of a complicated infection, if any are present. Updating the protocol helped better define the role of the physical examination, especially in the specific context of certain settings (e.g., community pharmacies, schools, community organizations, women’s shelters and prostitution sites), where performing a physical examination is sometimes difficult because there is no examination room or table. (#3 SPECIMENS AND TESTS WILL GENERALLY CONFIRM OR RULE OUT THE PRESUMED ETIOLOGY OF AN UNUSUAL VAGINAL DISCHARGE.): Depending on the health status assessment of a person with unusual vaginal discharge, certain clinical criteria may be evaluated at the point of service, and/or microbiological testing may be ordered. It is important to consult the list of the laboratory tests of the facility concerned to see what tests are available locally and their details. Test results permit optimal management that is suited to the type of infection confirmed by the test. To adjust the section on specimens and tests to the broadening of the clinical situation included in the updated NMP, some material was added, for example, screening for M. genitalium infection when indicated. (#4 THE THERAPEUTIC APPROACH SHOULD INCLUDE CHECKING THE TREATMENT INDICATIONS AND PRESCRIBING AN APPROPRIATE PHARMACOLOGICAL TREATMENT.): The treatment indications for vaginal discharge consistent with bacterial vaginosis, vulvovaginal candidiasis or trichomoniasis generally combine clinical manifestations and clinical or laboratory criteria. When an STI is suspected or confirmed, pharmacological treatment should be initiated to cure the symptoms, but also to prevent transmission. The recommended treatment varies according to the identified or presumed infection in the person with unusual vaginal discharge or according to the infection to which the asymptomatic partner has been exposed through sexual contact. As part of the update of the NMP, the treatment indications and the recommended treatments have been updated in light of the latest evidence. CONCLUSION: The update of the NMP and CP template on unusual vaginal discharge is based on clinical practice recommendations, which were enriched with the perspectives of the stakeholders consulted and contextualized for Québec practice. These tools should help improve and harmonize the practice and contribute to the effective management of persons with unusual vaginal discharge and, in certain situations, of their asymptomatic sexual partners. However, the improvement and harmonization of the practice will depend on: • The dissemination of the updated NMP and CP template; • The adherence to the changes and the uptake of the recommendations by the health professionals concerned; • The commitment of family medicine group administrators, nursing departments, and councils of physicians, dentists and pharmacists to adopting or adapting the INESSS collective prescription template accompanying the NMP; • The establishment of winning conditions for interprofessional work in the different care settings, in particular, front-line settings; • The availability of training when required; and • The promotion of these tools within the health and social services system.

Authors' recommendations: Following the iterative process with the advisory committee’s members, during which the clinical data and recommendations from the literature, the contextual information and the perspectives of the different stakeholders consulted were triangulated, a series of findings and recommendations were drawn up regarding the management of unusual vaginal discharge. These recommendations have been placed in boxes throughout this report, and they have been integrated into the clinical tools stemming from this project, namely, a national medical protocol and an accompanying collective prescription template.

Authors' methods: A systematic review of the literature on the best clinical practices for managing unusual vaginal discharge was conducted according to INESSS’s usual standards. The data were analyzed from the perspective of contextualizing Québec practice, using mainly legislative, regulatory and organizational contextual elements specific to Québec, and the perspectives of the different stakeholders consulted. To gather these perspectives, an advisory committee consisting of clinicians from different specialties and areas of expertise was created. Lastly, the overall quality of the work, its acceptability and its applicability were assessed by external reviewers specializing in the field of interest, and by future users who did not participate in the work.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/protocole-medical-national-pertes-vaginales-inhabituelles.html

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/protocole-medical-national-pertes-vaginales-inhabituelles.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)