Bacterial Vaginosis

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Bacterial vaginosis is caused by a shift from the normal lacto-bacilli-dominated vaginal flora to a polymicrobial flora dominated by gram-positive anaerobes. Although BV is the most common cause of vaginal discharge and foul odor, more than half of women with BV are asymptomatic (CDC, 2006). BV is associated with postoperative infection, pelvic inflammatory disease (PID), premature delivery in women with certain risk factors (French et al., 2004), and an increased risk of human immunodeficiency virus type 1 (HIV-1) transmission (Oduyebo et al., 2009). Risk factors for acquisition of BV include tobacco use, intrauterine contraception (IUC) use, new male sexual partner, sex with another woman, and use of vaginal foreign bodies, perfumed soaps. or douching (Allsworth and Peipert, 2007).

The diagnosis of BV can usually be made by history and laboratory microscopy (Fig. 25-1). Self-diagnosis by the patient is unreliable (ACOG, 2006). A strong "musty cheese" odor predicts BV, whereas lack of a perceived odor makes BV unlikely (Anderson et al., 2004). Use of the Amsel criteria on a vaginal (not cervical) sample can be used to diagnose BV in clinical practice (Box 25-5).

Table 25-3 Comparison of Findings for Vaginitis

Type

Symptoms

Signs

pH

KOH

Saline Wet Mount

Bacterial vaginosis

Malodorous discharge

Thin, gray adherent discharge

>4.5

Amine/fishy odor

Clue cells

Vulvovaginal candidiasis

Itching, burning pain

Curdlike discharge, vulvar erythema

3.8-4.5

Pseudohyphae; budding yeast

Occasional hyphae; yeast

Trichomoniasis

Fish-odor discharge

Erythema, tenderness

6-7

Negative

Trichomonads, many WBCs

Atrophic vaginitis

Dryness, pain

Pale, friable

>4.5

Negative

RBCs, WBCs; many bacteria

Aerobic vaginitis

Foul odor

Heavy purulent discharge

>4.5

Negative

Cocci or coarse rods

Irritant/allergic vaginitis

Itching, swelling

Erythema

Any

Negative

Negative

WBCs, White blood cells; RBCs, red blood cells.

Box 25-4 Differential Diagnosis of Vaginal Discharge: Vaginitis

Candida spp. (C. albicans, C. glabrata)

Bacterial vaginosis (anaerobic bacteria: Gardnerella vaginalis, Bacteroi-des spp.)

Desquamative inflammatory vaginitis (DIV): aerobic bacteria

Trichomonas vaginalis

Allergic vaginitis/contact dermatitis

Chlamydial infection/gonorrhea

Erosive lichen planus vaginitis

Actinomyces Behcet's syndrome (associated with IUC use) Vulvar vestibulitis Physiologic (leukorrhea) Atrophic vaginitis

IUC, Intrauterine contraceptive.

IUC, Intrauterine contraceptive.

Vaginal Candida Types Microscopy

Figure 25-1 Bacterial vaginosis. Typical clue cells of vaginal epithelium are heavily covered by coccobacilli, with loss of distinct cell margins. (Magnification X400.)

(From Holmes KK. Lower genital tract infections in women: cystitis/urethritis, vulvovaginitis, and cervicitis. in Holmes KK, Märdh PA, Sparling PF, et al [eds]. Sexually Transmitted Diseases. New York, McGraw-Hill, 1984.

Box 25-5 Amsel Criteria for Bacterial Vaginosis*

1. Vaginal pH >4.5 (most sensitive) (89% sens, 74% spec)

2. Clue cells >20% on wet-mount (74% sens, 86% spec)

3. Homogeneous discharge, gray, adherent, but wipes off easily (79% sens, 54% spec)

4. Whiff test (amine odor when KOH added; 67% sens, 93% spec)

Modified from Gutman RE et al. Evaluation of clinical methods for diagnosing bacterial vaginosis. Obstet Gynecol 2005;105:551-556. *A score of 3 of 4 is diagnostic.

sens, Sensitivity; spec, specificity; KOH, potassium hydroxide.

Figure 25-1 Bacterial vaginosis. Typical clue cells of vaginal epithelium are heavily covered by coccobacilli, with loss of distinct cell margins. (Magnification X400.)

(From Holmes KK. Lower genital tract infections in women: cystitis/urethritis, vulvovaginitis, and cervicitis. in Holmes KK, Märdh PA, Sparling PF, et al [eds]. Sexually Transmitted Diseases. New York, McGraw-Hill, 1984.

There are many effective options for the treatment of BV. A 2009 Cochrane review states that clindamycin and metronidazole have equivalent efficacy, regardless of regimen. The standard oral dose of metronidazole for BV is 500 mg twice daily for 7 days. Both metronidazole and clindamycin vaginal cream are dosed daily. Clindamycin has lower adverse event rates. Intravaginal lactobacilli gelatin tablets are also effective (Oduyebo et al., 2009). The 2006 CDC guidelines do not recommend treatment with single-dose metronida-zole. Tinidazole is effective with no serious side effects but is more expensive (Livengood et al., 2007). The FDA has recently approved metronidazole, 750 mg daily for 7 days, and a single dose of intravaginal clindamycin for treatment of BV, but only limited data are available on efficacy (CDC, 2006). Hydrogen peroxide douching and triple-sulfonamide cream are considered ineffective (Oduyebo et al., 2009).

Recurrent BV can present a treatment challenge. If recurrence is suspected, the diagnosis should be confirmed, risk factors identified and controlled, and other causes considered while retreating BV (Alfonsi et al., 2004). Metronidazole gel used twice weekly reduces recurrence of BV but is offset by increased vaginal candidiasis and pain complaints. (Sobel et al., 2006). If re-treatment fails, suppressive therapy with metronidazole 0.75% gel for 10 days, then twice weekly for 4 to 6 months, should be tried. There is no evidence that treatment of sexual partners (BASHH, 2006) or using oral or vaginal Lactobacillus acidophilus is effective to prevent recurrence (Alfonsi et al., 2004).

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Bacterial Vaginosis Facts

Bacterial Vaginosis Facts

This fact sheet is designed to provide you with information on Bacterial Vaginosis. Bacterial vaginosis is an abnormal vaginal condition that is characterized by vaginal discharge and results from an overgrowth of atypical bacteria in the vagina.

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