Treating a case of bacterial vaginosis - case

study

THE CASE
Emma, aged 22 years, presented at the practice complaining of an abnormal
vaginal discharge. On questioning, she described it as offensive and fishy
smelling. She reported no vulval itching, soreness, or pain during intercourse.
There is no history of post-coital bleeding, intermenstrual bleeding or dysuria.
She had no pelvic or abdominal pain. Her last menstrual period was three weeks
ago and was normal. She has had one sexual partner for the past 10 months. She
has no concurrent medical conditions and her only medication is the combined
oral contraceptive pill.

Assessment and history

Taking an accurate history is important to assess whether this is a physiological discharge, not
requiring treatment, or pathological. Physiological patterns of discharge vary from woman to
woman. Pathological discharge can be the result of STIs, infections that are not sexually acquired
or non-infective causes (see box 1).

BOX 1: POSSIBLE CAUSES OF VAGINAL

DISCHARGE
Non-sexually transmitted Non-infective causes
infections
Retained tampon or
Bacterial vaginosis condom
Candidiasis Allergic reactions
Ectropian
STIs Cervical polyp
Fistulae
Trichomonas vaginalis Atrophic changes
Chlamydia Genital tract
trachomatis malignancy
Neisseria gonorrhoeae

Questions should include duration, amount, colour, consistency, blood staining, malodour,
cyclical pattern, previous episodes and associated symptoms of dysuria, itching, soreness,
intermenstrual or post-coital bleeding, superficial or deep dyspareunia, or lower abdominal and
pelvic pain.1-3

These characteristics can then be assessed to help determine a diagnosis and act as a prompt for
investigations.

Despite vaginal discharge being a poor predictor of STIs, an assessment of STI risk and a clinical
history can help the clinician to decide whether STI exclusion is an important element of
managing the patient's condition.

Women considered to be at increased risk of STI include those under the age of 25, those who
have changed partner within the past year and those who have had more than one sexual partner
in the past year.3

Examination
In view of Emma's age and history, she should be examined and tested for STIs. Genital
examination will assess condition of skin, inflammation, cuts, fissuring, ulcers and blisters.
Observe for any areas of abnormality.
Speculum examination is performed to look for consistency of discharge, amount, colour, odour,
vaginitis, cervicitis, cervical discharge and contact bleeding, and to allow for collection of
specimens for further investigation.

Emma was examined and these signs noted: thin, white/grey homogenous discharge coating the
vaginal walls, offensive (fishy) odour present, no vulvitis or vaginitis, no cervical discharge,
contact bleeding or cervicitis, and raised vaginal pH of 6.

Investigations
Raised vaginal pH (>4.5) may be indicative of bacterial vaginosis or trichomoniasis. It is
important to ensure vaginal discharge is sampled from the lateral vaginal walls because
menstrual blood and cervical mucus can raise the pH.

Endocervical swabs are taken for chlamydia and gonorrhoea. The value of the high vaginal swab
(HVS) is unclear. It is reasonable in primary care settings to take a syndromic approach to the
management of vaginal discharge based on history, signs and symptoms and initiate a trial of
treatment.1,2,4 HVS can be used to look for trichomonas vaginalis, but the sensitivity is low.

Diagnosis and differential diagnosis

Bacterial vaginosis is the most likely diagnosis. This is the most common cause of abnormal
vaginal discharge in women of childbearing age and is characterised by an overgrowth of
predominantly anaerobic organisms, leading to a replacement of lactobacilli and an increase in
vaginal pH.5

There are four differential diagnoses. First, trichomoniasis, which can cause a thin, frothy,
green/yellow, malodorous vaginal discharge with raised pH (>4.5). This is less likely than
bacterial vaginosis because Emma has no dyspareunia or soreness, no cervicitis and no erythema
of the external genitalia or vagina. Second, candidiasis, which is unlikely because vaginal
discharge with candida has a pH ≤4.5 and the discharge is thick, white and 'cottage cheese' like,
with no odour. Associated symptoms include vulval itch, oedema and fissures.

Third and fourth, chlamydia and gonorrhoea. Mucopurulent discharge from the cervical os may
be present with these infections. Any associated deep dyspareunia, pelvic or lower abdominal
pain should be investigated for pelvic inflammatory disease. Despite Emma having no associated
symptoms, cultures should be taken for these STIs in view of her sexual history and age.
Concurrent infection with chlamydia or gonorrhoea is possible with a diagnosis of bacterial
vaginosis.

Treatment and advice

Therapy options include metronidazole 2g as a single dose, or metronidazole 400mg twice a day
for seven days. Topical treatments (intravaginal metronidazole gel or intravaginal clindamycin
cream) can be used if the patient cannot tolerate oral metronidazole, but can be more expensive
options.

Patients should be advised to avoid vaginal douching, washing the genitals with shower gels or
soaps and adding antiseptics to the bath, because these can affect the normal vaginal flora and
allow bacterial vaginosis to develop