Clinical Focus

Bacterial vaginosis:
diagnosis and treatment

Abstract
Bacterial vaginosis is the most common cause of abnormal
discharge in sexually active women between the ages of 1545
years. It is experienced by 10% of women over a lifetime and is
a common cause of acute vaginitis. This article discusses the
diagnosis, and the different treatment options. Prevention strategies
are also suggested.

acterial vaginosis is the most common cause of

abnormal discharge in sexually active women
between the ages of 1545 years (British Association
for Sexual Health and HIV (BASHH), 2012). It is
experienced by 10% of women over a lifetime and
is a common cause of acute vaginitis (Pattman et al,
2010). It has a significant effect on quality of life and
can negatively impact on personal, professional and
intimate relationships. Women report feelings of shame
or embarrassment, and implement excessive hygiene
regimes that can exacerbate the condition (Payne et
al, 2010). Bacterial vaginosis rarely occurs in children,
but it has been reported in sexually inactive adolescent
females (Verstraelen et al, 2010).
Epidemiological studies indicate that the risk
of bacterial vaginosis (BV) is increased in women
of African ethnicity (Klatt et al, 2010). A study by
Verstraelen et al (2005) suggested that iron deficiency
(anaemia) is a strong predictor of BV in pregnant
women. Neggars et al (2007) reported that increased
dietary fat intake is associated with an increased risk
of BV, and severe BV in non-pregnant women. An
increase in certain nutrients, including folic acid and
calcium may decrease the risk of severe BV.
Other risk factors include low socioeconomic status,
smoking (possibly due to anti-oestrogenic effect), the
menopause, young age of coitarche, acquisition of a
new sex partner, and a recent history of multiple sex
partners (Verstraelen et al, 2010).
Karen Powell is clinical lead nurse, continence service,
Birmingham Community Healthcare NHS Trust
Email: Karen.Powell@Sbhamcommunity.nhs.uk

172

Karen Powell

Anecdotal evidence suggests links with BV and

women who wear thongs, suggesting that bacteria could
be introduced into the vagina due to the movement
of the garment; however, there is no robust clinical
reference to back this up.
Men do not experience BV as such, and it is not
considered to be a sexually transmitted infection (STI).
However, several studies have revealed associations
with STIs (BASHH, 2012). Gardnerella vaginalis has
been found in men with underlying phimosis and
poor hygiene. It usually responds well to an improved
hygiene regime, but in some men it will require
systemic antibiotics or cream preparations (Pattman et
al, 2010).
BV is often misdiagnosed or mismanaged by women
who believe they have a yeast infection, although BV can
co-exist with other causes of abnormal vaginal discharge
such as candidiasis, trichomoniasis and cervicitis.

Aetiology

BV is caused by a bacteriological imbalance of vaginal

flora, with overgrowth of commensal bacteria replacing
normally predominant and protective lactobacilli.
The overgrowth by harmful organisms may include
the anaerobic bacteria, Gardnerella vaginalis or
mycoplasmas, and can result in the production of an
altered vaginal discharge (Pattman et al, 2010).
The symbiotic relationship between vaginal
lactobacilli and their human host is regulated by
hormones produced by the endocrine system, which
stimulate the vaginal epithelia to produce glycogen.
Lactobacilli in the vagina metabolize glycogen secreted
by the vaginal epithelia, in turn producing lactic acid,
which is largely responsible for the normal vaginal pH
being acidic (range 3.84.2) The acidic environment of
a healthy vagina is not permissive for growth of many
potential pathogens (Donati et al, 2010).
However, vaginal pH can be altered after the
introduction of highly perfumed hygiene products,
vaginal douching, or medications such as antibiotics
taken for other conditions.

Diagnosis

There are two recognized approaches for testing and

diagnosing BV. In the first approach, clinical setting,
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Clinical Focus

Amsels criteria is utilized (Amsel et al, 1983). Diagnosis

is based on the presence of three out of four clinical
criteria that are listed below:
Vaginal pH of more than 4.5
Off-white adherent discharge
The discharge consists of exfoliated epithelial cells
with bacteria (gram-variable polymorphic rods)
attached to their surface (clue cells)
A characteristic fishy odour especially when 10%
potassium hydroxide is added.
In the second approach, a gram-stained vaginal
smear is evaluated with the Hay-Ison criteria or Nugent
criteria. The Hay-Ison criteria (2002) is a simple,
qualitative method of grading smears:
Grade 0: epithelial cells/no bacteria
Grade 1 (normal): lactobacillus morphotypes
predominate
Grade 2 (intermediate): mixed flora with some
lactobacilli present, but Gardnerella or Mobiluncus
morphotypes present
Grade 3 (bacterial vaginosis): predominantly
Gardnerella and/or Mobiluncus morphotypes.
Lactobacilli are minimal or absent
Grade 4: epithelial cells covered with gram-positive
cocci only.
The Nugent (1991) method is complex and time
consuming for routine clinical use. It is based on
quantitative scoring of Bacteroides morphotypes,
Lactobacillus and Gardnerella vaginalis on a gramstained smear. It scores as follows:
High: more than 6 confirms bacterial vaginosis
Intermediate: 46
Normal: 03.

Differential diagnosis

Differential diagnosis for BV includes normal discharge,

candidiasis, and trichomoniasis. Unlike BV, these
infections do not occur as a result of bacterial growth.
Candidiasis, a fungal infection caused commonly
by Candida albicans, leads to the production of a thick,
creamy vaginal discharge, with symptoms of irritation
and soreness.
Trichomoniasis is caused by the parasite
Trichomonas vaginalis. As with BV, women who acquire
trichomoniasis can be asymptomatic while 30% of
women may develop a frothy, yellow vaginal discharge,
experience dysuria, soreness or pain during sexual
intercourse (French, 2005).

Clinical features

Up to 50% of women with BV can be asymptomatic.

The main symptom is a moderate, off-white vaginal
discharge that adheres to the walls of the vagina
(Figure1). The discharge has an offensive fishy smell
that is enhanced when vaginal pH is elevated to more
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Jean Watkins

Clinical Focus

than 4.5, which can occur during menstruation or

after sexual intercourse, owing to contact with alkaline
prostatic fluid (with has a pH range 7.357.5). Bacterial
vaginosis is not usually associated with symptoms of
burning, irritation, itching or soreness.

Complications

It is thought that BV may contribute to spontaneous

pelvic inflammatory disease (PID) following elective
termination or pregnancy (Blackwell et al,1993). PID
is an inflammation and infection of the upper female
genital tract, with infertility caused by damage to the
fallopian tubes.
There is some evidence that bacterial vaginosis
increases susceptibility to gonorrhoea, HIV in pregnant
women, and genital herpes (Trexler et al, 1997).
In pregnancy, increased bacterial production of
cytokines, prostaglandins and amniotic fluid infection
can lead to a number of complications including
late miscarriage, pre-term birth (where the baby is
delivered before the 37th week of pregnancy), pre-term
premature rupture of membranes, and postpartum
endometritisinflammation of the endometrial lining
of the uterus following delivery (Jacobsson et al, 2002).

Treatment

Treatment for bacterial vaginosis is usually effective in up

to 90% of cases. However, it is common for the symptoms
to return, and approximately 25% of women experience
a recurrent episode of infection within 1month. Male
sexual partners do not need to be treated.
Metronidazole is effective against certain gramnegative organisms, especially Bacteroides species.
Tinidazole is similar to metronidazole but has a
longer duration of action, and it is also more expensive.
Clindamycin is effective against gram-positive cocci
and many anaerobes including Bacteroides fragilis.
Pseudomembranous colitis has been reported with both
oral clindamycin and clindamycin cream (Trexler et al,
1997). Pseudomembranous colitis is an infection of the
colon frequently caused by the bacterium Clostridium
difficile. Common symptoms include diarrhoea, fever
and abdominal pain, but symptoms can be more severe
and result in fatality. Clindamycin treatment should be
discontinued if diarrhoea is experienced. Recommended
treatment regimes can be viewed in Table 1.
Lactic acid gel, although licensed for the treatment of
BV has not been evaluated adequately in well designed
randomized controlled trials and is therefore not
included in BASHH (2012) guidance.

Alternative treatments

Neggers et al (2007) suggested that women who

experience recurrent episodes of BV should take
vitamins to assist in preventing bacterial infection,
since vitamins may help in controlling infections and
allowing bacterial colonies become balanced again.
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Figure 1. Off-white discharge adhering to vaginal walls.

Vitamin C, as ascorbic acid, displays antibiotic

properties and is a strong stimulator of the immune
system. Petersen et al (2011) found that vitamin C
tablets inserted into the vaginas of women suffering
from bacterial vaginosis led to a 55% resolution of all
symptoms, compared to 25% for those given placebo.
Taking vitamin C orally can stimulate the immune
system and create more white blood cells to fight the
unwanted bacteria in the vagina.
Vitamin D deficiency may encourage bacterial
infections to proliferate more readily in the vagina
(Bodnar et al, 2009). The researchers found a link
between low levels of vitamin D and bacterial vaginosis,
and reported that the more deficient a woman was
in vitamin D, the more likely she was plagued with
bacterial infections of the vagina. They also found that
nearly twice as many African American women were
affected by both vitamin D deficiency and BV compared
with Caucasians (Bodnar et al, 2009).
Vitamin A has immune boosting properties that help
to synthesize and maintain healthy mucous membranes.
The vagina has a lining of mucous membrane on which
the bacteria reproduce (Dubois, 2011).
Eriksson et al (2005) found that prebiotics can be
effective when used in combination with systemic
antibiotic therapy such as metronidazole.
Anecdotal evidence suggests that cranberry juice
may help remedy symptoms. Cranberries are a source of
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Clinical Focus

antioxidants known as proanthocyanidins that can fight

infection and have a strong acidic component.

Prevention

Complete prevention of BV is not possible. However,

there are a number of measures that can be considered
when attempting to avoid recurrence of BV:
Comply with treatment regimens
Avoid from using scented soaps, perfumed products
when bathing or showering or vaginal deodorants
Avoid vaginal douching
Avoid putting antiseptic products or shampoo in the
water when bathing
Do not use strong detergents when washing
underwear.
Although BV is not considered to be an STI, women
who experience BV should be given advice regarding

safer sex including limiting the number of sexual

partners, using a barrier method of contraception
such as condoms, and avoid sharing devices used for
enhancing sexual pleasure.

Conclusion

Bacterial vaginosis is a common vaginal condition

experienced by women, many of whom express great
impact on quality of life and lifestyle. Therefore,
thorough clinical assessment and diagnosis is essential
to enable implementation of an effective treatment or
management regimen.
Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes
KK (1983) Nonspecific vaginitis. Diagnostic criteria and
microbial and epidemiologic associations. Am J Med 74: 1422
Blackwell AL, Thomas PD, Wareham K, Emery SJ (1993) Health

Table 1. Recommended treatment regimens

Medication

Dose/administration

Side effects

Cautions

Metronidazole
400500mg twice daily

for 57 days

Orally

Nausea
Diarrhoea
Taste changes
Loss of appetite
Headache

Avoid alcohol
Avoid high dose regimens in pregnancy
or breast-feeding women
In severe liver disease reduce total
daily dose to a third

Metronidazole

As above

As above

Metronidazole
Once daily for
gel (0.75%)
5 days

Intravaginally

Irritation
Candidiasis
Abnormal
discharge
Pelvic discomfort

Not recommended during menstruation

Some absorption may occur

Clindamycin
Once daily for 7 days
cream (2%)
Intravaginally

Irritation
Cervicitis
Vaginitis

Can weaken condoms/diaphragms/cap

Clindamycin

Mild diarrhoea
Nausea
Vomiting

Stop if diarrhoea or colitis develops

Monitor liver and renal functions
Avoid in women who are breast-feeding

Metallic or bitter
taste
Nausea/vomiting
Fatigue
Indigestion
Cramps
Loss of appetite
Headache/dizziness
Constipation

Avoid alcohol
Avoid in acute porphyria (group of
inherited or acquired disorders of
certain enzymes)
Avoid in women who are breast-feeding
or in first trimester pregnancy

2g single dose
Orally

Alternative regimens

300mg twice daily

for 7 days
Orally

Tinidazole
2g single dose

Orally

From: British Association for Sexual Health and HIV, 2012

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istock

Clinical Focus

Women showing bacterial vaginosis symptoms should be advised to use barrier contraceptive methods.
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Bodnar LM (2009) Maternal vitamin D deficiency is associated with
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British Association for Sexual Health and HIV (2012) Management
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Donati L, Di VA, Nucci M, Quagliozzi L, Spagnuolo T, Labianca A,
Bracaglia M, Ianniello F, et al (2010) Vaginal microbial flora and
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Eriksson K, Carlsson B, Forsum U, Larsson PG (2005) A doubleblind treatment study of bacterial vaginosis with normal vaginal
lactobacilli after an open treatment with vaginal clindamycin
ovules. Acta Derm Venereol 85: 426

Key Points
Bacterial vaginosis is the most common cause of abnormal
discharge in sexually active women
Although it is not considered a sexually transmitted disease,
a recent history of multiple sexual partners has been identified
as a risk factor
Bacterial vaginosis is often mistaken for thrush
A vaginal pH of more than 4.5 and a fishy smell are indicators
of possible vaginal infection
Bacterial vaginosis is characterized by an off-white discharge
that sticks to the vaginal walls.
Treatment is by antibiotics
Women should be advised to avoid using scented soaps or
perfumed products when bathing or showering, and to avoid
vaginal douching

178

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(2002) Bacterial vaginosis in early pregnancy may predispose for
preterm birth and postpartum endometritis. Acta Obstet Gynecol
Scand 81(11): 100610
Klatt TE, Cole DC, Eastwood DC, Barnabei VM (2010) Factors
associated with recurrent bacterial vaginosis. J Reprod Med 55:
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Neggers YH, Nansel TR, Andrews AA, Schwebke JR, Yu K,
Goldenberg RL, Klebanoff MA (2007) Dietary intake of selected
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Nugent RP, Krohn MA, Hillier SL (1991) Reliability of diagnosing
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Nurse Prescribing 2012 Vol 10 No 4

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