Bacterial vaginosis overview

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Bacterial vaginosis (BV) is a syndrome that results from an imbalance in the different types of bacteria in the vagina (also known as vaginal "flora"). Lactobacilli play an important role in maintaining the female genital tract health by keeping the vagina's pH at normal levels. When the pH levels of the vagina become unbalanced, certain microorganisms may overtake the normal flora, which can cause a low-grade infection that often produces an abnormal vaginal discharge.[1][2] Bacterial vaginosis must be differentiated from other diseases that cause purulent, malodorous, thin vaginal discharge with elevated vaginal pH (<4.5), such as trichomoniasis, atrophic vaginitis, and desquamative inflammatory vaginitis. Additionally, bacterial vaginosis must also be differentiated from such other conditions as vaginal candidiasis, vaginitis, and cervicitis.[3]

Bacterial vaginosis is the most common cause of vaginal symptoms among women; it is not clear what role sexual activity plays in the development of BV. The prevalence of BV in the United States is estimated to be 21.2 million (29.2%) among women ages 14–49.[4] Untreated BV can lead to premature delivery, postpartum infections, clinically apparent and subclinical pelvic inflammatory disease (PID), post-surgical complications (after abortion, hysterectomy, cesarean section, and other reproductive procedures), increased vulnerability to HIV infection and, sometimes, infertility.

Antimicrobial therapy is recommended for all symptomatic women and high-risk, asymptomatic pregnant women with bacterial vaginosis. Metronidazole is the drug of choice for pregnant patients.[5] Basic effective measures for the primary prevention of bacterial vaginosis include limiting the number of sexual partners, avoiding douching, and using condoms and estrogen-containing contraceptives while sexually active.[6][7]

Historical perspective

In 1892, Albert Döderlein first described the hypothesis that bacterial flora may be a cause of vaginal infectious conditions. In 1955, Gardner and Dukes first named Haemophilus vaginalis (Gardnerella vaginalis) as a new genus and the cause of foul-smelling, watery vaginal discharge.[8][9]

Pathophysiology

Bacterial vaginosis is a syndrome that results from an imbalance in the different types of bacteria in the vagina (also called vaginal "flora"). The healthy vaginal microflora is comprised mainly of Gram-positive bacilli of the genus lactobacillus. Lactobacilli play an important role in maintaining the health of the female genital tract by keeping the vagina's pH at normal levels. When the pH levels of the vagina become unbalanced, certain microorganisms may overtake the normal flora, causing a low-grade infection that often produces an abnormal vaginal discharge.[1][2]

Causes

Common causes of bacterial vaginosis include gardnerella vaginalis, mycoplasma hominis, ureaplasma, and anaerobes.[8][10]

Differential Diagnosis

Bacterial vaginosis must be differentiated from other diseases that cause purulent, malodorous, thin vaginal discharge with elevated vaginal pH (<4.5), such as trichomoniasis, atrophic vaginitis, and desquamative inflammatory vaginitis. Additionally, bacterial vaginosis also must be differentiated from such other conditions as vaginal candidiasis, vaginitis, and cervicitis.[3][11][12][13][14]

Epidemiology

Bacterial vaginosis is the most common cause of vaginal symptoms among women; it is not clear what role sexual activity plays in the development of BV. The prevalence of BV in the United States is estimated to be 21.2 million (29.2%) among women ages 14–49.[4]

Risk Factors

Common risk factors in the development of bacterial vaginosis include sexual activity, having a new sexual partner or multiple sexual partners, being a woman who has sex with women, the presence of other sexually transmitted infections, douching, and cigarette smoking.[15][16]

Screening

General screening for bacterial vaginosis is not recommended. According to the United States Preventive Services Task Force, sufficient evidence does not exist for the recommendation of routine screening for bacterial vaginosis (BV) in asymptomatic pregnant women at high or low risk for preterm delivery for the prevention of preterm birth.[17]

Natural history, complications, and prognosis

Most women who present with bacterial vaginosis (BV) report no symptoms. Symptomatic patients may present with vaginal odor and white/gray vaginal discharge.[4] If left untreated, bacterial vaginosis may progress to more serious conditions such as salpingitis, endometritis, bacteremia, and pelvic inflammatory disease (PID). In most cases, BV causes no complications. However, some complication of bacterial vaginosis may include endometritis, cervicitis, pelvic inflammatory disease (PID), bacteremia, and an increased susceptibility to other STDs.[18][19][20] Approximately one-third of pregnant women have bacterial vaginosis. If left untreated in pregnant women, bacterial vaginosis may result in serious pregnancy-related complications including premature rupture of membranes, premature labor, chorioamnionitis, postpartum endometritis, and septic abortion.[21][22]

Diagnosis

Amsel criteria

BV is a common vaginal condition characterized by at least three of the following four Amsel criteria, which include thin, gray/white vaginal discharge; malodorous, “fishy” discharge upon adding 10% potassium hydroxide; high vaginal pH (>4.5); and the identification of clue cells.[5][23]

History and Symptoms

It is necessary to obtain a detailed and thorough sexual history from the patient in order to diagnose BV. Specific areas of focus when obtaining a history from the patient include number and type of sexual partners (new, casual, or regular) and any previous history of STDs. 50-75% of women with bacterial vaginosis (BV) are asymptomatic. Common symptoms of bacterial vaginosis include thin white/gray vaginal discharge and unpleasant vaginal odor, especially after sex.[23][24]

Physical Examination

A genital examination of patients with bacterial vaginosis is usually remarkable for fishy odor from the vagina; thin, white/gray vaginal discharge; and the lack of significant vulvovaginal inflammation.[5]

Laboratory Findings

Bacterial vaginosis can be diagnosed through the use of clinical criteria (amsel’s diagnostic criteria) or gram stain. A gram stain is considered the gold standard laboratory method for diagnosing bacteria vaginosis.[5]

Imaging findings

No imaging findings are associated with bacterial vaginosis.

Other diagnostic studies

Other diagnostic studies associated with diagnosis of bacterial vaginosis (BV) include the Affirm VP III test, chromogenic diagnostic test (OSOM BVBlue system), and quantitative polymerase chain reaction (PCR).[5][25][26][27]

Treatment

Medical Therapy

Antimicrobial therapy is recommended for all symptomatic women and high-risk asymptomatic pregnant women with bacterial vaginosis. Metronidazole is the drug of choice in pregnant patients with BV.[5]

Primary Prevention

Basic, effective measures for the primary prevention of bacterial vaginosis include limiting one's number of sexual partners, avoiding douching, and using condoms and estrogen-containing contraceptives while sexually active.[6][7][28]

Secondary prevention

Effective measure for the secondary prevention of infective conjunctivitis include maintaining a vaginal pH of 4.5, bacteriotherapy, avoiding douching, and changing one's method of contraception.[29][28][30][31]

References

  1. 1.0 1.1 Machado D, Castro J, Palmeira-de-Oliveira A, Martinez-de-Oliveira J, Cerca N (2015). "Bacterial Vaginosis Biofilms: Challenges to Current Therapies and Emerging Solutions". Front Microbiol. 6: 1528. doi:10.3389/fmicb.2015.01528. PMC 4718981. PMID 26834706.
  2. 2.0 2.1 Borges S, Silva J, Teixeira P (2014). "The role of lactobacilli and probiotics in maintaining vaginal health". Arch Gynecol Obstet. 289 (3): 479–89. doi:10.1007/s00404-013-3064-9. PMID 24170161.
  3. 3.0 3.1 Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Bacterial Vaginosis. http://www.cdc.gov/std/tg2015/bv.htm Accessed on October 13, 2016
  4. 4.0 4.1 4.2 Centers for Disease Control and Prevention. Bacterial Vaginosis (BV) Statisticshttp://www.cdc.gov/std/bv/stats.htm Accessed on October 18, 2016
  5. 5.0 5.1 5.2 5.3 5.4 5.5 Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016
  6. 6.0 6.1 Ness RB, Hillier SL, Richter HE, Soper DE, Stamm C, McGregor J; et al. (2002). "Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina". Obstet Gynecol. 100 (4): 765. PMID 12383547.
  7. 7.0 7.1 Bradshaw CS, Walker SM, Vodstrcil LA, Bilardi JE, Law M, Hocking JS; et al. (2014). "The influence of behaviors and relationships on the vaginal microbiota of women and their female partners: the WOW Health Study". J Infect Dis. 209 (10): 1562–72. doi:10.1093/infdis/jit664. PMID 24285846.
  8. 8.0 8.1 Donders GG (2007). "Definition and classification of abnormal vaginal flora". Best Pract Res Clin Obstet Gynaecol. 21 (3): 355–73. doi:10.1016/j.bpobgyn.2007.01.002. PMID 17434799.
  9. GARDNER HL, DUKES CD (1955). "Haemophilus vaginalis vaginitis: a newly defined specific infection previously classified non-specific vaginitis". Am J Obstet Gynecol. 69 (5): 962–76. PMID 14361525.
  10. Livengood CH (2009). "Bacterial vaginosis: an overview for 2009". Rev Obstet Gynecol. 2 (1): 28–37. PMC 2672999. PMID 19399292.
  11. Bachmann GA, Nevadunsky NS (2000). "Diagnosis and treatment of atrophic vaginitis". Am Fam Physician. 61 (10): 3090–6. PMID 10839558.
  12. Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J, Kiviat NB; et al. (1988). "Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens". JAMA. 259 (8): 1223–7. PMID 2448502.
  13. Sobel JD, Reichman O, Misra D, Yoo W (2011). "Prognosis and treatment of desquamative inflammatory vaginitis". Obstet Gynecol. 117 (4): 850–5. doi:10.1097/AOG.0b013e3182117c9e. PMID 21422855.
  14. Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK (1998). "Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm". Obstet Gynecol. 92 (5): 757–65. PMID 9794664.
  15. Fethers KA, Fairley CK, Hocking JS, Gurrin LC, Bradshaw CS (2008). "Sexual risk factors and bacterial vaginosis: a systematic review and meta-analysis". Clin Infect Dis. 47 (11): 1426–35. doi:10.1086/592974. PMID 18947329.
  16. Yen S, Shafer MA, Moncada J, Campbell CJ, Flinn SD, Boyer CB (2003). "Bacterial vaginosis in sexually experienced and non-sexually experienced young women entering the military". Obstet Gynecol. 102 (5 Pt 1): 927–33. PMID 14672465.
  17. United States Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/bacterial-vaginosis-in-pregnancy-to-prevent-preterm-delivery-screening?ds=1&s=bacterial%20vaginosis Accessed on October 13, 2016
  18. Laxmi U, Agrawal S, Raghunandan C, et al. Association of bacterial vaginosis with adverse fetomaternal outcome in women with spontaneous preterm labor: a prospective cohort study. J Matern Fetal Neonatal Med 2012;25:64–7.
  19. Koumans EH, Kendrick JS, CDC Bacterial Vaginosis Working Group (2001). "Preventing adverse sequelae of bacterial vaginosis: a public health program and research agenda". Sex Transm Dis. 28 (5): 292–7. PMID 11354269.
  20. Persson E, Bergström M, Larsson PG, Moberg P, Platz-Christensen JJ, Schedvins K; et al. (1996). "Infections after hysterectomy. A prospective nation-wide Swedish study. The Study Group on Infectious Diseases in Obstetrics and Gynecology within the Swedish Society of Obstetrics and Gynecology". Acta Obstet Gynecol Scand. 75 (8): 757–61. PMID 8906013.
  21. Chaim, W., M. Mazor, and J. R. Leiberman. "The relationship between bacterial vaginosis and preterm birth. A review." Archives of gynecology and obstetrics 259.2 (1997): 51-58.
  22. Faro S, Martens M, Maccato M, Hammill H, Pearlman M (1993). "Vaginal flora and pelvic inflammatory disease". Am J Obstet Gynecol. 169 (2 Pt 2): 470–4. PMID 8357048.
  23. 23.0 23.1 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 (1):14-22. PMID: 6600371
  24. Klebanoff MA, Schwebke JR, Zhang J, Nansel TR, Yu KF, Andrews WW (2004). "Vulvovaginal symptoms in women with bacterial vaginosis". Obstet Gynecol. 104 (2): 267–72. doi:10.1097/01.AOG.0000134783.98382.b0. PMID 15291998.
  25. Mulhem E, Boyanton BL, Robinson-Dunn B, Ebert C, Dzebo R (2014). "Performance of the Affirm VP-III using residual vaginal discharge collected from the speculum to characterize vaginitis in symptomatic women". J Low Genit Tract Dis. 18 (4): 344–6. doi:10.1097/LGT.0000000000000025. PMID 24832170.
  26. Rumyantseva T, Shipitsyna E, Guschin A, Unemo M (2016). "Evaluation and subsequent optimizations of the quantitative AmpliSens Florocenosis/Bacterial vaginosis-FRT multiplex real-time PCR assay for diagnosis of bacterial vaginosis". APMIS. doi:10.1111/apm.12608. PMID 27714844.
  27. Myziuk L, Romanowski B, Johnson SC (2003). "BVBlue test for diagnosis of bacterial vaginosis". J Clin Microbiol. 41 (5): 1925–8. PMC 154737. PMID 12734228.
  28. 28.0 28.1 Bradshaw CS, Vodstrcil LA, Hocking JS, Law M, Pirotta M, Garland SM; et al. (2013). "Recurrence of bacterial vaginosis is significantly associated with posttreatment sexual activities and hormonal contraceptive use". Clin Infect Dis. 56 (6): 777–86. doi:10.1093/cid/cis1030. PMID 23243173.
  29. Wilson J (2004). "Managing recurrent bacterial vaginosis". Sex Transm Infect. 80 (1): 8–11. PMC 1758381. PMID 14755028.
  30. Reid G, Beuerman D, Heinemann C, Bruce AW (2001). "Probiotic Lactobacillus dose required to restore and maintain a normal vaginal flora". FEMS Immunol Med Microbiol. 32 (1): 37–41. PMID 11750220.
  31. Andersch B, Lindell D, Dahlén I, Brandberg A (1990). "Bacterial vaginosis and the effect of intermittent prophylactic treatment with an acid lactate gel". Gynecol Obstet Invest. 30 (2): 114–9. PMID 2245947.

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