Story of The Month 12-2012

Dr. Jacqueline M. Walters

Case Report 12-17-2012

Lisa is a 29 year old female who presents complaining of a thin milky vaginal discharge for the last week.  Lisa said immediately following her period she noticed this discharge (d/c) became more noticeable at her introitus (opening to vagina).  The d/c had a disagreeable fishy odor.  It became more noticeable after unprotected sexual intercourse.  She also noticed mild to moderate itching.  The patient did a betadine douche and the odor became even more prominent.  She also did an over the counter (OTC) cream for yeast and for a day or two the symptoms seem to have resolved.  A few days later all of the symptoms returned.  Lisa tried washing several times/day and a second douche.  This time the discharge had a corn meal consistency.  Lisa became frustrated and presented to her OB/GYN.

On examination there was a copious amount of a thin milky homogenous adherent discharge that had a very obvious foul fishy odor.    This was pooled at the introitus.   On speculum exam a large amount of discharge was also pooling in the back of the vagina.  A sample from the vaginal side wall was taken to test the pH, and perform a wet prep and KOH test.  The vaginal pH (using pH sticks/paper) was greater than 4.5 (this is one of the most sensitive test for the diagnosing of bacterial vaginitis).  KOH was done by mixing a small sample of the discharge with potassium hydroxide (KOH).  This test will give a positive whiff test when the strong fishy odor is noted indicating the presence of amines.  A wet prep was done and the presence of clue cells (squamous epithelial cells which come from the walls of the vagina and a covered with bacterial rods or cocci, giving the cells a grainy appearance) by inspecting the vaginal fluid on light microscopy ( done by looking under the microscope).    

The patient was diagnosed with Bacterial Vaginosis/BV.  She was treated with an antibiotic and told to call office it this didn’t clear in 24-48 hours.

BV is a common disorder that occurs among 10 to 26% of women attending gynecologic offices.  Typically, BV affects women of reproductive age, indicating a possible role of sex hormones in its pathogenesis(cause), but it may occur in pre-pubertal and menopausal women infrequently.  Some women develop symptoms on a cyclical basis.  There has been some association between  some contraception and BV.  This disruption of the normal flora causes a change in the vaginal pH.  BV can occur in all women even women with a hysterectomy.  

BV is a polymicrobial condition where there is a decrease in vaginal acidity and the concentration of lactobacilli (the good bacteria that is normal to the vagina is called normal flora).  This occurs when there is more concentration of other organisms instead of the lactobacilli.

Treatments include the following: (always see your doctor, FIRST)

1. Antimicrobial agents
2. Intravaginal therapy
3. Probiotics
4. The role of sexual transmission of micro-organisms in BV is controversial.  The data indicates no benefit in treating the sexual partners of women with BV unless recurrent BV continues.
5. Boric acid vaginal suppositories re-acidifies the vagina and creates a hostile environment for BV to grow.

Remember, to always contact  your physician for proper diagnosis and treatment.  This is intended for education only.