Makindo Medical Notes

Bacterial vaginosis (BV) is diagnosed based on clinical presentation and investigation findings. BV is characterised by an imbalance in vaginal flora, with a decrease in Lactobacilli and an overgrowth of anaerobic bacteria.

Clinical Findings

• Symptoms:
  • Thin, greyish-white vaginal discharge.
  • Foul, fishy odour, especially after intercourse.
  • Possible mild irritation or itching, although BV is often asymptomatic.
• Examination Findings:
  • Characteristic discharge noted on examination.
  • pH of vaginal discharge > 4.5 (alkaline).
  • Positive "whiff" test (release of fishy odour when potassium hydroxide [KOH] is added to the discharge).
  • Microscopy shows clue cells (epithelial cells with adherent bacteria).

Investigations

• Vaginal pH testing (> 4.5 suggests BV).
• Microscopic examination of a vaginal swab to identify clue cells.
• Gram stain of vaginal discharge (can confirm diagnosis in unclear cases).
• Culture is not routinely required, as BV is not caused by a single organism.

Management: eradicate the overgrowth of anaerobic bacteria and restore the normal vaginal flora

1. First-line Treatment:
   • Oral metronidazole 400 mg twice daily for 5-7 days (first-line treatment).
   • Alternative: Vaginal metronidazole gel (0.75%), applied once daily for 5 days.
   • Alternative: Clindamycin cream (2%) applied vaginally for 7 days.
   • Consider clindamycin 300 mg orally for 7 days if metronidazole is contraindicated.
2. Patient Education:
   • Explain that BV is not a sexually transmitted infection, though it is associated with sexual activity.
   • Recommend avoiding douching and the use of perfumed products in the genital area, can disrupt vaginal flora.
   • Discuss recurrence prevention, as BV has a high recurrence rate (up to 50% within 6 months).
3. Considerations for Pregnancy:
   • BV is associated with preterm labour and low birth weight, so it should be treated during pregnancy if symptomatic or if identified during routine screening.
   • Metronidazole is safe during pregnancy, but vaginal preparations are preferred during the first trimester.
4. Follow-up:
   • Routine follow-up is not required unless symptoms persist or recur.
   • If symptoms recur, offer re-treatment with the same regimen or consider long-term suppressive therapy with metronidazole gel (twice weekly for 6 months).

Referral to a specialist may be considered if:

• The patient has persistent symptoms despite treatment.
• Recurrent BV despite multiple treatment attempts.
• Concerns about misdiagnosis or other underlying pathology (e.g., in the case of atypical symptoms or recurrent infections).