What are the symptoms of bacterial vaginosis?

Symptoms of Bacterial Vaginosis

The primary symptoms of bacterial vaginosis (BV) include a fishy or musty odor, thin homogeneous white discharge that adheres to vaginal walls, and often minimal to no inflammation or irritation. 1

Key Clinical Manifestations

Bacterial vaginosis presents with the following characteristic symptoms:

• Vaginal discharge:

  • Homogeneous, thin, white, milky discharge 1, 2
  • Discharge that adheres to vaginal walls 1
  • May be more noticeable after intercourse 3

• Odor:

  • Fishy or musty odor, particularly noticeable after intercourse 1, 4
  • The odor is often the most bothersome symptom for patients 1
  • Becomes more pronounced when mixed with alkaline substances (e.g., semen, menstrual blood) 2

• Other characteristics:

  • Typically minimal or no inflammation 1
  • Usually minimal or no itching (unlike yeast infections) 1
  • Elevated vaginal pH (>4.5) 1, 3

Important Clinical Considerations

• Asymptomatic cases: More than 50% of women with BV may be asymptomatic 3, making routine screening important in certain high-risk populations

• Diagnostic criteria: BV is diagnosed using Amsel's criteria, which requires the presence of at least 3 of 4 findings 1, 5:

  1. Homogeneous, white, non-inflammatory discharge adhering to vaginal walls
  2. Presence of clue cells on microscopic examination
  3. Vaginal fluid pH greater than 4.5
  4. Fishy odor of vaginal discharge before or after addition of 10% KOH (positive whiff test)

• Differential diagnosis: BV must be distinguished from other common vaginal infections 1:

  • Vulvovaginal candidiasis: characterized by thick "cottage cheese-like" discharge, intense itching, and normal pH (≤4.5)
  • Trichomoniasis: typically presents with yellow-green discharge and vaginal/vulvar irritation

Clinical Pitfalls and Caveats

• BV symptoms may be confused with normal physiologic discharge, especially in women who have mild symptoms 1
• The fishy odor may be temporarily masked by douching or recent bathing, leading to missed diagnosis 1
• BV increases susceptibility to sexually transmitted infections, including HIV 6
• BV is associated with numerous obstetric complications including preterm birth, premature rupture of membranes, and postpartum endometritis 1, 3
• Self-diagnosis and treatment without proper evaluation may lead to delayed diagnosis of other conditions with similar symptoms 1

Risk Factors

Several factors increase the risk of developing bacterial vaginosis 3:

• Multiple sexual partners
• Exposure to semen
• Prior trichomoniasis
• Intrauterine device usage
• Smoking
• Frequent use of scented soaps
• African-American ethnicity
• Low socioeconomic status
• Previous preterm or low-birthweight deliveries 1

Understanding these symptoms and risk factors is essential for proper diagnosis and management of bacterial vaginosis, which remains the most common cause of vaginal odor, accounting for 40-50% of cases 1.