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 elevatedvaginal PH (<4.5) such as trichomoniasis, atrophic vaginitis, and desquamative inflammatory vaginitis. additionally bacterial vaginosis also must be differentiated other conditions such as from vaginal candidiasis, vaginitis and cervicitis.

Differential Diagnosis

Bacterial vaginosis diagnosis is unlikely In the absence of following findings:

• Fishy odor (negative whiff test)
• Normal vaginal PH (<4.5)
• Presents of dysuria
• signs of inflammation in vagina

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)

trichomoniasis, atrophic vaginitis, and desquamative inflammatory vaginitis. These four entities are easily distinguishable by clinical and microscopic features.

●Women with BV do not have dyspareunia or signs of vaginal inflammation; in contrast, women with atrophic vaginitis, desquamative inflammatory vaginitis, and trichomoniasis usually have these signs and symptoms. ●Both atrophic vaginitis and desquamative inflammatory vaginitis are associated with an increased number of parabasal cells on microscopy, which is not observed in women with BV. ●A large number of polymorphonuclear leukocytes on microscopy are characteristic of desquamative inflammatory vaginitis, trichomoniasis, and atrophic vaginitis with infection, but not BV. ●Visualization of trichomonads readily makes the diagnosis of trichomoniasis in the setting of an elevated pH, however, in other cases, we suggest using more sensitive and specific diagnostic tests to diagnose or exclude trichomoniasis.

References

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