II. Epidemiology

  1. Accounts for 35-50% of Vaginitis

III. Risk Factors

  1. Vaginal Douching
  2. Tobacco Abuse
  3. New or multiple sexual partners
  4. Unprotected intercourse
  5. Women Who Have Sex With Women

IV. Etiology

  1. Marked reduction in normally predominant lactobacillus
  2. Polymicrobial infection: facultative Anaerobic Bacteria
    1. Peptostreptococcus
    2. Gardnerella Vaginalis (Corynebacterium vaginale, Haemophilus vaginalis)
    3. Bacteroides
    4. Mobiluncus species
    5. Mycoplasma hominis
    6. Ureaplasma
    7. Prevotella

V. Symptoms

  1. Often asymptomatic, or mild
  2. Musty or fishy odor to genitalia or Vaginal Discharge
  3. Profuse thin gray-white, non-clumping Vaginal Discharge

VI. Signs: Amsel Criteria (3 of 4 needed for diagnosis)

  1. Vaginal pH > 4.5 (more alkaline than normal)
    1. See Vaginal pH for differential diagnosis
    2. Test Sensitivity: 77%
    3. Test Specificity: 35%
      1. False Positive with Cervical Mucus, Menses or semen
  2. Clue Cells present (on >20% of cells) on saline preparation
    1. Bacteria adhered to vaginal epithelial cells
    2. Test Sensitivity: 53-90%
    3. Test Specificity: 40-100%
    4. Images
      1. GynVaginitisClueCell.jpg
  3. Positive whiff test (Amine Test)
    1. Test Sensitivity: 67%
    2. Test Specificity: 93%
    3. Volatile amines produce a fishy odor with 10% KOH
    4. Also present with Trichomonal Vaginitis
  4. Discharge characteristics
    1. Thin, non-clumping, gray-white, adherent discharge
  5. Efficacy of Amsel Criteria: At least 3 of 4 findings present
    1. Test Sensitivity: 70-97%
    2. Test Specificity: 90-94%

VII. Labs: Non-Microscopy

  1. High sensitivity and Specificity tests (>92% Test Sensitivity and Specificity)
    1. DNA Probe Test (e.g. Affirm VPIII Microbial Identification Test)
      1. Identifies candida, gardnerella vaginalis, Trichomonas
    2. Sialidase Activity
      1. Specific for gardnerella vaginalis
  2. Older tests
    1. Fem Exam Card 1 (pH and amine) and 2 (proline aminopeptidase)
      1. Rapid, 2 minute test with high sensitivity (91%) but low Specificity
    2. Trimethylamine Card for pH
      1. Rapid test with Low sensitivity, but high Specificity (97%)

VIII. Management

  1. Non-Pregnant
    1. Test and treat only symptomatic patients
    2. First-Line: Oral Metronidazole (Flagyl)
      1. Flagyl 500 mg orally twice daily for 7 days
    3. Other oral options
      1. Clindamycin 300 mg orally twice daily for 7 days
      2. Tindazole (Tindamax) 2 g orally once daily for 2 days (or 1 g orally daily for 5 days)
      3. Secnidazole (Solosec) 2 grams for single dose
        1. Sprinkle entire packet into applesauce, yogurt or pudding
        2. Avoid in pregnancy and Lactation
        3. Risk of Vulvovaginal Candidiasis
        4. Expensive in 2018 ($270, instead of $10 for Metronidazole)
        5. (2018) presc lett 25(7): 42
    4. Topical, intravaginal options (higher recurrence rate, does not cover Trichomoniasis)
      1. MetroGel (0.75%) 37.5 mg per 5g applicator intravaginally at bedtime for 5 days
      2. Clindamycin
        1. Clindamycin Cream (2%) 5g applicator intravaginally at bedtime for 7 days
        2. Clindamycin Ovules (Cleocin Ovules) 100 mg intravaginally at bedtime for 3 days
        3. Clindamycin Topicals weaken latex Condoms, diaphragms until 3 days after stopping
  2. Pregnancy
    1. Precautions
      1. Bacterial Vaginosis is associated with Preterm Labor
      2. Treat all symptomatic Bacterial Vaginosis cases in pregnancy (but screening not indicated)
    2. First Trimester
      1. Avoid treatment if possible in first trimester
      2. Clindamycin (Cleocin) 300 mg PO bid for 7 days
      3. Clindamycin Cream 5 grams PV qhs for 7 days
      4. Metronidazole Gel PV bid for 5 days
    3. After First Trimester (prefer after 37 weeks)
      1. Metronidazole (Flagyl) 500 mg twice daily for 7 days
      2. Metronidazole (Flagyl) 250 mg three times daily for 7 days
      3. Clindamycin 300 mg orally twice daily for 7 days
  3. Resistant or Refractory Cases
    1. Metronidazole 500 mg orally twice daily for 14 days (preferred) or
    2. Consider treating sexual partner and patient (not recommended)
      1. Male Urethra may be co-infected
      2. Based on anecdotal reports (evidence lacking)
    3. Other options
      1. Clindamycin at above dose
      2. Povidone-Iodine gel OR suppository (Betadine)
        1. Apply vaginally bid for 14 to 28 days ($59)
  4. Recurrent Bacterial Vaginosis (common)
    1. Treat as refractory cases above
    2. Combined protocol
      1. Metronidazole 500 mg twice daily for 7 days AND followed by
      2. Boric Acid gelatin cap 600 mg intravaginallyat bedtime for 21 days AND followed by
      3. Metronidazole vaginal gel one 5 g applicator twice weekly for 16 week
      4. Reichman (2009) Sex Transm Dis 36:732-4 PMID:19704395 [PubMed]
    3. Consider maintenance therapy
      1. Induction: Metronidazole gel 0.75% (Metrogel) nightly for 10 days
      2. Maintenance: When Wet Prep with no clue cells, pH lower
        1. Metronidazole gel twice weekly or (2 g oral monthly) for 3-6 months
        2. Treat concurrent Candida if present (e.g. Fluconazole 150 mg once monthly)
    4. References
      1. Sobel (2006) Am J Obstet Gynecol 194(5): 1283-9 [PubMed]

IX. Complications: Sexually Transmitted Infection

X. Complications: Pregnancy

  1. Antibiotic treatment has not be found to reduce preterm birth risk
    1. Brocklehurst (2013) Cochrane Database Syst Rev (1):CD000262 +PMID:23440777 [PubMed]
  2. Originally thought to be associated with preterm delivery (23-26 weeks)
    1. Hillier (1995) N Engl J Med 333: 1737-42 [PubMed]
    2. Hauth (1995) N Engl J Med 333: 1732-6 [PubMed]
  3. Originally, second trimester treatment with Clindamycin was found with better pregnancy outcomes
    1. Reduced preterm birth and late Miscarriage rate
    2. Ugwumadu (2003) Lancet 361:983-8 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Bacterial Vaginosis (C0085166)

Definition (MSH) Polymicrobial, nonspecific vaginitis associated with positive cultures of Gardnerella vaginalis and other anaerobic organisms and a decrease in lactobacilli. It remains unclear whether the initial pathogenic event is caused by the growth of anaerobes or a primary decrease in lactobacilli.
Concepts Disease or Syndrome (T047)
MSH D016585
SnomedCT 237092002, 85569008, 266655004, 198221007, 155981006, 419760006
LNC LP63734-5, MTHU043124
English Bacterial Vaginitis, Bacterial Vaginoses, Bacterial Vaginosis, Nonspecific Vaginitis, Vaginitis, Bacterial, Vaginitis, Nonspecific, Vaginoses, Bacterial, Vaginosis, Bacterial, Bacterial Vaginitides, Vaginitides, Bacterial, VAGINOSES BACT, BACT VAGINOSES, VAGINOSIS BACT, VAGINITIDES BACT, BACT VAGINITIS, BACT VAGINOSIS, BACT VAGINITIDES, VAGINITIS BACT, bacterial vaginitis (diagnosis), nonspecific vaginitis (diagnosis), vaginitis bacterial, bacterial vaginitis, nonspecific vaginitis, bacterial vaginosis, Vaginitis bacterial NOS, Vaginosis, Bacterial [Disease/Finding], gardnerella vaginitis, bacterial vaginoses, gardnerella infection, gardnerella vaginosis, non-specific vaginitis, gardnerella vaginalis vaginitis, gardnerella, non specific vaginitis, bactria infection of the vagina, Vaginosis bacterial, Vaginosis bacterial NOS, Vaginitis bacterial, Non-specific vaginitis, AV - Anaerobic vaginosis, BV - Bacterial vaginosis, Bacterial vaginosis, Bacterial vaginitis, NSV - Nonspecific vaginitis, Nonspecific vaginitis, Bacterial vaginosis (disorder)
Spanish vaginosis bacteriana (trastorno), vaginosis bacteriana, Vaginitis bacteriana NEOM, Vaginitis inespecífica, Vaginosis bacteriana, Vaginosis bacteriana NEOM, Vaginitis bacteriana, Vaginitis Bacteriana, Vaginitis no Específica, Vaginosis Bacteriana
Dutch niet-specifieke vaginitis, vaginitis bacterieel NAO, vaginose bacterieel NAO, vaginose bacterieel, bacteriële vaginose, vaginitis bacterieel, Vaginitis, niet-specifieke, Bacteriële vaginosis, Vaginitis, bacteriële, Vaginosis, bacteriële
French Vaginite bactérienne SAI, Vaginite non précisée, Vaginose bactérienne SAI, Vaginite bactérienne, Vaginite non spécifique, Vaginose bactérienne
German nicht-spezifische Vaginitis, Kolpitis bakteriell NNB, Bakterielle Vaginosen, Bakterielle Vaginosis, Bakterielle Vaginitiden, Bakterielle Vaginitis, Unspezifische Vaginitis, Vaginose bakteriell, bakterielle Kolpitis, Vaginose bakteriell NNB, Kolpitis bakteriell, Bakterielle Vaginose, Vaginitis, bakterielle, Vaginitis, unspezifische, Vaginose, bakterielle
Italian Vaginite batterica NAS, Vaginite non specifica, Vaginiti aspecifiche, Vaginosi batterica, Vaginosi batteriche, Vaginosi batterica NAS, Vaginite batterica
Portuguese Vaginite bacteriana NE, Vaginite inespecífica, Vaginose bacteriana NE, Vaginose bacteriana, Vaginite bacteriana, Vaginite Bacteriana, Vaginite não Específica, Vaginose Bacteriana
Japanese 細菌性腟炎NOS, サイキンセイチツエン, ヒトクイセイチツエン, サイキンセイチツエンNOS, 腟症-細菌性, 細菌性腟炎, サイキンセイチツショウ, 細菌性腟症NOS, サイキンセイチツショウNOS, 細菌腟症, 腟炎-細菌性, 非特異性腟炎, 細菌性腟症, 細菌性膣炎, 細菌性膣症, 腟炎-非特異性, 膣炎-細菌性, 膣炎-非特異性, 膣症-細菌性, 非特異性膣炎
Swedish Vaginos, bakteriell
Czech vaginitida nespecifická, vaginitida bakteriální, Blíže neurčená vaginitida, Bakteriální vaginitida, Bakteriální vaginitida NOS, vaginóza bakteriální, bakteriální vaginitida, bakteriální vaginóza, Vaginóza bakteriální NOS, Bakteriální vaginóza, Aminová kolpitis
Finnish Bakteerivaginoosi
Polish Waginoza pochwy, Waginoza bakteryjna, Bakteryjne zakażenie pochwy
Hungarian Nem specifikus vaginitis, bacterialis vaginitis k.m.n., bacterialis vaginitis, Bacterialis vaginosis, Bacterialis vaginosis k.m.n.
Norwegian Bakteriell vaginose, Vaginose, bakteriell, Bakteriell vaginitt, Vaginitt, bakteriell

Ontology: Gardnerella vaginitis (C1622505)

Concepts Disease or Syndrome (T047)
SnomedCT 85569008, 237092002, 419468003
English Gardnerella, Gardnerella vaginalis infectn, Gardnerella infection NOS, Gardnerella infections, Gardnerella vaginalis vaginitis, Vaginitis gardnerella, Gardnerellal vaginitis, Gardnerella vaginitis (diagnosis), vaginitis gardnerella, Gardnerella; vaginitis (manifestation), vaginitis; Gardnerella (manifestation), gardnerella, Gardnerella infection, Gardnerella vaginalis infection, Vaginitis due to Gardnerella vaginalis, Gardnerella vaginitis (disorder), Gardnerella vaginitis
Spanish vaginitis por Gardnerella vaginalis, vaginitis por Gardnerella vaginalis (trastorno), vaginitis por Gardnerella, Vaginitis por Gardnerella vaginalis, Infección por gardnerella NEOM, Infecciones por gardnerella, Vaginitis por Gardnerella, Infección por gardnerella
Italian Infezione da Gardnerella, Infezioni da Gardnerella, Vaginite da gardnerella, Infezione da Gardnerella, NAS, Vaginite da Gardnerella vaginalis, Vaginite da Gardnerella
Dutch Gardnerella vaginalis-vaginitis, Gardnerella-infectie NAO, Gardnerella; vaginitis, vaginitis; Gardnerella, Gardnerella-infecties, Gardnerella-infectie, Gardnerella-vaginitis
French Vaginite à Gardnerella vaginalis, Infection à Gardnerella SAI, Infection à gardnerella, Infections à Gardnerella, Vaginite à Gardnerella
German Vaginitis Gardnerella, Gardnerella-Infektion NNB, von Gardnerella vaginalis verursachte Vaginitis, Gardnerella-Infektionen, Gardnerella-Infektion, Vaginitis gardnerella
Portuguese Vaginite a Gardnerella, Vaginite a Gardnerella vaginalis, Infecção a Gardnerella NE, Vaginite a gardnerela, Infecção por gardnerella, Infecções a Gardnerella
Japanese ガードネレラ感染, ガードネレラ感染NOS, ガードネレラ菌性腟炎, ガードネレラ・バジナリス性腟炎, ガードネレラキンセイチツエン, ガードネレラバジナリスセイチツエン, ガードネレラカンセンNOS, ガードネレラカンセン
Czech Gardnerelové infekce, Gardnerelová infekce NOS, Gardnerelová vaginitida, Gardnerelová infekce, Vaginitida vyvolaná Gardnerella vaginalis
Hungarian Gardnerella fertőzések, Gardnerella vaginalis vaginitis, Gardnerella fertőzés, gardnerella okozta vaginitis, Gardnerella fertőzés k.m.n., Gardnerella vaginitis