Bacterial Vaginosis in Gynecologic Outpatient Clinic

Dr. Soetomo Hospital January – June 2017: A Cross Sectional Study

Muhammad Arief Adibrata

, Rozi Aditya

, Khanisyah Erza Gumilar

, Manggala Pascawardhana

Budi Wicaksono

, Ernawati

, Agus Sulistyono

, Aditiawarman

, Hermanto Tri Joewono

Muhammad Nadir Abdullah

, Erry Gumilar Dachlan

Muhammad Ilham Aldika Akbar

Resident of Obstetrics and Gynecology, Faculty of Medicine, University of Airlangga, Surabaya, Indonesia

Department Obstetrics and Gynecology Dr. Soetomo General Hospital – UNAIR Hospital

Keywords: bacterial vaginosis, vaginal discharge, vaginal odor, nugent score.

Abstract: Bacterial vaginosis (BV) is a common cause of vaginal discharge in women without a sign of inflammatory.

BV prevalence in Indonesia is around 17-32.5%, and most are women of reproductive age. To determine the

characteristics of patients with bacterial vaginosis. In this cross-sectional study, we include 113 medical

records of patients with whitish vaginal discharge complaints that accompanied by the results of vaginal

swab and Nugent Score at Gynecology outpatient clinic Dr Soetomo Hospital, period January 2017 to June

2017. Prevalence of BV in this study is 11,5%. The productive age of 15-64 years dominates as many as

112 patients (99.1%), with 96% patients married, and 10% already in menopause stated. The most frequent

symptoms found was vaginal itching (59.3%). The use of vaginal douching was found in 60% of patients.

The patients parity averaged 0-1 (nullipara and primparity) were 40%. From the risk factor, we found that

88% of patients did not smoke, majority of contraceptive methods used were IUDs of 49%, and the average

patient BMI status was overweight. Most comorbid infections found was candidiasis (20 patients). About 76

patients (78.4%) show good response to therapy by expressed negative BV with Nugent score criteria. BV

cases show a small prevalences in our gynecology outpatient clinic, but have a significant morbidity to

patients. Appropriate management is needed to improve healing rates and reduce the rate of bacterial

vaginosis recurrence.

1 INTRODUCTION

Bacterial vaginosis (BV) is the most common cause

of vaginal discharge in reproductive age women.

Symptoms are generally characterized by vaginal

discharge (most colored gray to yellow), thin,

homogeneous, smelling, and accompanied by

increased vaginal pH. BV is not an inflammatory

process, so the diagnosis is supported by several

simple clinical and laboratory criteria (Karim, 2016).

Bacterial vaginosis is a disease in the vagina,

caused by disturbance of normal environment of

vagina and vaginal microbiota population. In most

BV cases there are overgrowth of anaerobic bacteria

such as Garnerella sp, Prevotella sp and sp

Atopobium. and commonly affects reproductive age

women. BV infections increases the risk of type 2

HSV infection, Trichomonans vaginalis, Neisseria

gonorrhoeae, Chlamydia trachomatis and HIV. The

prevalence of BV in Indonesia is around 17- 32.5%,

relatively high comparing to other southeast asian

countries such as Thailand 11.5 to 15.9%;

Philippines 7.5%; and Vietnam from 7 to 27.4%.

The risk factors of BV including multipartner sexual

activity, the use of IUDs, ethnicity, use of douching

product, smoking, menstruation, uncircumcised

patner, malnutrition, stress and genetic factors

(Kenyon, Colebunders and Crucitti, 2013)

Gram smear is a standard examination for

diagnosing BV, with sensitivity of 62-100% This

examination is evaluated by Nugent criteria.

(Nugent, Krohn and Hillier, 1991) However, the

data of the prevalence, characteristic and risk factor

of BV patients in Gynecology Outpatient clinic,

have never been reported. Because BV is the most

common vaginal discomfort, investigation of risk

factor BV is important to decide a proper

management for BV patient.

Adibarata, M., Aditya, R., Gumilar, K., Pascawardhana, M., Wicaksono, B., Ernawati, ., Sulistyono, A., Aditiawarman, ., Joewono, H., Abdullah, M., Dachlan, E. and Akbar, M.

Bacterial Vaginosis in Gynecologic Outpatient Clinic Dr. Soetomo Hospital January – June 2017: A Cross Sectional Study.

DOI: 10.5220/0008156303070311

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 307-311

ISBN: 978-989-758-494-7

 2021 by SCITEPRESS – Science and Technology Publications, Lda. All r ights reserved

307

2 METHODS

This research is an analytic observational study with

cross-sectional design to determine the

characteristics and risk factors of BV in our

outpatient clinic. The study was conducted in

Gynecology Outpatient Clinic Dr Soetomo Hospital

Surabaya, in July-September 2017. Data was

collected from January to June 2017 from medical

records (secondary data). Sampling were obtained

with consecutive sampling method, with the

inclusion criteria were all patients with complain of

excessive vaginal discharge (flour albus), who had a

vaginal swab examination, and then assessed by

Nugent criteria. Data collected consist of age,

marital status, chief complaints, use of vaginal

douching, education, patient origin, parity, smoking,

contraceptive methods, BMI (Body Mass Index),

therapy category, comorbidity, menopausal status,

Nugent score, and relapse after Nugent score. The

spesific data collected includes the therapeutic

response and the factors associated with bacterial

vaginosis. Data were analyzed statistically using

SPSS program (Statistical Product and Service

Solutions) no 23. Comparison between groups was

performed by using the Chi-square test or Fisher’s

exact test for the categorical variables. Odds ratios

and 95% confidence intervals were calculated.

Values of p < 0,05 were considered statistically

significant.

Table 1: Characteristics of Patients with symptoms of excessive vaginal discharge in Gynecology Outpatient Clinic of Dr

Soetomo Hospital (January-June 2017).

Variables n (%) median Variables n (%) median

Age (years)

<15 years

15-64

> 64 years

Menopause status

Yes

Originally patient

In the city

Out of town

Etnicithy patients

Java

Madura

Etc

Marital status

Married

Single

Accompanying

symptoms

Vaginal odor

Vaginal itching

Vaginal irritation

Dispareuni

Vaginal douching

Yes

Education

≤ SMP

High School

Bachelor

Parity

0/1

≥ 3

Smoker

0 (0)

112 (99.1)

1 (0.9)

11 (10)

102 (90)

61 (54)

52 (46)

77 (68)

32 (28)

4 (4)

108 (96)

5 (4)

62 (54.8)

67 (59.2)

3 (2.6)

5 (4.4)

68 (60)

45 (40)

37 (32.7)

59 (52.2)

17 (15)

45 (39.8)

39 (34.5)

29 (25.6)

31 BMI

Underweight

Normal

Overweight

Obesity 1

Obesity 2

Obesity 3

Category therapy

Metronidazole po

Metronidazole ovule

Metronidazole

Combination po and

ovules

The combination of

po Metronidazole,

Clindamycin ovules

and po

Combination +

probiotics

The combination of

nystatin

Comorbid patients

Prolapsed uteri

HIV

Inf Gonorrea

Inf Trichomoniasis

Inf Candidiasis

Nugent score

Before therapy

0-3

4-6

7-10

After Nugent score

therapy

0-3

9 (7.9)

28 (24.7)

37 (32.7)

29 (25.6)

8 (7)

2 (1.7)

33 (29.2)

39 (34.5)

36 (31.8)

5 (4.4)

36 (31.8)

13 (11.5)

4 (3.5)

0 (0)

20 (17.6)

16 (14.1)

68 (60.2)

29 (25.6)

92 (81.5)

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

308

Yes

Contraception

IUD

Injectable

Pill

Condom

Sterile

13 (12)

100 (88)

26 (23)

15 (13.2)

2 (1.7)

9 (7.9)

1 (0.8)

60 (53)

4-6

7-10

Recurrence after

normal Nugent

score

<3 months

3-6 months

> 6-12 months

> 12 months

Never relapse

21 (18.5)

0 (0)

11 (9.7)

25 (22.1)

20 (17.6)

16 (14.2)

41 (36.4)

3 RESULTS

This research is an analytic observational study with

cross-sectional design to determine the

characteristics and risk factors of BV in our

outpatient clinic. The study was conducted in

Gynecology Outpatient Clinic Dr Soetomo Hospital

Surabaya, in July-September 2017. Data was

collected from January to June 2017 from medical

records (secondary)

After treatment, re-examination of the Nugent

score was performed to evaluate the effectiveness of

therapy. The results showed 92 patients (81.5%)

had a nugent score 0-3, and 21 patients (18.5%) had

a nugent score >3. Good response was categorized if

Nugent score become 0-3 after therapy. The most

common complaint from all patients with positive

BV, had symptoms vaginal discharge (89,7%),

vaginal odor (56,7%) and vaginal itching (59,8%).

But in this study, there was no significantly

associated with bacterial vaginosis.

This study also analyzes the correlation between

variety risk factors with actual BV diagnosed by

Nugent score, as shown in Table 2. Risk factor

analised consists of menopause, vaginal douching

habits, obesity, IUD, etnicithy, and smoke habits.

We did not find any significant association between

all risk factors and the occurence of BV.

4 DISCUSSION

In this study BV positive cases were found in 97

patients who constitute prevalence of 11.5% in

Gynecology Outpatient Clinic Dr Soetomo Hospital.

99.1% of patients were on their productive age,

around 15-64 years old. This finding is consistent

with previous study, that women on productive age

is a risk factor for BV. And over 40 years old

women is also a risk factor for BV, due to

hipoestrogen state on perimenopausal period.

Decrease estrogen levels can increase vaginal pH,

leading to suboptimal environment for the growth of

Lactobacillus spp. (vaginal normal flora), but in

contrast excessive growth of other microorganisms.

Petricevic et al in his study also found that the levels

of vaginal Lactobacillus spp. decreases with age,

supporting the higher risk of BV in older women

(Karim, 2016) (Kenyon, Colebunders and Crucitti,

2013)

Most patients (96%) were married, consistent

with previous studies finding that sexual intercourse

increases the risk of BV (Karim, 2016) (Bilardi et

al., 2016). The other symptoms that arise beside

vaginal discharge were vaginal odor 54.8%, and

vaginal itching 59,2%. The vaginal odor occurred

due to increased amin especially trimethylalamine

Table 2: Risk Factors Associated with BV.

Risk factor

BV Positive BV Negative

OR (95% CI) p-value

n (%) n (%)

Menopause 10 (10.3%) 1 (6.3%) 1,7 (0,2-14,4) 1.00

Vaginal douching habits 57 (58.8%) 11 (68.8%) 0,6 (0,2-2,0) 0.58

Obesity 41 (42.3%) 6 (37.5%) 1,2 (0,4- 3,6) 0.79

IUD 22 (22.7%) 4 (25%) 0,8 (0,2-3,0) 0.76

Etnicithy

Java

Madura

68 (70.1%)

25 (25.8%)

9 (56.3%)

7 (43.8%)

2,1 (0,7-6,2)

ref

0.23

Smoke 11 (11.3%) 2 (12.5%) 0,8 (0,1-4,4) 1.00

isher’s exact tes

Bacterial Vaginosis in Gynecologic Outpatient Clinic Dr. Soetomo Hospital January – June 2017: A Cross Sectional Study

309

produced by microorganisms such as G. vaginalis,

M. hominis, and Mobiluncus spp, which is

overgrowth in BV. Semen which is alkaline (pH 7.2)

lead to the release of amin from its attachment with

the protein amine and producing a typical odor

(Karim, 2016) (Bradshaw et al., 2013).

The use of vaginal douching is a risk factor for

BV occurence in some women. This study found

that 60% BV patients frequently used vaginal

douching. Washing the vagina (douching) associated

with complaints of dysuria, vaginal discharge, and

itching of the vagina. Vaginal douching, reported to

cause changes in vaginal pH and reduces the

concentration of normal microbiota, facilitating the

growth of opportunistic pathogenic bacteria. The

cessation of this habit may reduce the risk of BV

(Brotman et al., 2008).

Most patients with BV in this study were

classified overweight and obesity. Ventolini et al

showed that obesity increases the risk of BV by 4

fold. Obesity is a mild inflammatory condition,

which affect the mechanisms of immunity in the

vagina. Obesity is an independent risk factor of BV

(Ventolini et al., 2017).

IUD is a contraceptive method that widely used

in patients with BV. Previous study showed that

IUD users had 1.84 times increased risk of BV. The

IUD can alter the normal vaginal flora, and promote

the growth of pathogenic bacteria (Joesof et al.,

2001) (Oduyebo, Anorlu and Ogunsola, 2009).

Analysis on our study showed contrary result, that

IUD was not significantly increases the risk of BV.

Most symptoms that emerged in this study was

excessive vaginal discharge, vaginal odor and

itching. These are in line with previous study

conducted by Abdul Karim and Jusuf Barakbah in

Dermatology Outpatient Clinic Dr. Soetomo

Hospital, where 33.3% of patients experiencing

vaginal odor and 28.6% complained vaginal itching.

Association between accompanying complain and

BV in this study were not significant (p>0.05).

In term of response to BV therapy, 78.4%

showed good result and improved condition, as seen

by negative BV examination. Treatment evaluation

was performed using vaginal swab then assessed by

Nugent score. Metronidazole and Clindamycin are

used as the first line therapy in this study, as

recommended by CDC in 2014 (Oduyebo, Anorlu

and Ogunsola, 2009) (Hoffman et al., 2016).

Metronidazole inhibit anaerobes that support

Gardnerella vaginalis but do not affect Lactobacilli

spp., thereby reducing the risk of late-stage relapse.

Clindamycin is effective alternative drug. All these

antibiotics have been shown to achieve cure rates of

70% to 80% after treatment (Oduyebo, Anorlu and

Ogunsola, 2009). The reccurance rate of BV after

successfull therapy show variety result, starting from

< 3 month until > 1 years, and fortunately 36.4% of

patients never experienced relapse This study did not

found any significant association between all risk

factors and BV.

5 CONCLUSIONS

In this study, it was concluded that the

characteristics of the patients who come to the

Gynecology Outpatient Clinic Dr Soetomo Hospital

complaining excessive vaginal discharge are on

productive age. Most patients diagnosed using

vaginal swab and Nugent score. The treatment of

BV using standard regimen such as Metronidazole

and Clindamycin still proven to be effective, and

able to prevent some relapse.Unfortunately in this

study we could not found any significant association

between all risk factors and BV.

ACKNOWLEDGEMENTS

The authors wish to thank all Resident Obstetric

Gynecolgy and staff in Gynecology Outpatient

Clinic Dr Soetomo Hospital for their dedication in

collecting data, and all the women whose

participation contributed to the success of this study.

REFERENCES

Bilardi J, Walker S, Mooney-Somers J, Temple-Smith M,

McNair R, Bellhouse C, et al. 2016. Women’s views

and experiences of the triggers for onset of bacterial

vaginosis and exacerbating factors associated with

recurrence. PLoS One [Internet]. 11(3):1–15.

Available from:

http://dx.doi.org/10.1371/journal.pone.0150272

Bradshaw CS, Vodstrcil LA, Hocking JS, Law M, Pirotta

M, Garland SM, et al. 2013. Recurrence of bacterial

vaginosis is significantly associated with posttreatment

sexual activities and hormonal contraceptive use. Clin

Infect Dis, 56(6):777–86.

Brotman RM, Ghanem KG, Klebanoff MA, Taha TE,

Scharfstein DO, Zenilman JM. 2008. The effect of

vaginal douching cessation on bacterial vaginosis: a

pilot study. Am J Obstet Gynecol, 198(6).

Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM,

Schaffer JI, Corton MM. 2016. Gynecologic Infection.

In: Williams Gynecology. 3rd ed. New York:

McGraw-Hill Education LLC; p. 50–2.

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

310

Joesoef MR, Karundeng A, Runtupalit C, Moran JS,

Lewis JS, Ryan CA. 2001. High rate of bacterial

vaginosis among women with intrauterine devices in

Manado , Indonesia. Contraception, 64:169–72.

Karim A, Barakbah J., 2016. Studi Retrospektif :

Vaginosis Bakterial ( Retrospective Study : Bacterial

Vaginosis ). Period Dermatology Venereol 5, 127-33.

Kenyon C, Colebunders R, Crucitti T. 2013. The global

epidemiology of bacterial vaginosis : a systematic

review “ B. Am J Obstet Gynecol [Internet]. Elsevier

Inc; Available from:

http://dx.doi.org/10.1016/j.ajog.2013.05.006

Nugent RP, Krohn MA, Hillier SL. 1991. Reliability of

diagnosing bacterial vaginosis is improved by a

standardized method of gram stain interpretation. J

Clin Microbiol, 29(2):297–301.

Oduyebo OO, Anorlu RI, Ogunsola FT. 2009. The effects

of antimicrobial therapy on bacterial vaginosis in non-

pregnant women ( Review ), (3).

Ventolini G, Khandelwal N, Hutton K, Lugo J, Gygax SE,

Schlabritz-Loutsevitch N. 2017. Obesity and recurrent

vulvovaginal bacterial infections in women of

reproductive age. Postgraduate Medical Journal. p.

297.

Watcharotone W, Sirimai K, Nukoolkarn P, Pibulmanee S,

Leckyim N, Kiriwat O, et al. 2014. Prevalence of

bacterial vaginosis in Thai women attending the

Family Planning Clinic , Siriraj Hospital Prevalence of

Bacterial Vaginosis in Thai Women attending the

Family Planning Clinic , Siriraj Hospital;(December

2004).

Bacterial Vaginosis in Gynecologic Outpatient Clinic Dr. Soetomo Hospital January – June 2017: A Cross Sectional Study

311