INCIDENCE AND AETIOLOGY
Bacterial vaginosis (BV) is the commonest cause of abnormal discharge in women of childbearing age. The incidence of BV varies from 5 per cent in a group of asymptomatic college students to 50 per cent of Ugandan women (BASHH, 2001). It occurs when there is a decreased number of lactobacilli and an overgrowth of organisms such as Gardnerella vaginalis, ureaplasmas, mycoplasmas, Mobiluncus species and anaerobes (Wisdom and Hawkins, 1997).
Bacterial vaginosis has been diagnosed more frequently in women who have sex with women (31.4 per cent) (Bailey et al., 2004). It is also associated with a new sexual partner and frequent change of sexual partners (Mitchell, 2004).
ADVANCED CLINICAL SKILLS FOR GU NURSES Table 9
Thin white homogeneous • Offensive fishy smelling discharge discharge coating the walls • Not associated with soreness, itching or of the vagina and vestibule irritation
• Many women (approximately 50%) are asymptomatic
The isolation of Gardnerella vaginalis itself cannot be relied upon to diagnose bacterial vaginosis, as it can be cultured vaginally in more than 50 per cent of women. However, in research studies a high concentration of Gardnerella vaginalis is associated with the presence of bacterial vaginosis (McDonald et al., 1997).
ISON/HAY CRITERIA (HAY ET AL. 1994)
This involves using a Gram-stained vaginal smear and grading the findings on microscopy.
Grade 1 (Normal): Lactobacillus morphotypes predominate.
Grade 2 (Intermediate): Mixed flora, with some lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present.
Grade 3 (BV): Predominantly Gardnerella and/or
Mobiluncus morphotypes. Few or absent lactobacilli.
AMSEL CRITERIA (AMSEL ET AL. 1983)
At least three of the four criteria need to be present for the diagnosis to be confirmed.
1. Thin, white, homogeneous discharge
2. Clue cells on microscopy
4. Release of a fish odour on adding alkali (10 per cent).
NUGENT SCORE (NUGENT ET AL. 1991)
This is derived from estimating the relative proportions of bacterial morphotypes to gain a score between 0 and 10.
<4 is normal
4-6 is intermediate
>6 is bacterial vaginosis.
MANAGEMENT (BASHH, 2001) Treatment for bacterial vaginosis is indicated for:
• Symptomatic women
• Women undergoing some surgical procedures
• Some pregnant women.
• Metronidazole 400-500mg BD for 5-7 days
• Metronidazole 2g immediately
• Other treatments include:
° Intravaginal metronidazole gel (0.75 per cent) once daily for 5 days ° Intravaginal clindamycin cream (2 per cent) once daily for 7 days ° Clindamycin 300mg bd for 7 days.
Women should be advised to stop vaginal douching and/or the use of shower gel and/or antiseptic agents or shampoo in the bath in order to maintain the integrity of a healthy vaginal flora.
Routine screening and treatment of male partners is not indicated. However, Berger et al. (1995) reported a high incidence of bacterial vaginosis in female partners of lesbians with BV. While no study has investigated the value of treating partners of lesbians simultaneously, this may be worth considering.
While a test of the cure is not indicated if the woman announces the cessation of her symptoms, it is recommended that pregnant women who are treated in order to prevent pre-term birth should repeat a test after one month, and treatment should be offered if the test is positive.
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