Can bacterial vaginosis (BV) present with symptoms of pelvic pressure and itching?

Bacterial Vaginosis Does Not Typically Present with Pelvic Pressure and Itching

Bacterial vaginosis (BV) typically presents with a fishy odor and homogeneous white discharge, but does not commonly cause significant vulvar irritation, itching, or pelvic pressure. 1

Clinical Presentation of Bacterial Vaginosis

• BV is the most prevalent cause of vaginal discharge and malodor, with up to 50% of women with BV being asymptomatic 2, 1
• The classic symptoms of BV include:
  • A homogeneous, white, non-inflammatory discharge that smoothly coats the vaginal walls 2
  • A fishy odor of vaginal discharge, especially noticeable after addition of 10% KOH (positive "whiff test") 2
• BV is not typically associated with significant vulvar irritation or itching 1
• Pelvic pressure is not a characteristic symptom of BV 1, 3

Diagnostic Criteria for Bacterial Vaginosis

BV is diagnosed using clinical criteria (Amsel criteria) requiring three of the following:

• Homogeneous, white, non-inflammatory discharge that smoothly coats vaginal walls 2, 1
• Presence of clue cells on microscopic examination 2
• Vaginal fluid pH greater than 4.5 2
• Fishy odor of vaginal discharge before or after addition of 10% KOH (whiff test) 2

Alternatively, Gram stain (Nugent criteria) can be used for diagnosis, determining the relative concentration of bacterial morphotypes characteristic of BV 2, 1

Differential Diagnosis When Itching is Present

• Vulvovaginal candidiasis (yeast infection) is more commonly associated with itching, burning, and sometimes pelvic discomfort 3

  • Presents with white, cottage cheese-like discharge and vulvar erythema 4, 3
  • Microscopy shows yeast or pseudohyphae in KOH preparation 2

• Trichomoniasis can cause vaginal or vulvar irritation with profuse yellow-green discharge 4, 3

  • Motile trichomonads can be seen on saline microscopy 2

• Noninfectious causes of vaginal itching and discomfort include:

  • Atrophic vaginitis 3
  • Irritant or allergic vaginitis 2, 3
  • Inflammatory vaginitis 3

Clinical Significance and Pitfalls

• The presence of itching and pelvic pressure should prompt consideration of other diagnoses beyond BV 3
• Misdiagnosis can lead to inappropriate treatment and persistent symptoms 4, 3
• BV is associated with increased risk for pelvic inflammatory disease, preterm birth, and increased susceptibility to STIs 1, 5
• Laboratory testing fails to identify the cause of vaginitis in a substantial minority of women 2

Treatment Approach

• BV is treated with antibiotics such as metronidazole (500 mg orally twice daily for 7 days) or clindamycin 2, 1
• Treatment of male sexual partners is not beneficial in preventing recurrence of BV 2, 1
• BV has a high recurrence rate (50-80% within a year) 1, 6
• If symptoms of itching and pelvic pressure persist after appropriate BV treatment, further evaluation for other causes is warranted 3