Bacterial vaginosis

In the western world, bacterial vaginosis is now being recognised as the commonest cause of vaginitis. Bacterial vaginosis represents a major disturbance in vaginal microbiology with the massive overgrowth of predominantly anaerobic bacteria normally found in the vagina. Accordingly, high population levels of non-fragilis Bacteroides sp., peptostreptococci, Gardnerella vaginalis and Mobiluncus sp. are found, with a corresponding decline in Lactobacillus sp. Excessive polyamine production by anaerobes is responsible for the offensive vaginal discharge, and G. Vaginalis adherent to epithelial cells produces pathognomonic clue cells, which together with elevated vaginal pH constitute the hallmark of diagnosis. The pathogenesis of bacterial vaginosis remains poorly understood and the role of sexual transmission is controversial. Bacterial vaginosis may cause symptoms but is frequently asymptomatic. It is more than a nuisance vaginal infection in that (a) many patients have recurrent episodes, and (b) it has recently been associated with post-partum and post-operative fever, upper genital tract infection, amnionitis and prematurity. Therapy for symptomatic bacterial vaginosis is currently dominated by metronidazole; however, clindamycin and a host of new agents may enjoy similar success. Women with recurrent bacterial vaginosis constitute a major therapeutic problem, as do pregnant women. The cause of frequently recurring bacterial vaginosis remains obscure. New data are presented here indicating that early recurrences are due to relapse and not reinfection. No evidence has emerged that suggests that relapse is due to antimicrobial resistance.