VULVOVAGINITIS, BACTERIAL

VULVOVAGINITIS, BACTERIAL - J. C.Chava-Zimmerman, MD
BASICS
DESCRIPTION
A syndrome in which H2O2-producing lactobacilli are replaced by anaerobic bacteria
• System(s) Affected: Reproductive
• Synonym(s): Gardnerella vaginosis; Bacterial vaginosis; Nonspecific vaginitis; Haemophilus vaginitis; Corynebacterium vaginitis
GENERAL PREVENTION
• Good hygiene
• Use of condoms for sexual intercourse
EPIDEMIOLOGY
Predominant sex: Female
Prevalence
• As low as 4% in unselected populations
• Up to 33% in sexually transmitted disease clinics
• Up to 44% in patients with vaginitis
RISK FACTORS
• Controversial regarding multiple sexual partners
• Intrauterine device use
ETIOLOGY
• Polymicrobial: Gardnerella vaginalis, Mobiluncus species, Mycoplasma hominis, Peptostreptococcus, other various anaerobes, including Prevotella, Bacteroides, and Fusobacterium
• Shift from a healthy lactobacilli-based endogenous flora to an anaerobically based endogenous flora
• Rectal reservoir of organisms leading to autoinfection


DIAGNOSIS
SIGNS AND SYMPTOMS
• Unpleasant musty or fishy vaginal odor, exacerbated immediately after intercourse
• Thin gray-white vaginal discharge, mildly adherent to vaginal walls
• 10-30% with vaginal/vulvar irritation
• 10% with frothy discharge
TESTS
Lab
• Affirm VP Microbial Identification Test
• pH paper test (pH >4.5)
• Wet prep: Clue cells in >10-20% of epithelial cells; fewer white blood cells than epithelial cells
• 10% potassium hydroxide (KOH); "whiff test"  transient but potent amine or fishy odor
• Gram stain indicating absence of lactobacilli
• May be seen on cytology
• Culture difficult for mycoplasma; not useful
• Lab results may be altered by recent douching
DIFFERENTIAL DIAGNOSIS
• Gonorrhea
• Chlamydial infection
• Trichomoniasis
• Escherichia coli vaginitis
• Staphylococcal vaginitis
• Fungal vaginitis
• Atrophic vaginitis
TREATMENT
STABILIZATION
Outpatient treatment
GENERAL MEASURES
Consider repletion of lactobacilli.
Diet
No restrictions
Activity
No restrictions
MEDICATION (DRUGS)
First Line
• Metronidazole (Flagyl): 500 mg PO 2 b.i.d. for 7 days, or
• Metronidazole vaginal gel: 0.75% 5 g intravaginally daily for 7 days, or
• Clindamycin: 2% vaginal cream 5 g intravaginally daily for 7 days
• Contraindications: Refer to the manufacturer's literature.
• Precautions: Refer to the manufacturer's literature.
• Significant possible interactions: Metronidazole and alcohol
ALERT
Pregnancy Considerations
All symptomatic women and those who have had preterm delivery should be treated. Avoid creams; Metronidazole 250 mg PO t.i.d. for 7 days or clindamycin 300 mg PO 2 b.i.d. for 7 days
Second Line
• Metronidazole: 2 g PO single dose
• Clindamycin: 300 mg PO daily for 7 days
• Clindamycin ovules: 100 g intravaginally at bedtime for 3 days (clindamycin creams are less effective than metronidazole)
FOLLOW-UP
PROGNOSIS
Relapses are fairly common; may be decreased by increased colonization of lactobacilli
COMPLICATIONS
• Uncommon but include:
- Adnexal tenderness
- Pelvic inflammatory disease (PID)
- Intrauterine infections
- Chorioamnionitis
- Postabortion PID
- Postpartum endometritis
- Pelvic abscesses
- Vaginitis emphysematosa
- Rare extravaginal disease
- Preterm labor
- Premature rupture of membranes
- Chorioamnionitis
- Newborn infections, including scalp electrode sites, abscesses, and one reported case of meningitis
- Fetal loss
• Posthysterectomy infection, septicemia, gaseous crepitation in wound
PATIENT MONITORING
None indicated
REFERENCES
1. Briselden AM, Hillier SL. Evaluation of affirm VP microbial identification test for Gardnerella vaginalis and Trichomonas vaginalis. J Clin Microbiol. 1994;32:148-152.
2. Caitlin BW. Gardnerella vaginalis: Characteristics, clinical considerations and controversies. Clin Microbiol Rev. 1992;5:213-217.
3. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2002. MMWR Recomm Rep. 2002;51(RR-06):1-80.
4. Curry SL, Barclay DL. Benign disorders of the vulva-vagina. In: DeCherney AH, Perroll ML, eds. Current Obstetric and Gynecologic Diagnosis and Treatment. 8th ed. Norwalk, CT: Appleton  Lang; 1994.
5. Herbst A, Mishell D Jr, Stenchever A, Droegemueller W. Comprehensive Gynecology. 2nd ed. St. Louis, MO: Mosby-Year Book; 1992.
6. Kharsany AB, Hosen AA, Vanden Ende J. Antimicrobial susceptibility of Gardnerella vaginalis. Antimicrob Agents Chemother. 1993;37:2733-2735.
7. Majeroni BA. Bacterial vaginosis: An update. Am Fam Physician. 1998;57:1285-1289.
8. Ray A, Gulati AK, Pandey LK, Pandey S. Non-specific vaginitis vis-a-vis Gardnerella vaginalis. J Commun Dis. 1990;22:274-276.
9. Reed B, Eyler A. Vaginal infections: Diagnosis and management. Am Fam Physician. 1993;47:1805-1818.