Amsel’s Criteria
Presence of any 3 of the 4 features:
- Homogenous, thin, white discharge that smoothly coats the vaginal wall
- “Clue cells” on microscopic examination
- Vaginal fluid pH>4.5
- Fishy odour vaginal discharge before or after addition of 10% KOH (the Amine’s sniff test)
Hay/Ison Criteria
| Grade |
|
Description |
| 1 |
Normal |
Lactobacillus morphotypes predominate |
| 2 |
Intermediate |
Mixed flora with some Lactobacilli present but Garnerella or Mobiluncus morphotypes are present as well |
| 3 |
Bacterial vaginosis |
Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli |
Nugent criteria
Nugent score is derived from estimating the relative proportions of Lactobacilli and bacterial vaginosis morphotypes to give a score of between 0 and 10.
| Score |
Description |
| <4 |
Normal |
| 4-6 |
Intermediate |
| >6 |
Bacterial vaginosis |
Related topic:
Reference:
- Malaysia Guidelines In The Treatment of Sexual Transmitted Infections. 2008.
Bacterial vaginosis (BV) is a common cause of vaginal discharge other than candidiasis and normal physiological vaginal secretion which is found during ovulation, sexual excitement or pregnancy. BV is not an infection per say but rather a polymicrobial clinical syndrome. It results from the replacement of the normal hydrogen peroxide-producing Lactobacillus species in the vagina with high concentration of anaerobic bacteria (e.g.: Prevetella sp and Mobiluncus sp.), Gardnerella vaginalis and mycoplasma hominis. It is not sexual transmitted infection (STI) but commonly found during the screening. The prevalence is 10%-40% depends on the population.
BV is characterized by an offensive vaginal discharge with a strong fish-like odor. The discharge frequently seen after sexual intercourse and usually homogenous thin, white or grey in color an uniformly adherent. Vaginal wall is usually not inflamed. Some will also complaint of dysuria (pain during passing urine) or itching of the perenium, especially outside the vagina. 50% of women with BV are asymptomatic.
Investigation and diagnosis
Investigation is done by doing high vaginal swab. The lab test available is the Amine’s Sniff test. An alternative is to use a Gram stained vaginal smear. Diagnosis is made using the Amsel’s criteria, Hay/Ison criteria or Nugent criteria. It is made by suggestive history and clinical examination, positive Amine’s sniff test and the presence of “clue cells” on microscopic examination.
Treatment and management
Indication of treatment:
- Symptomatic women
- Women undergoing gynaecological procedures
- Pregnant women
Recommended treatment:
- Oral metronidazole 400mg twice daily for 5-7 days or
- Oral metronidazole 2g as single dose
Alternative treatment:
- Intravaginal metronidazole 75% gel once daily for 5 days or
- Intravaginal clindamycin 2% cream once daily for 7 days or
- Oral clindamycin 300mg twice daily for 7 days
*2% clindamycin cream is given if the woman is allergic to metronidazole.
*From the meta-analyses studies, they have concluded that metronidazole is not teratogenic and safe to be given to pregnant women during the first trimester.
Unlike sexual transmitted infection, routine screening and treatment of male partners are not indicated. Vaginal douching should be avoided. Regular follow up is not necessary and will be decided on individual basis. If the symptoms resolve, a repeat test is not required. However, if the treatment is prescribed in pregnancy, a repeat test should be made after 1 month and further treatment should be offered if recurrence infection is expected in view of to reduce the risk of preterm birth.
Related:
Reference:
- Malaysia Guidelines In The Treatment of Sexual Transmitted Infections. 2008.
- Gynaecology in Focus. Janice Rymer et al. Elsevier Churchill Livingstone. 2005.
- Chantal Simon et al. Oxford Handbook of General Practice. Oxford. 2005
