Makindo Medical Notes

📖 Introduction

Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge in reproductive-age women. It results from an imbalance in the vaginal microbiota: reduced Lactobacilli (which normally produce protective lactic acid and hydrogen peroxide) and overgrowth of anaerobes such as Gardnerella vaginalis and Mobiluncus. BV is not a classical STI, but sexual activity and new/multiple partners increase risk.

🩺 Clinical Findings

• Symptoms:
  • Thin, grey-white vaginal discharge.
  • Foul, “fishy” odour (often worse after intercourse).
  • Mild irritation/itching (though many women are asymptomatic).
• Examination:
  • Homogeneous discharge coating vaginal walls.
  • pH > 4.5 (alkaline).
  • Positive “whiff test” → fishy odour after adding KOH.
  • Microscopy: clue cells (epithelial cells studded with bacteria).

🔬 Investigations

• Vaginal pH testing (>4.5 supports BV).
• Microscopy for clue cells (diagnostic).
• Gram stain (gold standard in research/uncertain cases).
• Culture not needed (BV is polymicrobial, not a single organism).

💊 Management

Aim = eradicate anaerobic overgrowth & restore Lactobacilli.

1. First-line:
   • Metronidazole 400 mg PO twice daily for 5–7 days ✅
   • Alternative: Metronidazole gel 0.75% intravaginally OD × 5 days
   • Alternative: Clindamycin cream 2% intravaginally × 7 days
   • Clindamycin 300 mg PO × 7 days if metronidazole unsuitable
2. Patient Advice:
   • BV is not strictly an STI but is associated with sexual activity.
   • Avoid douching & perfumed products → disrupt normal flora.
   • Recurrence is common (up to 50% within 6 months).
3. Pregnancy:
   • BV ↑ risk of preterm labour, PPROM, low birth weight.
   • Treat if symptomatic or detected on screening.
   • Metronidazole is safe; use vaginal preparations in 1st trimester.
4. Follow-up:
   • No routine follow-up if asymptomatic post-treatment.
   • If recurrent → consider suppressive regimen (e.g. metronidazole gel 2× weekly × 6 months).

📌 Referral

• Persistent symptoms despite adequate treatment.
• Recurrent BV (multiple episodes, difficult control).
• Unclear diagnosis or atypical features (exclude STIs, malignancy, atrophic vaginitis).

📝 Key Exam Pearls

• BV discharge = thin, grey, fishy; unlike candidiasis (thick, curdy) or trichomonas (frothy, yellow-green).
• Not usually associated with pain or pruritus.
• Remember: pH > 4.5 + clue cells = BV.
• High recurrence rate → discuss prevention and patient reassurance.