SOGC

CLINICAL PRACTICE GWDELNES

COMMITTEE OPINION
No. 14, March 1997
BACTERIAL VAGINOSIS
This Committee Opinion has been reviewed and approved by the Clinical Practice Gynaecdogy Committee and the Social and Sex&
Issues Committee of the Society of Obstetticiens and Gynaecologists of Canada and approved by its CounaJ in June 1996.

Clinical PracticeCynaecology

Committee:

Celine Bouchard, MD, FRCSC

Mark S. Heywood, MD, FRCSC
Robert H. Lea, MD, FRCSC
Dr. Guylaine Lefebvre, FRCSC
Dr. Nicole Racette, FRCSC

Ste-Foy, Que.
Winnipeg, Man.
Halifax. N.S.
Ottawa, Ont.
New Westminster, B.C.

Social and Sexual Issues Committee:

Beth Brunsdon-Clark
Victoria J. Davis, MD, FRCSC
Loma Grant, MD, FRCSC
Yves Lefebvre, MD, FRCSC
Barbara Parish, MD, FRCSC
Marc Steben, MD, FRCSC
Sydney Thomson, MD, FRCSC

Winnipeg, Man.
Toronto, Ont.
Winnipeg, Ont.
Outremont, Que.
Halifax, N.S.
Candiac, Que.
Richmond, B.C.

Clinical Practice-Obstetrics Committee:

Guy-Paul Gagnk, MD, FRCSC

LaSalle. Clue

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Summary

Bacterial Vaginosis (BV) is the most common vaginal infection in women of reproductive age.
Bacterial vaginosis is not only sexually transmitted but is seen more frequently in women who visit
Sexually Transmitted Diseases (STD) clinics.
Affected women complain predominantly of vaginal odour. Fifty percent of women fulfilling the
criteria for diagnosis are asymptomatic.
Bacterial Vaginosis represents a complex change in the vaginal ecosystem characterized by a
reduction in the prevalence and concentration of lactobacilli and an increase in the prevalence and
concentration of Gardnerella vagina/is, anaerobic Gram-negative rods, and Mycoplasma hominis.
Criteria for the diagnosis of BV must be based on objective characteristics of the discharge.
Culture of G.vaginalis is not recommended as a diagnostic method because it is not specific.
The high concentrations of anaerobic bacteria in a vagina with especially virulent species could
explain the role of bacterial vaginosis in such postsurgical infections as postpartum endometriis,
vaginal cuff cellulitis and pelvic inflammatory disease following induced abortion. Recently, BV has
been related to premature delivery thus playing an important role in womens and childrens health.
All symptomatic women must be treated. There is no indication to treat asymptomatic women who
represent 50 percent of patients suffering from BV.
Controversy regarding treatment of pregnant asymptomatic women still remains and it seems
prudent to suggest that patients at risk for preterm delivery and premature rupture of membranes
be treated.
Vaginal therapy has decreased systemic absorption and reduced side effects but has the same
efficacy in cure rate as oral therapy.

Introduction
Bacterial vaginosis is a clinical syndrome characterized by malodorous vaginal discharge. Bacterial
Vaginosis is the most common type of vaginal infection in women of reproductive age, accounting for 45
percent of all vulvovaginal infections. This vaginal infection is becoming recognized increasingly by the
medical community to be important as a cause of symptomatic disease with a vaginal odour and discharge.
More importantly, it has been related to a variety of upper genital tract infections and obstetrical
complications. These include pelvic inflammatory disease (PID), post-caesarean endometritis,
posthysterectomy pelvic infection, chorioamnionitis, premature rupture of membranes (PROM) and preterm
labour and delivery. The prevention of these infections for a woman and her child is an important issue in
womens health.
Epidemiology
A rough approximation of the prevalence has been proposed by Mead. Fifteen percent of private
gynaecologic patients and 10 to 30 percent of pregnant women have BV. Prevalence increases in women
who visit STD clinics. Up to 60 percent of these women have BV.
Bacterial vaginosis has been associated with non-white race, parity, sexual activity, and the intrauterinedevice. Unfortunately studies of the determinants of BV are imprecise, non-randomized, and have selection
and confounding bias.
The precise contribution of sexual transmission to the overall epidemiology of the condition remains
controversial. Support for the idea that sexual transmission plays a significant role is based on the following
evidence: increased prevalence of BV among women with a recent new partner, Gardnerella vagina/is
recovered from the urethras of more than 89 percent of the male sexual partners of infected women and
increased prevalence among women in STD clinics. However, several observations argue against exclusive
heterosexual transmission since the infection can be demonstrated in virgins and homosexual populations.
The organisms associated with BV can be cultured from the rectum and might then go from there on to
colonize the vagina.
Bacterial vaginosis is rarely acquired during pregnancy, the infection having already been present at the first
obstetrical visit. In 50 percent of patients BV will disappear spontaneously during pregnancy
Pathophysiology
The normal vaginal flora is dominated by lactobacilli which account for 95 percent of the bacteria present in
the vagina, with other facultative and anaerobic bacteria present in only small numbers. Bacterial Vaginosis
represents a complex change in the vaginal ecosystem characterized by a reduction in the prevalence and
concentration of lactobacilli and an increase in the prevalence and concentration of Gardnerella vagina/is,
anaerobic gram-negative rods, and Mycoplasma hominis. In BV, a flora consisting primarily of benign
lactobacilli is replaced by a flora consisting of high concentrations of potentially virulent bacteria. Facultative
lactobacilli maintain the acid pH of the vagina by producing lactic acid which maintains a low pH of normally
less than 4.5. Low pH directly inhibits the growth of anaerobic organisms. Hydrogen peroxyde-producing
lactobacilli also appear to play a major role in limiting Gardnerella and the anaerobic flora of the vagina.
These lactobacilli are present in the vagina of 96 percent of normal women but in only five percent of
women with Bacterial Vaginosis4
The term Bacterial Vaginosis was introduced to describe increased vaginal discharge without signs of
vulvovaginal inflammation and a noticeable absence of leukocytes. Bacterial Vaginosis is a condition of
bacterial overgrowth in the vagina. The number of facultative and anaerobic bacteria in the vagina of
patients with BV is 100 to 1000 times higher than the number in patients whose flora is dominated by
lactobaccilli. In addition Prevotella and Porphyromonas species are especially virulent, and these species
are present in particularly high concentrations in patients with BV.
-3-

Clinical manifestations
When affected women are symptomatic they complain predominantly of vaginal odour. This odour is
described as fishy. Patients often refer to embarrassing vaginal odour especially after intercourse. The foul
smell can be more prominent after intercourse without a condom, probably because the alkaline ejaculate
elicits the odour by liberating various amines of anaeorobic metabolism. About 90 percent of patients also
notice a mild to moderate discharge. Dysuria, dyspareunia and vulvar itching are rare because this
infection is not linked to an inflammatory response of the surrounding tissue. Patients with BV may not
display the symptoms which would normally alert their physicians to the infection. In fact, nearly half of the
patients with BV do not complain of excess or malodorous vaginal discharge.
During clinical examination, discharge is often present at the introitus and visible on the labia minora. The
labia and vulva are generally not erythematous or edematous. The vagina often contains a grayish, thin,
homogenous discharge which contains small bubbles.
Diagnosis
Criieria for the diagnosis of bacterial vaginosis must be based on objective characteristics of the discharge.
Three of the following symptoms or signs must be present before the diagnosis can be made.
l234-

A homogenous, white or gray, noninflammatory discharge that adheres to the vaginal

walls.
The presence of clue cells ( z 20% of the epithelial cells in 400 magnification) on
microscopic examination of fresh smears.
The pH of vaginal secretions greater or equal to 4.7.
A fishy odour of vaginal discharge before or after addition of 10 percent KOH (whiff test).

Gram staining is also used to diagnose BV and standard clinical and microbiologic criteria are described.
The smear, interpreted as consistent with the diagnosis of BV, consists of mainly small gram-positive
organisms for Gardnerella morphotypes, gram-negative coccobacilli, and curved rods, the presence of clue
cells and absence of Lactobacillus morphotypes. Culture of G.vaginalis is not recommended as a
diagnostic tool because it is not specific. G.vaginalis can be isolated from vaginal cultures taken from fifty
percent of normal women and vaginal colonization in women treated for BV might be similar to that of
healthy control subjects.Clue cells and changes in bacterial flora can be found in the Papanicolaou smear
which would normally be an incidental finding and has limited diagnostic potential in comparaison to the
diagnosis based on clinical criteria or the gram stain.
Bacterial vaginosis and Obstetric and Gynaeocologic Complications
While the presence of anaerobic infections of the upper genital tract has now been well appreciated, the
association between bacterial vaginosis and upper genital tract infection has only recently been established.
The high concentrations of anaerobic bacteria in a vagina with especially virulent species could explain the
role of bacterial vaginosis in a variety of postsurgical infections such as postpartum endometritis, vaginal
cuff cellulitis and pelvic inflammatory disease (PID) following induced abortion. Recently, BV has been
related to premature delivery thus playing an important role in women and childrens health.
A study showed that patients with BV had a 5.1-fold higher risk of postpartum endometritis following
Caesarean section than did patients with a lactobacilli-dominant flora.5 Patients with BV also had increased
rates of abdominal wound infection following Caesarean section.
Patients with BV have a markedly increased rate of vaginal-cuff cellulitis following abdominal hysterectomy.
Vaginal-cuff cellulitis following hysterectomy was four times more common among patients without
lactobacilli-dominant flora.6*7

-4-

Recently PID following induced first-trimester abortion was found to be related to Bacterial vaginosis.
Postabortion PID was three times more common in patients with Bacterial Vaginosis than in patients with
lactobacillidominant flora. In a randomized double-blind study, the rate of postabortion PID in
metronidazole-treated patients was three times less than the rate in patients treated with placebo. The role
of BV in PID that is not associated with abortion is less cleaT(). Presently the treatment of asymptomatic
women with BV aimed at PID prevention is not advisable because PID is more closely related to chlamydial
and gonoccocal infections than to BV.
Prematurity occurs on average of 1.9 times more commonly in women with Bacterial Vaginosis than in
those without BV. Premature rupture of membranes (PROM) in the same study carried an increased risk
of 3.5 among BV affected patientsThe mechanisms involved in explaining the role of BV in PROM or
premature labour are multifactorial. Infectious agents may produce phospholipases which could trigger
prostaglandin production. Microorganisms could also produce proteases that may destroy or weaken
collagen membranes causing PROM.
Bacterial vaginosis bacteria are also involved in the causation of chorioamionitis. Bacteria are isolated from
the amniotic fluid of 10 percent of afebrile patients in preterm labour with intact membranes. * Anaerobic
bacteria found in BV are frequently isolated from amniotic fluid and amniotic fluid infection is more
common among patients who deliver before term () . Infection of the amniotic fluid leads to high levels of
prostaglandins in the amniotic fluid which could play a major role in premature delivery.
Treatment Options
The same cure rate has been reported with clindamycin or metronidazole. Cost of drugs, side effects,
whether or not a woman is pregnant and rate of recurrence are important issues for the choice of therapy.

Treatment with systemic antibiotics

Metronidazole
Since the early 1980s metronidazole has been widely used for the treatment of BV. The usual dosage is
500 mg twice a day for seven days. The seven days regimen has been associated with cure rates ranging
from 80 to 90 percent at one month. The single dose (Zgr) is less effective than the seven-day regimen
with cure rates ranging from 47 to 85 percent. l4
The common side effects of
should always be advised to
metronidazole may produce
first trimester of pregnancy15
humans.16

metronidazole are nausea, abdominal cramps and a metallic taste.The patient

refrain from alcohol intake because the combination of alcohol and
disulflram (antabuse) like effects. Metronidazole is not recommended in the
although a literature review shows little evidence of teratogenic risk in

Clindamycin
Oral clindamycin 300 mg twice daily for seven days is as effective as oral metronidazole. Clindamycin could
be particularly useful in the treatment of BV during pregnancy, in metronidazole failure and when patients
cannot tolerate metronidazole. Although adverse effects are infrequent and usually mild, the patient must
be informed about possible diarrhoea. Concern about Closfridium &W/e colitis, even if rare and not
specific to clindamycin use, has prevented widespread use of this medication.
Treatment with topical regimens
The recent introduction of vaginal preparations of metronidazole and clindamycin have minimized systemic
absorption resulting from the oral route which has decreased side effects and fetal exposure. However,
this approach is more expensive.

-!i-

Metronidazole gel
lntravaginalO.75 percent metronidazole gel twice a day for five days is a good alternative.The cure rate is
87 percent up to 91 percent at one month.14 The product is associated with a mean maximum serum
concentration of drug less than two percent of that resulting from an oral dose.The restoration of normal
vaginal pH is more rapid than with clindamycin since metronidazole spares the lactobacilli. Metronidazole
gel does not weaken condoms.This product is not recommended in the first trimester of pregnancy but
could be used safely in the second or third trimester. Although there is minimal systemic absorption,
patients should be warned to avoid alcohol consumption at the time of treatment.
Clindamycin 2 percent cream
lntravaginal application of five gr of clindamycin two perecent cream for seven nights results in minimal
systemic absorption. Reported cure rates are in the order of 83 percent one month after completion of
therapy.lg The cure rate is similar to that seen with oral metronidazole. Topical therapy has the
advantage of fewer side effects because of lower dosage and low systemic absorption of clindamycin
cream.The risk is reduced in treatment during pregnancy as only five percent of each 1 OOmg dose of
intravaginal drug is absorbed.This product should be considered for treatment of BV in the first trimester of
pregnancy. Clindamycin cream contains mineral oil, which may weaken condoms or diaphragms, so
patients should be advised to abstain from intercourse or use alternative methods of birth control during
therapy and for 72 hours afterward. This medication is not recommended for patients with a history of
antibiotic-induced colitis because diarrhoea could occur in less than one percent of patients using the
cream. A slight increase (8.5% versus 4.7%) of vaginal candidiasis is associated with clindamycin cream
use in comparison to oral metronidazole.
Others
Amoxicillin plus clavulinic acid is less effective than metronidazole. It offers another choice for second line
therapy. Tetracycline, ofloxacin, and erythromycin are not effective for therapy of BV. Triple sulfa cream
has no greater activity than placebo. Proviodine solution has an unacceptably low cure rate.Vaginal
douches with acetic acid have no value. Preliminary European experience supports the value of a topical
lactate gel. Further study of this product is warranted.
Indications for therapy
All symptomatic women must be offered treatment. There is no indication to treat asymptomatic women
who represent 50 percent of patients suffering from BV.Treatment of asymptomatic women with BV for the
prevention of PID complications has not been proven to be of any benefit and at the present time is not
recommended.
Special considerations
Induced first trimester abortion
Women requiring a first trimester abortion should be screened for BV. Since Larssons studf confirming
that treatment of BV decreases the rate of PID following induced abortion, it is now well accepted that
asymptomatic and symptomatic patients be screened and treated, as described for the prevention of
postabortion PID.
Preterm delivery
In a recent study, McGregor found that treatment of BV with oral clindamycin in pregnancy by oral was
associated with a 50 percent reduction in rates of preterm birth and PROM. This study was unfortunately
not a randomized or double-blind study but a prospective controlled treatment conducted on two cohorts of
patients, the first cohort being observed and the second cohort being treated. In 1994, Morales conducted a
randomized double-blind placebo-controlled study in patients with a history of preterm delivery who were
treated with metronidazole in the hopes of reducing the risk of subsequent preterm birtth. He concluded
that treatment of BV with oral metronidazole was effective in reducing preterm birth by 50 percent in
patients with a history of prematurity.
-6-

D E C I S I O N T R E E 3: CE R V I C A L D I S C H A R G E

Treat right away, covering

Gonococcus and Chlamydia

Treat according
to resuk%i
Assess and trea
partners in
positive cases

Follow-up Visit:
l

Il

Check-up Test: Search for Gonococcus following

treatment in initially positive cases at the site(s) where
Gonococcus had been found (Particularly if it is a Strain
of N. Gonorrhoeae producing Penicillinase (NGPP) or
when treatment did not consist of Ceftriaxone. No
check-up test is carried out for C. Trachomafis if the
recommended treatment is administered. if signs and
symptoms disappear and If there is no reexposure to an
untreated partner.
Repeat diagnostic tests if signs and symptoms persist.

Assess and treat partners right

away

Swab test : Presence of pus on the swab after passing it through the endocervix.
leukocyte count: View at 1 x)(30X

Excerpt from Maladies trunsmissibles sexuellement, Guide de prutique , Regional Health and Social Services Authority,
Montreal-Centfe and lava/ 1995.

DECISION TREE 3

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D E C I S I O N T R E E 3: CE R V I C A L D I S C H A R G E

Treat right away, covering

Gonococcus and Chlamydia

Treat according
to resuk%i
Assess and trea
partners in
positive cases

Follow-up Visit:
l

Il

Check-up Test: Search for Gonococcus following

treatment in initially positive cases at the site(s) where
Gonococcus had been found (Particularly if it is a Strain
of N. Gonorrhoeae producing Penicillinase (NGPP) or
when treatment did not consist of Ceftriaxone. No
check-up test is carried out for C. Trachomafis if the
recommended treatment is administered. if signs and
symptoms disappear and If there is no reexposure to an
untreated partner.
Repeat diagnostic tests if signs and symptoms persist.

Assess and treat partners right

away

Swab test : Presence of pus on the swab after passing it through the endocervix.
leukocyte count: View at 1 x)(30X

Excerpt from Maladies trunsmissibles sexuellement, Guide de prutique , Regional Health and Social Services Authority,
Montreal-Centfe and lava/ 1995.

DECISION TREE 3

kc

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.:

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DECISION TREE 4

Rewh wIII ~dnflr~ in the tUttIre

If we nqed ta treat all asympMn#c
patier@ to decrease the r&a of
premature delkwy.