Benha University Hospital, Egypt

E-mail: elnashar53@hotmail.com
Non-specific vaginitis:
Haemophilus vaginalis
Gardnerella vaginitis:
Gardnerella vaginalis
Anaerobic vaginosis:
Gardnerella vaginalis & anaerobic
bacteria
Bacterial vaginosis:
polymicrobial alteration in vaginal
flora causing an increase in vaginal
BV is the most
common cause of
vaginal discharge in
young women of
reproductive age.
Prevalence between
Polymicrobial:
G. vaginalis (coccobacilli,
surface pathogen),
Anaerobic bacteria (Bacteroids,
Mobiluncus, Prevotella) &
Mycoplasma hominis.
There is synergistic relationship
between the acquired
organisms.
Their metabolism produces
volatile amines & organic acids
other than lactic acids leading to
smell & increase pH.
Mobiluncus produce
trimethylamine giving the smell of
rotting fish.
Mobiluncus & Bacteroids produce
succinate (Keto-acid) which raises
vaginal pH.
Absence of lactic acid & the
Gram stain
b= bacteroids, c= mobilincus, g= gardenerlla, p=peptostreptococci
Electron micrograph of Mobiluncus
1. Increase vaginal pH:
Semen,
after menstruation when estradiol
levels increase.
2. Decrease lactobacilli:
Douching,
change of sexual partner (change
of vaginal environment),
episodes of candida
.
3. Smoking: suppresses the
immune system facilitating
infection.
4. IUCD:
5. Black ethnic groups
6. Lesbians
•It is not STD:
Treatment of the husband is
not beneficial in preventing
recurrence of BV.
The reason for the alteration in
flora is unclear.
1.Hormonal changes: the
mechanism is unclear
2.Enzymatic changes: Mucinase
& siallidase are elevated in
vaginal discharge of BV.
Breaking down the mucosal
barrier
Up to half the women diagnosed
with BV are asymptomatic.
.Discharge: thin, homogenous,
whitish-grey, frothy & fishy.
Absence of discharge does not
imply the absence of BV. It is not
accepted as a reliable indicator on
its own as it is neither sensitive
nor specific to BV.(Deborah et
al,2003)
1.pH of discharge: 5.7
A low pH virtually
excludes BV. An elevated
pH is the most sensitive
but least specific as an
increase can also associated
with menstruation, recent
2.Whiff test (amine
test).
Addition of 10% KOH
to a sample of vaginal
discharge produces
fishy odor.
It has a positive
3.Wet film (drop of vaginal
secretion & drop of saline):
clue cells (epithelial cells
covered by coccobacilli,
borders are indistinct), No
WBC.
It is the single most sensitive &
specific criterion for BV. , but it
is operator dependent. Debris
& degenerated cells may be
4. Gram stain:
90% sensitivity, highly
sensitive & specific (Gr.
Variable c.bacilli, no WBC, no
lactobacilli).
Scoring systems which weight
numbers of lactobacilli &
numbers of G vaginalis &
Mobiluncus. It is simple &
objective method. However
5.Rapid tests:
.Diamine test: rapid, sensitive
& specific
.Proline aminopeptidase test
(Pip Activity test Card)
.A card test for detection of
elevated pH & trimethylamine
(FemExam test card)
.DNA probe based test for high
concentration of G. vaginalis
. Pap. smear: clue
cells. Limited clinical
utility because of low
sensitivity
.Culture: It is not
recommended as a
diagnostic tools
•Amsel’s criteria
3 of the following:
.Homogenous discharge.
.pH> 4.5.
. Amine test.
.Clue cells.
•Gram stain alone corresponds
well to Amsel’s criteria & to the
presence of the associated
bacteria.
 Gynecological
1. Psychological disturbance

2. PID:
The microorganisms of BV &
PID are similar. There is 10
fold-increased risk of PID in
females with BV.
3. Tubal infertility: 1/3 of
4. Post-hysterectomy
vaginal cuff infection.
5. Uretheral syndrome.
6. HIV susceptibility
infection.
The presence of BV
increases susceptibility to
HIV infection
 Obstetric
1. Miscarriage:
Women with BV had a higher rate of
first trimester miscarriage than those
with normal vaginal flora. Recurrent first
trimester miscarriage has not been
associated with BV.
The incidence of late miscarriage (13-
23 w) is higher in women with BV.
2. Postabortal sepsis.
The use of antibiotic prophylaxis
before surgical termination of
3.Preterm labour.
The earlier in pregnancy that
BV is detected the greater the
risk of PTL. Treatment of high
risk, BV positive pregnant
women has resulted in
reduction of PTL by 40-50%.
4.Bactraemia after instrumental
delivery
6.Chorioamnionitis.
 A. Non pregnant
Benefits of treatment:
. relieve vaginal symptoms & signs of
infection.
. Reduce the risk for infectious
complications after hysterectomy or
abortion.
. Reduction of other infectious
complications e.g., HIV, STD
Indications
1. Symptomatic women (Grade A
Recommended regimens
(CDC,2002)
Metronidazole 500 mg orally
twice a day for 7 days, OR
Metronidazole gel 0.75%, one
full applicator (5g)
intravaginally, once a day for 5
days OR
Clindamycin cream 2%, one full
applicator (5g) intravaginally at
Alternative regimens
(CDC,2002)
Metronidazole 2 g orally in a
single dose, OR
Clindamycin 300 mg orally
twice a day for 7 days, OR
Clindamycin ovules 100 mg
intravaginally once at
bedtime for 3 days.
Notes:
•The recommended metronidazole
regimens are equally effective.
Metronidazole gel is more
expensive than tablets
•The vaginal clindamycin is less
effective than the metronidazole
regimens.
•The alternative regimens have
lower efficacy for BV.
•No data support the use of non-
•Clindamycin cream or oral is
preferred in case of allergy or
intolerance to metronidazole.
•Theoretically, Metronidazole
has an advantage because it is
less active against lactobacilli
than clindamycin.
•Conversely, clindamycin is
more active than
metronidazole against most of
.Follow up
Follow-up visits are
unnecessary if symptoms
resolve.
Another recommended
treatment regimen may
be used to treat recurrent
disease.
 B. Pregnant
Natural history:
•BV is present in up to 20% of
pregnant women depending on
how often the population is
screened.
•The majority is asymptomatic.
•It may spontaneously resolve
without treatment, although
the majority is likely to have
Recommended
regimen
Metronidazole 250
mg orally three
times a day for 7
days, OR
Notes:
•Existing data do not support
the use of topical agents during
pregnancy. Evidence from
three trials suggests an
increase in adverse events
(e.g. prematurity & neonatal
infection), particularly in
newborns, after use of
clindamycin cream (McGregor
•Multiple studies &
meta-analysis have not
demonstrated a
consistent association
between
metronidazole during
pregnancy &
Indications
1. All symptomatic
pregnant women should
be tested & treated.
2. Asymptomatic
pregnant women at high
risk for PTL ( previous
history), should be
3. Asymptomatic pregnant females
at low risk for PTL:
Data are conflicting whether
treatment reduces adverse
outcomes of pregnancy.
One trial, using oral clindamycin
demonstrated a reduction in PTL
& postpartum infectious
complications (Hay et al, 2001).
Oral clindamycin early in the
second trimester significantly
How to screen for BV ?
(Gierdingen et al, 2000)
Ask about symptoms & pH of
the vagina is determined
frequently during pregnancy.
If pH > 4.5 ( BV or TV in 84%),
do wet mount.
Follow-up of pregnant
women
One month after treatment to
 C. lactation
•Metronidazole enters breast milk & may
affect its taste. The manufacturer
recommend avoiding high doses if breast
feeding.
•Small amounts of clindamycin enter breast
milk.
•It is prudent therefore to use an
intravaginal treatment for lactating women
(Grade C recommendation)
Benha University Hospital, Egypt
E-mail: elnashar53@hotmail.com