I. See also

II. Epidemiology

  1. Accounts for 35-50% of Vaginitis

III. Etiology

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

IV. 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

V. Signs: Amsel's 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

VI. Labs: New 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%)

VII. Management

  1. Non-Pregnant
    1. First-Line: Oral Metronidazole (Flagyl)
      1. Flagyl 500 mg PO bid for 7 days ($5)
    2. Other oral options
      1. Clindamycin 300 mg twice daily for 7 days
    3. Topical options (higher recurrence rate, does not cover Trichomoniasis)
      1. MetroGel (0.75%) 5g intravaginally at bedtime for 5 days ($29)
      2. Clindamycin Cream (2%) 5g intravaginally at bedtime for 7 days ($31)
  2. Pregnancy:
    1. 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
    2. 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 ($28)
  3. Resistant or Refractory Cases
    1. Metronidazole 500 mg PO bid 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
    1. Treat as refractory cases above
    2. Consider maintenance therapy
      1. Induction: Metronidazole gel 0.75% (Metrogel) nightly for 10 days
      2. Maintenance: When wet prep with no clues, pH lower
        1. Metronidazole gel twice weekly for 3-6 months
        2. Treat concurrent Candida if present
          1. Fluconazole 150 mg qWeek
    3. References
      1. Sobel (2006) Am J Obstet Gynecol 194(5): 1283-9 [PubMed] (or open in [QxMD Read])

VIII. Complications

  1. Associated with higher risk of HIV Transmission
    1. Martin (1999) J Infect Dis 180(6):1863-8 [PubMed] (or open in [QxMD Read])
  2. Associated with preterm delivery (23-26 weeks)
    1. Hillier (1995) N Engl J Med 333: 1737-42 [PubMed] (or open in [QxMD Read])
    2. Hauth (1995) N Engl J Med 333: 1732-6 [PubMed] (or open in [QxMD Read])
  3. Early second trimester with better pregnancy outcomes
    1. Reduces preterm birth and late Miscarriage rate
    2. Study used Clindamycin
    3. Ugwumadu (2003) Lancet 361:983-8 [PubMed] (or open in [QxMD Read])

Images: Related links to external sites (from Google)

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, 198221007, 155981006, 266655004, 85569008, 419760006
English Bacterial Vaginitis, Bacterial Vaginoses, Bacterial Vaginosis, Nonspecific Vaginitis, Vaginitis, Bacterial, Vaginitis, Nonspecific, Vaginoses, Bacterial, Vaginosis, Bacterial, Bacterial Vaginitides, Vaginitides, Bacterial, BACTERIAL VAGINOSIS, NONSPECIFIC VAGINITIS, 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, Vaginosis bacterial NOS, VAGINOSIS BACTERIAL, VAGINITIS NON SPECIFIC, VAGINOSIS NON SPECIFIC, Vaginosis, Bacterial [Disease/Finding], gardnerella vaginitis, bacterial vaginoses, gardnerella infection, gardnerella vaginosis, non-specific vaginitis, gardnerella vaginalis vaginitis, bacteria infection of the vigina, gardnerella, non specific vaginitis, bactria infection of the vagina, 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, Vaginosis bacteriana, Vaginitis bacteriana NEOM, Vaginitis inespecífica, Vaginosis bacteriana NEOM, NSV - Nonspecific vaginitis, Gardnerella vaginalis infection, Bacterial vaginosis, AV - Anaerobic vaginosis, BV - Bacterial vaginosis, Gardnerella infection, Bacterial vaginitis, Nonspecific vaginitis, Vaginitis bacteriana, Vaginitis Bacteriana, Vaginitis no Específica, Vaginosis Bacteriana, Vaginitis no Especifica
Dutch vaginose bacterieel, bacteriële vaginose, niet-specifieke vaginitis, vaginitis bacterieel NAO, vaginose bacterieel NAO, vaginitis bacterieel, Vaginitis, niet-specifieke, Bacteriële vaginosis, Vaginitis, bacteriële, Vaginosis, bacteriële
French Vaginite bactérienne SAI, Vaginose bactérienne SAI, Vaginite non précisée, Vaginite bactérienne, Vaginite non spécifique, Vaginose bactérienne
German Kolpitis bakteriell NNB, nicht-spezifische Vaginitis, bakterielle Kolpitis, Bakterielle Vaginosen, Bakterielle Vaginosis, Bakterielle Vaginitiden, Bakterielle Vaginitis, Unspezifische Vaginitis, Kolpitis bakteriell, Bakterielle Vaginose, Vaginitis, bakterielle, Vaginitis, unspezifische, Vaginose, bakterielle
Italian Vaginite batterica NAS, Vaginosi batterica NAS, Vaginite non specifica, Vaginiti aspecifiche, Vaginosi batterica, Vaginosi batteriche, Vaginite batterica
Portuguese Vaginite bacteriana NE, Vaginose bacteriana NE, Vaginose bacteriana, Vaginite inespecífica, Vaginite bacteriana, Vaginite Bacteriana, Vaginite não Específica, Vaginose Bacteriana
Japanese 細菌性腟症NOS, 細菌性腟炎NOS, サイキンセイチツエン, サイキンセイチツショウ, サイキンセイチツショウNOS, 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, 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, vaginóza bakteriální, Blíže neurčená vaginitida, Vaginóza bakteriální NOS, Bakteriální vaginóza, Aminová kolpitis, Bakteriální vaginitida, Bakteriální vaginitida NOS
Finnish Bakteerivaginoosi
Russian VAGINIT NESPETSIFICHESKII, VAGINIT BAKTERIAL'NYI, BAKTERIAL'NYI VAGINIT, VAGINOZ BAKTERIAL'NYI, БАКТЕРИАЛЬНЫЙ ВАГИНИТ, ВАГИНИТ БАКТЕРИАЛЬНЫЙ, ВАГИНИТ НЕСПЕЦИФИЧЕСКИЙ, ВАГИНОЗ БАКТЕРИАЛЬНЫЙ
Croatian VAGINOZA, BAKTERIJSKA
Polish Waginoza pochwy, Waginoza bakteryjna, Bakteryjne zakażenie pochwy
Hungarian Nem specifikus vaginitis, Bacterialis vaginosis, Bacterialis vaginosis k.m.n., bacterialis vaginitis k.m.n., bacterialis vaginitis

Ontology: Gardnerella vaginitis (C1622505)

Concepts Disease or Syndrome (T047)
SnomedCT 237092002, 85569008, 419468003
English Gardnerella, GARDNERELLA ASSOCIATED VAGINAL DISCHARGE, Gardnerella vaginalis infectn, gardnerella vaginitis, Gardnerella infection NOS, Gardnerella infections, Gardnerella vaginalis vaginitis, Vaginitis gardnerella, Gardnerellal vaginitis, GARDNERELLA INFECTION, VAGINITIS GARDNERELLA, VAGINOSIS 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 (trastorno), vaginitis por Gardnerella, Vaginitis por Gardnerella vaginalis, Infección por gardnerella NEOM, vaginitis por Gardnerella vaginalis, 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