ContextVaginal symptoms are one of the most common reasons for gynecological
consultation. Clinicians have traditionally diagnosed vaginal candidiasis,
bacterial vaginosis, and vaginal trichomoniasis using some combination of
physical examination, pH, the wet mount, and the whiff test.ObjectivesTo evaluate the role of the clinical examination and determine the positive
and negative likelihood ratios (LRs) for the diagnosis of vaginal candidiasis,
bacterial vaginosis, and vaginal trichomoniasis.Data SourcesUsing a structured literature review, we abstracted information on sensitivity
and specificity for symptoms, signs, and office laboratory procedures. We
chose published (1966 to April 2003) articles that appeared in the MEDLINE
database and were indexed under the combined search terms of diagnosis with vaginitis, vaginal discharge, candidiasis, bacterial vaginosis, and trichomoniasis.Study SelectionIncluded studies of symptomatic premenopausal women seen in primary
care settings. Tests were evaluated only if they would provide diagnostic
information during the office visit and were compared with an acceptable criterion
standard.Data ExtractionAll 3 authors extracted the data and computed sensitivity and specificity
from each article independently. The absence of standard definitions for symptoms
and signs made it impossible to combine results across studies.Data SynthesisSymptoms alone do not allow clinicians to distinguish confidently between
the causes of vaginitis. However, a patient's lack of itching makes candidiasis
less likely (range of LRs, 0.18 [95% confidence interval {CI}, 0.05-0.70]
to 0.79 [95% CI, 0.72-0.87]) and lack of perceived odor makes bacterial vaginosis
unlikely (LR, 0.07 [95% CI, 0.01-0.51]). Similarly, physical examination signs
are limited in their diagnostic power. The presence of inflammatory signs
is associated with candidiasis (range of LRs, 2.1 [95% CI, 1.5-2.8] to 8.4
[95% CI, 2.3-31]). Presence of a "high cheese" odor on examination is predictive
of bacterial vaginosis (LR, 3.2 [95% CI, 2.1-4.7]) while lack of odor is associated
with candidiasis (LR, 2.9 [95% CI, 2.4-5.0]). Office laboratory tests, particularly
microscopy of vaginal discharge, are the most useful way of diagnosing these
3 conditions.ConclusionsThe cause of vaginal complaints may be easily diagnosed when typical
findings appear in microscopy. However, the poor performance of individual
symptoms, signs, and office laboratory tests often makes it problematic to
identify the cause of vaginal symptoms.

Evaluation of Vaginal Complaints

Opportunistic pathogenic microbes are indigenous to the female lower genital tract and etiologic in many types of pelvic infections and, apparently, a portion of preterm birth (PTB) cases. Bacterial vaginosis (BV) is a clinical syndrome based on an altered genital microflora in which Gardnerella vaginalis; anaerobic species primarily among Prevotella, Porphyromonas, Bacteroides, Peptostreptococcus, and Mobiluncus; Mycoplasma hominis; and Ureaplasma urealyticum become predominant in vaginal secretions. This BV complex of microbes, compared to a normal vaginal microflora dominated by facultative lactobacilli, is associated with significantly increased risks for preterm labor, preterm premature rupture of membranes, PTB, and other perinatal infectious complications. Pathogenetic mechanisms include an ascending route of infection and/or inflammatory process due to microbial products and maternal and/or fetal response(s) with production of prostaglandins and cytokines. In the presence of periodontal disease, oral opportunistic pathogens and/or their inflammatory products also may have a role in prematurity via a hematogenous route. Fusobacterium nucleatum, a common oral species, is the most frequently isolated species from amniotic fluid cultures among women with preterm labor and intact membranes. Also, the species and subspecies of fusobacteria identified from amniotic fluid most closely match those reported from healthy and diseased subgingival sites, namely F. nucleatum subspecies vincentii and F. nucleatum subspecies nucleatum, compared to strains identified from the lower genital tract. Although these fusobacteria also could be acquired through cunnilingus from a partner, new data associating maternal periodontal disease with preterm low birth weight taken with the isolation of F. nucleatum, Capnocytophaga, and other oral species from amniotic fluid support further study of a possible additional route, oral-hematogenous, to PTB.

https://onlinelibrary.wiley.com/doi/pdf/10.1902/annals.1998.3.1.222

Preterm Birth: Associations With Genital and Possibly Oral Microflora

Bacterial vaginosis is a clinical condition caused by replacement of the normal hydrogen peroxide producing Lactobacillus sp. in the vagina with high concentrations of characteristic sets of aerobic and anaerobic bacteria. Bacterial vaginosis is the most prevalent cause of vaginal discharge or malodor, although 50 percent of women who meet the criteria for this condition are asymptomatic. Bacterial vaginosis is reported in 10 to 41 percent of women, and new evidence has shown association with maternal and fetal morbidity. Studies have shown that spontaneous abortion, preterm labor, premature birth, preterm premature rupture of the membranes, amniotic fluid infection, postpartum endometritis, and postcesarean wound infections are increased because of infection with bacterial vaginosis during pregnancy. Clinical trials demonstrated important reductions in many of these adverse events with appropriate screening and antimicrobial treatment protocols. New low-cost, diagnostic, point-of-care screening tools are available for rapid screening of patients, affording the physician the opportunity to potentially make a dramatic clinical and cost impact in preventing preterm birth and the costly sequelae of prematurity. Practicing physicians need to be aware of current guidelines for screening and treating pregnant patients for bacterial vaginosis. The authors recommend that all pregnant women be screened and treated with the Centers for Disease Control and Prevention (CDC-P) recommended oral regimens early in pregnancy. Each treated women should be evaluated for "test of cure" 1 month after treatment. Mothers likely to benefit from "screen and treat" approaches include 1) those with the highest concentrations of genital anaerobes and mycoplasmas, 2) women with prior preterm birth or who have low body mass (BMI < 19.8 kg/m2), 3) those with evidence of endometritis before pregnancy, and 4) those who are treated with oral agents effective for both presumed intrauterine mycoplasmas and other bacterial vaginosis flora (i.e., oral clindamycin or erythromycin and metronidazole).

Bacterial vaginosis in pregnancy.

The vaginal microflora of 49 women in idiopathic preterm labor was compared with that of 38 term controls to determine whether the presence of bacterial vaginosis (BV) and/or specific microorganisms would influence the rate of preterm delivery. Demographic factors, pregnancy outcome, and reproductive history were also studied. BV, as defined by the presence of clue cells in a vaginal wet mount and characteristic microbial findings in a stained vaginal smear and vaginal culture, was more common in women with preterm labor and delivery than in controls (P < 0.01). The condition, diagnosed in 41% of women who had both preterm labor and delivery (n = 22) and in 11% each of women who had preterm labor but term delivery (n = 27) and controls, was associated with a 2.1-fold risk (95% confidence intervals, 1.2 to 3.7) for preterm birth prior to 37 weeks of gestation. BV was associated with low birth weight. Of 49 women with preterm labor, 67% (8 of 12) of women with BV were delivered of low-birth-weight neonates (< 2,500 g) compared with 22% (8 of 37) of women without the condition (P < 0.0005). The presence of hydrogen peroxide-producing facultative Lactobacillus spp. was strongly negatively associated with both preterm delivery and BV. BV-associated microorganisms, i.e., Mobiluncus, Prevotella, and Peptostreptococcus species, Porphyromonas asaccharolytica, Fusobacterium nucleatum, Mycoplasma hominis, and high numbers of Gardnerella vaginalis were significantly associated with preterm delivery; all species also strongly associated with BV (P = 0.0001 for each comparison). Mobiluncus curtisii and Fusobacterium nucleatum were recovered exclusively from women with preterm delivery. Our study clearly indicates that BV and its associated organisms are correlated with idiopathic premature delivery.

Bacterial vaginosis and vaginal microorganisms in idiopathic premature labor and association with pregnancy outcome.

Bacterial vaginosis (BV) is a common vaginal disorder in women of reproductive age. Since the initial work of Leopoldo in 1953 and Gardner and Dukes in 1955, researchers have not been able to identify the causative etiologic agent of BV. There is increasing evidence, however, that BV occurs when Lactobacillus spp., the predominant species in healthy vaginal flora, are replaced by anaerobic bacteria, such as Gardenella vaginalis, Mobiluncus curtisii, M. mulieris, other anaerobic bacteria and/or Mycoplasma hominis. Worldwide, it estimated that 20–30 % of women of reproductive age attending sexually transmitted infection (STI) clinics suffer from BV, and that its prevalence can be as high as 50–60 % in high-risk populations (e.g., those who practice commercial sex work (CSW). Epidemiological data show that women are more likely to report BV if they: 1) have had a higher number of lifetime sexual partners; 2) are unmarried; 3) have engaged in their first intercourse at a younger age; 4) have engaged in CSW, and 5) practice regular douching. In the past decade, several studies have provided evidence on the contribution of sexual activity to BV. However, it is difficult to state that BV is a STI without being able to identify the etiologic agent. BV has also emerged as a public health problem due to its association with other STIs, including: human immunodeficiency virus (HIV), herpes simplex virus type 2 (HSV-2), Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). The most recent evidence on the association between BV and CT/NG infection comes from two secondary analyses of cohort data conducted among women attending STI clinics. Based on these studies, women with BV had a 1.8 and 1.9-fold increased risk for NG and CT infection, respectively. Taken together, BV is likely a risk factor or at least an important contributor to subsequent NG or CT infection in high-risk women. Additional research is required to determine whether this association is also present in other low-risk sexually active populations, such as among women in the US military. It is essential to conduct large scale cross-sectional or population-based case-control studies to investigate the role of BV as a risk factor for CT/NG infections. These studies could lead to the development of interventions aimed at reducing the burden associated with bacterial STIs worldwide.

/pdf/bacterial-vaginosis-a-synthesis-of-the-literature-on-2wlfboy3oy.pdf

Bacterial vaginosis: a synthesis of the literature on etiology, prevalence, risk factors, and relationship with chlamydia and gonorrhea infections

A prospective study was performed involving 101 women who consecutively attended a primary health care unit for complaints of genital malodour and/or abnormal vaginal discharge. Bacterial vaginosis was diagnosed in 34 women on the basis of four diagnostic criteria: vaginal pH > 4.7, homogeneous vaginal discharge, a positive amine test and clue cells. The sensitivity of these criteria was > 90 % except for homogeneous discharge (82 %). Their specificity was > 90% except for vaginal pH > 4.7 (46%); a specificity of 87% could have been achieved by using the criterion for vaginal pH ⩾ 5.0. There was a strong association between diagnosis of bacterial vaginosis and the concomitant occurrence ofGardnerella vaginalis, Mobiluncusspp. andBacteroidesspp. There was no difference between women with or without bacterial vaginosis as regards contraception methods (except for use of an intrauterine device), age at first intercourse, or earlier episodes of vaginal discharge. Sexual transmission of the predominant bacteria was not supported by data collected from the male consorts.

Bacterial vaginosis: Microbiological and clinical findings

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Bacterial vaginosis: Microbiological and clinical findings