CKS clinical solutions - Bacterial vaginosis

The case - A 26-year-old woman comes to see you complaining of a fishy-smelling vaginal discharge. You suspect bacterial vaginosis (BV).

What should you do next?
Check for any soreness, itching or irritation, which might suggest an alternative diagnosis such as trichomoniasis or candidiasis.

Speculum examination and swabs are required only if:

  • The woman is at high risk of an STI.
  • She has symptoms of other conditions causing vaginal discharge (for example itch, abdominal pain or fever).
  • She is pregnant, post-natal, post-miscarriage or post-termination, or symptoms have developed after a gynaecological procedure.
  • Symptoms have persisted following treatment for BV or recurred soon after treatment.

Swabs should include a high vaginal swab (with trichomoniasis culture) and specimens for chlamydia and gonorrhoea.

Asymptomatic BV rarely requires treatment.

If symptoms are present, treat empirically with metronidazole 400mg three times daily for seven days. Intravaginal metronidazole gel or intravaginal clindamycin cream are alternatives. A test of cure is not required if symptoms resolve.

What if symptoms persist?
Reconsider the diagnosis, perform a speculum examination and take swabs if this has not been previously done, and check adherence to treatment. If intravaginal preparations have been used, prescribe oral metronidazole for seven days.

Consider removing an IUD and advise alternative contraception. Routine screening and treatment of male partners is not indicated.

In the unlikely event that a woman with confirmed BV has not responded to a seven-day course of oral metronidazole (and you are confident that she has adhered to treatment), discussion with a specialist is advised.

What if symptoms recur?
Up to 30 per cent of women have a recurrence within three months.

Perform a speculum examination and swabs if this has not previously been done.

Treat with oral metronidazole for seven days, and advise the woman to avoid vaginal douching, shower gel and bubble baths.

If the diagnosis is confirmed and symptoms recur frequently, consider specialist referral.

CKS have based these recommendations on UK guidelines for the management of BV and for the management of vaginal discharge and STIs.1-3

Evidence from a systematic review4 and a randomised controlled trial5 demonstrates that oral metronidazole, intravaginal clindamycin and intravaginal metronidazole have similar cure rates, although oral metronidazole is preferred.1

Vaginal douching has been identified as a risk factor for BV6 and its avoidance is recommended.1

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP. See

1. British Association for Sexual Health and HIV (2006). National guideline for the management of bacterial vaginosis.

2. FFPRHC, BASHH. J Fam Plann Reprod Health Care 2006; 32(1): 33-42.

3. RCGP, BASHH (2006). Sexually transmitted infections in primary care.

4. Joesoef M, Schmid G, Hillier S. Clin Infect Dis 1999; 28 (Suppl 1): S57-S65.

5. Paavonen J, Mangioni C, Martin M, Wajszczuk C. Obstet Gynecol 2000; 96(2): 256-60.

6. Alfonsi G A, Shlay J C, Parker S. J Fam Pract 2004; 53(8): 650-2.

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