What are the signs and symptoms of bacterial vaginosis in a female patient of reproductive age?

Signs and Symptoms of Bacterial Vaginosis

Bacterial vaginosis presents with a characteristic homogeneous, thin, white-grey vaginal discharge with a fishy odor, though approximately 50% of women meeting diagnostic criteria are completely asymptomatic. 1, 2

Primary Clinical Features

Vaginal Discharge

• A homogeneous, thin, milklike or white-grey discharge that smoothly coats and adheres to the vaginal walls is the hallmark finding 3, 1, 2
• The discharge is characteristically non-inflammatory, meaning it lacks the inflammatory signs seen with other vaginitides 3, 4

Malodor

• A fishy odor is the most common presenting symptom, particularly noticeable after menses or intercourse 2, 5, 6
• This odor becomes more pronounced when vaginal secretions are alkalinized (positive "whiff test" with 10% KOH) 3, 1, 2
• The malodor is often the primary complaint that brings women to seek medical attention 6

Symptoms That Are Typically ABSENT

Minimal Irritative Symptoms

• Significant vulvar irritation, pruritus, dysuria, and dyspareunia are rare or absent in bacterial vaginosis 2, 6
• This distinguishes BV from candidiasis, which typically presents with significant pruritus and vulvovaginal erythema 1
• The absence of polymorphonuclear cells in vaginal discharge explains the lack of inflammatory symptoms, despite the term "vaginosis" rather than "vaginitis" 6

Asymptomatic Presentation

• Up to 50% of women who meet clinical diagnostic criteria for BV have no symptoms whatsoever 3, 2, 7
• Asymptomatic BV remains clinically significant due to associations with pelvic inflammatory disease, adverse pregnancy outcomes, and increased susceptibility to sexually transmitted infections 2, 8

Physical Examination Findings

Vaginal pH

• Vaginal fluid pH greater than 4.5 is a consistent finding 3, 1, 2

Microscopic Findings

• Presence of "clue cells" (vaginal epithelial cells with adherent bacteria obscuring cell borders) on microscopic examination 3, 1, 2
• Absence of significant polymorphonuclear leukocytes despite the presence of discharge 6

Colposcopic Findings

• Punctate colpitis with small regular points may be visible on colposcopy with Lugol test, corresponding to inflammatory foci in connective tissue 6

Common Clinical Pitfall

The most important pitfall is assuming all women with BV will be symptomatic—screening may be warranted before invasive gynecologic procedures even in asymptomatic women due to the association with post-procedural infections. 3, 8