QuestionSBA
QuestionChoice
IM ceftriaxone is the first-line treatment for uncomplicated anogenital gonorrhoea infections in the community. The white discharge and absence of any other genito-urinary symptoms make BV the most likely diagnosis.
Doxycycline
32496
d
IM ceftriaxone
QuestionChoice
Microscopy of vaginal secretions may reveal "clue cells" in BV. However, testing is not required if the history and examination findings suggest the diagnosis in non-pregnant women at low risk of having a sexually transmitted infection (STI)
32494
b
Send vaginal secretions for microscopy
QuestionChoice
Doxycycline is the first-line treatment for Chlamydia. The white discharge and absence of any other genito-urinary symptoms make BV the most likely diagnosis
32497
e
Oral doxycycline
QuestionChoice
This patient's symptoms and examination findings are suggestive of bacterial vaginosis (BV). It is the most common cause of abnormal vaginal discharge in women of child-bearing age and is characterised by an overgrowth of anaerobic organisms in the vagina. In addition, there is an associated increase in vaginal pH to above 4.5. In most women with characteristic signs and symptoms, empirical treatment should be started without further investigations
32493
a
Oral metronidazole
QuestionChoice
If measured, vaginal pH would be greater than 4.5 in BV. However, testing is not required if the history and examination findings suggest the diagnosis in non-pregnant women at low risk of having a sexually transmitted infection (STI)
32495
c
Measure vaginal pH
QuestionComment
The Amsel criteria are often used to diagnose bacterial vaginosis. Three out of the four following features are needed to confer a diagnosis:
Vaginal pH >4.5
Homogenous grey or milky discharge
Positive whiff test (addition of 10% potassium hydroxide produces a fishy odour)
Clue cells present on wet mount

Surely we don't start Abx yet?
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# Summary 
  
  
Bacterial Vaginosis (BV) is an imbalance in the vaginal microbiome characterised by an overgrowth of anaerobic bacteria and a loss of lactobacilli, leading to symptoms such as increased vaginal discharge with a characteristic "fishy" odour. It is the most common cause of abnormal vaginal discharge in women of childbearing age. Diagnosis is based on the Amsel criteria, which include elevated vaginal pH, homogeneous discharge, positive whiff test, and presence of clue cells on wet mount. Treatment involves the use of metronidazole or clindamycin, either orally or intravaginally. Pregnancy can increase the risk of BV and associated complications, although it generally does not cause issues in the majority of pregnancies.
  
  
# Definition
  
  
Bacterial vaginosis is a bacterial imbalance of the vagina caused by an overgrowth of anaerobic bacteria, such as Gardnerella vaginalis, and a loss of lactobacilli, the dominant bacterial species responsible for maintaining an acidic vaginal pH.
  
  
# Epidemiology
  
  
Bacterial vaginosis is the most common cause of abnormal vaginal discharge in women of childbearing age, with prevalence rates as high as 50% in some populations. It is more common in sexually active women, but it is not considered a sexually transmitted infection.
  
  
# Aetiology
  
  
The precise cause of bacterial vaginosis is unknown, but it is associated with a change in the balance of the normal bacteria found in the vagina. Factors that may contribute to this imbalance include:
  
  
- Having multiple sexual partners or a new sexual partner
- Douching
- Lack of consistent condom use
- Hormonal changes, such as those that occur in pregnancy
  
  
# Signs and Symptoms
  
  
- Increased vaginal discharge
- Grey-white watery discharge
- Characteristic "fishy" smelling discharge, particularly after intercourse
- Vaginal itching or irritation may be present but is less common
  
  
# Differential Diagnosis
  
  
When considering bacterial vaginosis, several other conditions can present with similar symptoms and should therefore be considered:
  
  
- **Vulvovaginal Candidiasis**: Characterised by itching, burning, dyspareunia, and white, curd-like discharge.
- **Trichomonas Vaginalis Infection**: Presents with purulent, frothy, greenish discharge, pruritus, dyspareunia, and dysuria.
- **Chlamydia or Gonorrhoea infection**: May present with increased vaginal discharge and possibly lower abdominal pain, but are often asymptomatic.
- **Atrophic Vaginitis**: Most commonly seen in postmenopausal women, presenting with dryness, burning, dyspareunia, and thin, watery discharge.
  
  
# Investigations
  
  
The **Amsel criteria** are often used to diagnose bacterial vaginosis. Three out of the four following features are needed to confer a diagnosis:
  
  
- Vaginal pH >4.5
- Homogenous grey or milky discharge
- Positive whiff test (addition of 10% potassium hydroxide produces a fishy odour)
- Clue cells present on wet mount
  
  
# Management
  
  
The treatment of choice for bacterial vaginosis is usually either Metronidazole or Clindamycin, which can be administered orally or intravaginally. Sexual partners do not typically require treatment. Recurrence is common and may require repeated or prolonged treatment. Avoidance of common triggers such as smoking, vaginal douching and bubble baths can help to prevent recurrence.
  
  
# Pregnancy 
  
  
Pregnant women are at increased risk of bacterial vaginosis due to hormonal changes. BV during pregnancy can increase the risk for premature birth and low birth weight, but in most cases, it causes no problems. If symptomatic, it can be managed with metronidazole (PO/PV). Regular antenatal care should include screening for BV and other infections to minimise potential risks.
  
# NICE guidelines
  
[Click here to see information on NICE about bacterial vaginosis](https://cks.nice.org.uk/topics/bacterial-vaginosis/)
  
# References
  
[WHO: Bacterial vaginosis](https://www.who.int/news-room/fact-sheets/detail/bacterial-vaginosis#
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Bacterial Vaginosis
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Genitourinary medicine
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Concept
12
Bacterial Vaginosis
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Preterm labour
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Bacterial vaginosis is characterised by a fishy-smelling discharge and is treated with oral metronidazole.
A 24-year-old woman presents to her GP with abnormal, fishy-smelling vaginal discharge for the last three days. She denies any other genitourinary symptoms.

On examination, there is a white homogenous discharge visible on the walls of the vagina.

Which of the following is the next best step in management?
a