Bacterial vaginosis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Bacterial vaginosis must be differentiated from other diseases that cause purulent, malodorous, thin vaginal discharge with elevated vaginal pH (<4.5). Such diseases include trichomoniasis, atrophic vaginitis, and desquamative inflammatory vaginitis. Additionally, bacterial vaginosis also must be differentiated other conditions such as vaginal candidiasis, vaginitis, and cervicitis.

Differential Diagnosis

A diagnosis of bacterial vaginosis is unlikely in the absence of the following findings:

• Fishy odor (negative whiff test)
• Normal vaginal pH (<4.5)
• Presence of dysuria
• Signs of vaginal inflammation

Bacterial vaginosis must be differentiated from:

Disease	Findings
Trichomoniasis	Presents with purulent, malodorous, thin discharge associated with burning, pruritus, and dysuria, with the sign of vaginal inflammation and elevated vaginal pH (>4.5) Motile trichomonads on wet mount Positive culture (Gold standard) Positive nucleic acid amplification test (NAAT)
Atrophic vaginitis	Progressive symptoms Presents with yellow and malodorous vaginal discharge, vaginal dryness, postcoital bleeding, and dyspareunia with the sign of vaginal inflammation and elevated vaginal pH (>5) Diagnosis is critical and laboratory tests can confirm hypoestrogenic state
Desquamative inflammatory vaginitis	Chronic clinical syndrome with unknown etiology Presents with dyspareunia, dyspareunia, yellow, grey, or green profuse vaginal discharge with the sign of vaginal inflammation and elevated vaginal pH (>4.5) Microscopy shows large number of parabasal (immature squamous epithelial cells) and inflammatory cells
Vaginal candidiasis	Presents with vulvar pruritus and cottage cheese-like vaginal discharge with no or minimal odor with normal vaginal pH (4-4.5) presence of Candida on wet mount (adding 10% KOH destroys the cellular elements and facilitates recognition of budding yeast, pseudohyphae, and hyphae)

References

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