A 19-year-old nulliparous woman presents to her gynecologist with the complaint of a vaginal discharge with a fishy odor over the past 2 weeks. The patient is sexually active and states that the odor is especially prominent after intercourse. Her last menstrual period was 3 weeks ago. She denies having any history of sexually transmitted diseases. She is in good health and takes no medications other than an oral contraceptive agent.
On examination, her blood pressure (BP) is 110/70 mm Hg, heart rate (HR) is 80 beats per minute, and temperature is afebrile. The thyroid is normal to palpation. The heart and lung examinations are normal. The external genitalia are normal; the speculum examination reveals a homogeneous, white vaginal discharge and a fishy odor. No erythema or lesions of the vagina are noted.
1. What is the most likely diagnosis?
2. What is the best treatment for this condition?
Answer And Discussion:
1. What is the most likely diagnosis?
Answer: Most likely diagnosis is Bacterial vaginosis.
Discussion: Avaginal discharge that has a fishy odor, is the most common symptom of bacterial vaginosis. The discharge associated with BV has a typical white, homogenous vaginal coating, described like “spilled milk over the tissue.” The pH is not given in this scenario and although a whiff test was not performed with KOH in this patient, the worsening of the discharge after intercourse is presumably due to the alkaline semen. The vaginal epithelium is not erythematous or inflamed, which also fits with bacterial vaginosis.
Of the three most common causes of infectious vaginal discharge (Candida, Trichomonas, and BV),
bacterial vaginosis is the only etiology that is not inflammatory.
2. What is the best treatment for this condition?
Answer: Best treatment for this condition: Metronidazole orally or vaginally; clindamycin is an alternative.
Discussion: Bacterial Vaginosis is a result of a predominance of anaerobic bacteria rather than a true infection. Hence, antibiotic therapy targeting anaerobes, such as metronidazole or clindamycin, is appropriate.
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