Pediatric emergency medicine trisk 2129 2129
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vaginal microflora is not understood. The high prevalence of the syndrome in
sexually active women and in women attending STI clinics suggests that a wide
range of epidemiologic and microbiologic factors may contribute to its
pathogenesis.
Clinical Assessment
The symptoms of bacterial vaginosis—malodor and discharge—are not
distinctive and can resemble those of trichomonal infection. A complaint of
dysuria or pruritus goes against the diagnosis. As many as half of women who
have signs of vaginosis are asymptomatic. The vaginal discharge is moderate or
copious, grayish-white, and homogeneous. On examination, the vulva, vagina,
and cervix are not inflamed, but concomitant infection with trichomonas or
gonococci can complicate this picture.
Compared with the composite Amsel criteria, the use of single tests (e.g., pH,
clue cells, or whiff test alone) produces lower positive and negative predictive
values for the diagnosis of bacterial vaginosis. When a wet mount of vaginal
discharge is examined, clue cells can be seen which are epithelial cells that are
studded with large numbers of small bacteria giving them a granular appearance
with shaggy borders ( Fig. 92.2 ). The ratio of epithelial cells to
polymorphonuclear leukocytes in the discharge is 1 or higher. Lactobacilli (long
rods) are sparse. Gram stain can be used to confirm the presence of clue cells and
the scarcity of long gram-positive rods (lactobacilli). Because 35% to 55% of
women without bacterial vaginosis have positive cultures for G. vaginalis, culture
is not a useful diagnostic test. In addition, a rapid, antigen-based test has been
developed to assess for bacterial vaginosis using a vaginal swab sample, similar
to the rapid antigen test for T. vaginalis. This test has improved sensitivity and
specificity over Gram stain but may not be widely available. Trichomonal
infection is the major diagnostic alternative for patients suspected of having
bacterial vaginosis.
