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Bacterial Vaginosis: Etiology, Clinical Features, Diagnosis, Treatment -
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Etiology -
Imbalance of Vaginal Flora
Normally, the vagina is colonized predominantly by Lactobacillus species, which produce lactic acid, maintaining a healthy acidic pH.
In BV, there is a decrease in Lactobacilli and an overgrowth of anaerobic bacteria such as Gardnerella vaginalis, Atopobium vaginae, Mobiluncus species, and Prevotella species.
These anaerobes raise the vaginal pH, creating an environment that supports bacterial overgrowth.

Pathogenesis -
Disturbed Vaginal pH
Normal vaginal pH is approximately 3.8–4.5, which is maintained by Lactobacilli.
The rise in pH above 4.5 allows anaerobic bacteria to thrive, contributing to the development of BV.
Biofilm Formation
Gardnerella vaginalis and other bacteria involved in BV form a biofilm on the vaginal epithelium, protecting themselves from the body’s immune defenses and antibiotics.
This biofilm further disrupts the vaginal ecosystem, allowing other pathogenic bacteria to colonize.

Risk Factors -
Sexual Activity
Increased frequency of new or multiple sexual partners can lead to disturbances in the vaginal flora.
Though BV is not an STI, it is more commonly observed in sexually active individuals.

Douching -
Douching can remove the natural protective bacteria and disrupt the vaginal environment, leading to BV.
Intrauterine Devices (IUDs)
Women with IUDs may have a higher incidence of BV due to changes in the vaginal flora.

Clinical Features -
Vaginal Discharge
Thin, watery, gray or white discharge with a distinct “fishy” odor, especially after intercourse or during menstruation due to the presence of volatile amines.
Vaginal Itching or Irritation
Mild itching, burning, or irritation may occur, but significant inflammation is usually absent.
Asymptomatic Cases
Some women may have BV without any noticeable symptoms, especially in the early stages.

Complications -
Pregnancy-Related Complications
BV has been associated with an increased risk of preterm labor, premature rupture of membranes, and low birth weight.
Increased Susceptibility to STIs
BV can increase the risk of acquiring STIs, including HIV, due to the loss of protective vaginal flora.

Diagnosis -
Amsel’s Criteria
Three out of four of the following criteria must be present to confirm BV:
Homogeneous, thin, white discharge that smoothly coats the vaginal walls.
Presence of clue cells (epithelial cells coated with bacteria) on microscopy.
pH of vaginal fluid greater than 4.5.
A positive whiff test: the release of a fishy odor when a drop of 10% potassium hydroxide (KOH) is added to the vaginal discharge.
Gram Stain
Gram stain of vaginal secretions can confirm BV by showing an altered ratio of Lactobacilli to anaerobes.
Nugent Score
Based on Gram stain, the Nugent scoring system evaluates bacterial morphology and provides a numerical score to diagnose BV.

Treatment -
Antibiotics
First-line treatment includes:
Metronidazole (oral or gel) 500 mg twice daily for 7 days.
Clindamycin (oral or cream) 300 mg twice daily for 7 days.
Probiotics
Use of Lactobacillus-containing probiotics can help restore the natural vaginal flora.
Avoidance of Risk Factors
Advise patients to avoid douching and to practice safe sex.
Prevention
Education on Sexual Practices
Educating sexually active individuals about the risk factors associated with BV.
Probiotic Use
Probiotics containing Lactobacilli may help maintain a healthy vaginal flora.
Regular Medical Check-Ups
Regular screening and treatment can prevent complications, especially in pregnant women.

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