Four common pathological conditions are associated with vaginal discharge: bacterial vaginosis, aerobic vaginitis, candidosis, and the sexually transmitted infection, trichomoniasis. Chlamydial or gonococcal cervical infection may result in vaginal discharge. Vaginal discharge may be caused by a range of other physiological and pathological conditions including atrophic vaginitis, desquamative inflammatory vaginitis, cervicitis, and mucoid ectopy. Psychosexual problems may present with recurrent episodes of vaginal discharge and vulval burning. These need to be considered if tests for specific infections are negative. Many of the symptoms and signs are non-specific and a number of women may have other conditions such as vulval dermatoses or allergic and irritant reactions.

Mycoplasma genitalium infection contributes to 10–35% of non‐chlamydial non‐gonococcal urethritis in men. In women, M. genitalium is associated with cervicitis and pelvic inflammatory disease (PID) in 10–25%. Transmission of M. genitalium occurs through direct mucosal contact. Clinical features and diagnostic tests Asymptomatic infections are frequent. In men, urethritis, dysuria and discharge predominate. In women, symptoms include vaginal discharge, dysuria or symptoms of PID – abdominal pain and dyspareunia. Symptoms are the main indication for diagnostic testing. Diagnosis is achievable only through nucleic acid amplification testing and must include investigation for macrolide resistance mutations. Therapy Therapy for M .genitalium is indicated if M. genitalium is detected. Doxycycline has a cure rate of 30–40%, but resistance is not increasing. Azithromycin has a cure rate of 85–95% in macrolide‐susceptible infections. An extended course of azithromycin appears to have a higher cure rate, and pre‐treatment with doxycycline may decrease organism load and the risk of macrolide resistance selection. Moxifloxacin can be used as second‐line therapy but resistance is increasing. Recommended treatment Uncomplicated M. genitalium infection without macrolide resistance mutations or resistance testing:Azithromycin 500 mg on day one, then 250 mg on days 2–5 (oral). Second‐line treatment and treatment for uncomplicated macrolide‐resistant M. genitalium infection:Moxifloxacin 400 mg od for 7 days (oral). Third‐line treatment for persistent M. genitalium infection after azithromycin and moxifloxacin:Doxycycline or minocycline 100 mg bid for 14 days (oral) may cure 40–70%.Pristinamycin 1 g qid for 10 days (oral) has a cure rate of around 75%. Complicated M. genitalium infection (PID, epididymitis):Moxifloxacin 400 mg od for 14 days. Main changes from the 2016 European M. genitalium guideline Due to increasing antimicrobial resistance and warnings against moxifloxacin use, indications for testing and treatment have been narrowed to primarily involve symptomatic patients. The importance of macrolide resistance‐guided therapy is emphasised.

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Epidemiological and microbiological investigations confirm that an outbreak of a gonococcal strain showing HL-AziR is ongoing in the North of England. Every effort should be made to identify and curtail dissemination of this strain as it presents a significant threat to the current recommended front-line dual therapy.

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Summary Background Gonorrhoea is a common sexually transmitted infection for which ceftriaxone is the current first-line treatment, but antimicrobial resistance is emerging. The objective of this study was to assess the effectiveness of gentamicin as an alternative to ceftriaxone (both combined with azithromycin) for treatment of gonorrhoea. Methods G-ToG was a multicentre, parallel-group, pragmatic, randomised, non-inferiority trial comparing treatment with gentamicin to treatment with ceftriaxone for patients with gonorrhoea. The patients, treating physician, and assessing physician were masked to treatment but the treating nurse was not. The trial took place at 14 sexual health clinics in England. Adults aged 16–70 years were eligible for participation if they had a diagnosis of uncomplicated genital, pharyngeal, or rectal gonorrhoea. Participants were randomly assigned to receive a single intramuscular dose of either gentamicin 240 mg (gentamicin group) or ceftriaxone 500 mg (ceftriaxone group). All participants also received a single 1 g dose of oral azithromycin. Randomisation (1:1) was stratified by clinic and performed using a secure web-based system. The primary outcome was clearance of Neisseria gonorrhoeae at all initially infected sites, defined as a negative nucleic acid amplification test 2 weeks post treatment. Primary outcome analyses included only participants who had follow-up data, irrespective of the baseline visit N gonorrhoeae test result. The margin used to establish non-inferiority was a lower confidence limit of 5% for the risk difference. This trial is registered with ISRCTN, number ISRCTN51783227. Findings Of 1762 patients assessed, we enrolled 720 participants between Oct 7, 2014, and Nov 14, 2016, and randomly assigned 358 to gentamicin and 362 to ceftriaxone. Primary outcome data were available for 306 (85%) of 362 participants allocated to ceftriaxone and 292 (82%) of 358 participants allocated to gentamicin. At 2 weeks after treatment, infection had cleared for 299 (98%) of 306 participants in the ceftriaxone group compared with 267 (91%) of 292 participants in the gentamicin group (adjusted risk difference −6·4%, 95% CI −10·4% to −2·4%). Of the 328 participants who had a genital infection, 151 (98%) of 154 in the ceftriaxone group and 163 (94%) of 174 in the gentamicin group had clearance at follow-up (adjusted risk difference −4·4%, −8·7 to 0). For participants with a pharyngeal infection, a greater proportion receiving ceftriaxone had clearance at follow-up (108 [96%] in the ceftriaxone group compared with 82 [80%] in the gentamicin group; adjusted risk difference −15·3%, −24·0 to −6·5). Similarly, a greater proportion of participants with rectal infection in the ceftriaxone group had clearance (134 [98%] in the ceftriaxone group compared with 107 [90%] in the gentamicin group; adjusted risk difference −7·8%, −13·6 to −2·0). Thus, we did n...

Objectives: High prevalence of bacterial vaginosis (BV) has been reported in lesbians but most studies were based in sexually transmitted infection clinic settings; therefore, we wished to determine the prevalence and risk factors of BV in lesbians and heterosexual women in a community setting in the UK. Methods: A cross-sectional study recruiting lesbian women volunteers from community groups, events, clubs and bars. Heterosexual women were recruited from a community family planning clinic. They self-swabbed to create a vaginal smear, which was Gram-stained and categorised as BV, intermediate or normal flora. They completed a questionnaire about age, ethnic group, smoking, genital hygiene practices and sexual history. Results: Of 189 heterosexuals and 171 lesbians recruited, 354 had gradeable flora. BV was identified in 43 (25.7%) lesbians and 27 (14.4%) heterosexuals (adjusted OR 2.45, 95% CI 1.25 to 4.82; p = 0.009). Concordance of vaginal flora within lesbian partnerships was significantly greater than expected (27/31 (87%) couples, k = 0.63; p,0.001). Smoking significantly increased the risk of BV regardless of sexuality (adjusted OR 2.65; p = 0.001) and showed substantial concordance in lesbian partnerships but less than for concordance of flora. Conclusions: Women who identified as lesbians have a 2.5-fold increased likelihood of BV compared with heterosexual women. The prevalence is slightly lower than clinic-based studies and as volunteers were recruited in community settings, this figure may be more representative of lesbians who attend gay venues. Higher concordance of vaginal flora within lesbian partnerships may support the hypothesis of a sexually transmissible factor or reflect common risk factors such as smoking.H igh prevalence of bacterial vaginosis (BV) (between 29 and 52%) has been reported in lesbians in UK and US studies, [1][2][3][4][5] with the suggestion that the prevalence is significantly higher than in heterosexual women. These studies were based in sexually transmitted infection (STI) clinic settings so may represent a selected sample of lesbian women who were symptomatic, or concerned about STI risk, and may not be representative of lesbian women in general. This is supported by a recent US study, which invited women who have sex with women (WSW) only volunteers to attend for a clinic assessment and found a slightly lower BV prevalence of 25%. 6Comparison of lesbian, WSW and heterosexual data can also be problematic since sexual behaviour surveys in both the UK and Australia have shown higher numbers of male partners reported by bisexual than heterosexual women, 7 8 with less male partners specifically indicated by Australian lesbian identifying women.8 Recent change of sexual partner 9 and having multiple partners compared to a single partner 10 have been associated with BV.Potential mechanisms for an increase in BV in lesbians may be because of genital hygiene behaviours or sexual practices. Certain vulval cleansing agents and vaginal douching may affect the vaginal ecology throug...