Bacterial vaginosis is the most common microbially caused vaginal infection of reproductive women, which is causally attributed to atypical colonization of the female genital area by anaerobic bacteria, predominantly Gardnerella vaginalis, and is readily treatable with medication.
What is bacterial vaginosis?
In bacterial vaginosis, there is a disturbance of the physiological balance of the vaginal environment due to an infection caused by bacteria. The healthy vaginal flora, which predominantly has the lactic acid-producing lactobacilli, is in the slightly acidic range with a pH of 3.8 to 4.5. In bacterial vaginosis, the bacterial balance shifts due to a decrease in lactobacilli, so that the pH is in the less acidic range and the vaginal flora can be colonized by other bacteria. These include the bacterial species Gardnerella vaginalis, which often enters the vagina at the same time as other anaerobic bacteria, multiplying and leading to a mixed infection. This causes the fishy-smelling vaginal discharge characteristic of bacterial vaginosis, which is part of the core symptomatology of bacterial vaginosis and is caused by formed amines (amine odor).
Causes
The imbalance of the vaginal environment that characterizes bacterial vaginosis may be caused by several factors. While sexual intercourse increases the risk of infection and is thought to be the main cause of bacterial vaginosis, psychosocial stress or excessive vaginal hygiene may disturb the pH of the vaginal flora and thereby promote colonization by pathogenic germs. In addition, prolonged menstruation is a risk factor, as the number of estrogen-dependent lactobacilli decreases due to lower estrogen levels during menstruation, making the pH less acidic. A less acidic pH of the vaginal flora can result in colonization and proliferation of other bacteria, leading to bacterial vaginosis.
Symptoms, complaints, and signs
In many women, bacterial vaginosis remains asymptomatic. Possible symptoms include redness in the intimate area and increased vaginal discharge. The discharge is usually gray-white and thin or sticky, but can also be bloody or mucous. In isolated cases, there are small vesicles in the discharge. The odor of the discharge is usually slightly acidic, or the discharge smells like fish. The odor increases in intensity when it comes into contact with semen. Furthermore, bacterial vaginosis can cause itching in the area of the vagina and labia. Sensory disturbances and insensitivity in the external genital area may also occur. Affected women experience the vagina as dry despite the discharge or feel an indefinable sensation of pressure on the lower labia. This is often accompanied by pain during urination and sexual intercourse. There may also be puffs of air from the vagina, which sufferers usually find very uncomfortable. Other symptoms may occur if bacterial vaginosis progresses and causes other conditions. Then there may be severe pain that can radiate into the abdomen. Urinary retention and heavy bleeding may also occur, usually outside the period.
Diagnosis and course
For a diagnosis of bacterial vaginosis, at least three of four tests on the vaginal swab taken must be positive. Thus, a grayish-white discharge must be detectable, with a fishy odor enhanced by the so-called amine test (addition of 10 percent potassium hydroxide solution). In addition, a pH value of over 4.5 and/or at least 20 percent bacterial colonization of the vaginal cells must be determined microscopically. For a definite diagnosis of bacterial vaginosis, possible other infections (Trichomonas vaginalis, Mycoplasma) as well as vaginitis and cervicitis should be excluded. In rare cases of bacterial vaginosis, itching and redness of the skin in the genital area may be observed in addition to the gray-white discharge. Furthermore, bacterial vaginosis can cause pain during urination and sexual intercourse. Without medical therapy, vaginal vaginosis carries a minimal risk of bacterial spread to the upper genital areas, which can cause further complications.
Complications
In nonpregnant women, bacterial vaginosis increases the risk of gynecologic inflammation. The mucosa of the cervix may become inflamed (cervicitis). In addition, inflammation of the lining of the uterus (endometritis) and inflammation of the fallopian tubes (salpingitis) may occur. In addition, the external female genital area and the vaginal entrance (vulvitis) can become inflamed. Inflammation of the Bartholin glands (Bartholinitis) is also not excluded. Pregnant women may also experience some complications associated with bacterial vaginosis. Pregnant women affected by bacterial vaginosis have an increased risk of going into preterm labor. In addition, they may have a premature birth or premature rupture of the amniotic sac. During pregnancy, infection of the embryonic lining, called amnionitis, can occur. Various complications associated with bacterial vaginosis can also occur after delivery. Inflammation may occur and the healing process of the episiotomy may be delayed. Abdominal abscess may occur after a cesarean section. Inflammation of the endometrium is also possible. Bacterial vaginosis can also be transmitted to men during sexual intercourse. In this context, a usually mild and short-lasting inflammation of the glans (balanoposthitis) may occur.
When should you go to the doctor?
In most cases, the body can regulate an imbalance of the vaginal environment on its own. Assuming a healthy lifestyle and a strengthened immune system, a visit to the doctor is not absolutely necessary. Women who are in poor health should discuss the symptoms of bacterial vaginosis (e.g. itching, redness and pain when urinating) with their gynecologist promptly. If the course is severe, in which symptoms increase rapidly and physical and mental well-being worsens, a physician should be consulted immediately. With severe symptoms such as rashes and stabbing pain during urination, hospitalization should be sought. This is especially true if the infection occurs during pregnancy. Improper or too late treatment can then, in the most severe case, lead to rupture of the membranes and cause premature birth. Otherwise, bacterial vaginosis should be medically clarified if secondary infections of the fallopian tubes, cervix and endometrium are suspected. The gynecologist can usually treat the disease quickly and give tips on how to avoid a new infection.
Treatment and therapy
Spontaneous recovery can be observed in 10 to 20 percent of those affected by bacterial vaginosis. Otherwise, bacterial vaginosis is treated medicinally with antibiotics (metronidazole, clindamycin, or nifuratel), which can be administered orally or vaginally and produce positive results in more than 90 percent of affected individuals within a few days. However, recurrence of bacterial vaginosis occurs in many cases. Drug therapy is especially recommended for pregnant women, as untreated bacterial vaginosis increases the risk of preterm labor, premature birth, and the likelihood of neonatal sepsis. Preparations containing lactic acid (vaginal suppositories with lactobacilli), glycogen with a growth-promoting effect on lactobacilli, and suppositories containing ascorbic acid can help stabilize the vaginal flora. To avoid a “ping-pong effect”, it may be useful to treat the partner as well. The male genital area may also have bacteria that cause bacterial vaginosis, but these often do not cause discomfort or an altered skin condition in affected men, so they may unknowingly cause bacterial vaginosis in women.
Outlook and prognosis
The prognosis for bacterial vaginosis depends greatly on proper treatment. Therefore, women who experience symptoms of bacterial vaginosis are strongly advised to seek medical attention. The therapy is carried out through the administration of antibiotics. The standard antibiotic prescribed is metronidazole, which is usually taken orally. After about a week, the normal vaginal flora is restored in four out of five patients. However, the recurrence rate for bacterial vaginosis is high, at about 60 to 70 percent. Alternative treatments such as local administration of lactic acid bacteria are less promising.However, they can help maintain healthy vaginal flora following antibiotic therapy. This can reduce the likelihood of bacterial vaginosis recurring. Another sensible measure is to use condoms during sexual intercourse to avoid re-infection by your partner. If left untreated, bacterial vaginosis can lead to various complications. These include inflammation of the fallopian tubes, ovaries, uterus or cervix. In addition, the bacterial imbalance can be the cause of other infections. Bacterial vaginosis can thus increase the risk of contracting STDs such as chlamydia or even HIV.
Prevention
Bacterial vaginosis cannot be prevented directly. However, the risk of bacterial vaginosis can be minimized by using a condom during sexual intercourse. Furthermore, excessive vaginal hygiene, which can destabilize the balance of vaginal flora, should be avoided. The use of probiotic tampons during menstruation and relaxation techniques to minimize psychosocial stress can also reduce the risk of contracting bacterial vaginosis.
Follow-up
After antibiotics have been administered as scheduled and freedom from symptoms has been achieved, bacterial vaginosis is considered cured. To build up the attacked vaginal flora after antibiotic administration, probiotic pharmaceuticals containing lactobacilli, lactic acid, or preparations containing ascorbic acid are recommended. These are administered intravaginally and promote the reconstruction of the vaginal mucosa. To prevent recurrence of bacterial vaginosis, excessive intimate hygiene should be avoided. It is sufficient to clean the intimate area with clear water; disposable washcloths available in the drugstore can also be used. It is important to dry the vaginal area carefully afterwards. Women should also avoid synthetic underwear or panty liners with plastic protectors, as these can cause heat build-up and excessive moisture in the intimate area. Intimate sprays, soaps and wet wipes are also not recommended for vaginal use, as these can alter the pH value of the vaginal environment and thus make the vaginal flora more susceptible to infection. In addition, care should be taken to clean the anus with toilet paper “from front to back” after using the toilet. This prevents harmful intestinal bacteria from entering the vaginal flora or the urethra and triggering infections there again. Women who developed bacterial vaginosis during their pregnancy should continue to watch for any alarm signals even after successful treatment. If premature labor, rupture of the membranes, or bleeding occurs, medical attention should be sought immediately.
What you can do yourself
Good success is achieved with lactobacillus cultures, because they restore the balance of bacteria. Lactobacilli can also be injected directly into the muscle for a quick effect. The advantage of this is that no hydrogen peroxide is formed, which results in a direct effect in the form of antibodies against the harmful bacteria. A lactic acid cure with a lactic acid gel over a period of seven to ten days is also promising in most cases. The gel is carefully inserted into the vagina using disposable applicators. The ideal acidic ph value can be quickly restored in this way. The vaginal flora can also be restored with high doses of vitamin C, for example as a concentrate in powder form with a high bioavailability. It is simply dissolved in water and can be drunk throughout the day. A sitz bath with vinegar can kill the bad bacteria, clearing the way for healthy bacteria to colonize. Likewise, a sitz bath with a tablespoon of tea tree oil should be applied once a day, this is considered a healing home remedy also for bacterial vaginosis. The mentioned self-help measures are not a substitute for treatment by a family doctor or gynecologist. Contacting the doctor in case of bacterial vaginosis is strongly recommended.