Epidemiology

Bacterial vaginosis (BV) is the most common cause of vaginitis in women of childbearing age [2]. BV has been diagnosed in 17–19% of women who seek gynecologic care in family practice or student health care settings [2]. It has also been observed in 16–29% of pregnant women, and its prevalence increases considerably among symptomatic women in STI clinics, ranging from 24% to 37% [2]. Although Gardnerella vaginalis, one of the predominant organisms found in BV, has been found in 10–31 % of virgin adolescent girls, it is still found significantly more often among sexually active women, reaching a prevalence of 50–60% in some populations at risk for infection [3], Epidemiologie study has revealed that intrauterine devices, intravaginal pessaries, smoking, and douches were found to be more common in women with BV. BV is significantly more common in blacks and lesbians, and in women with a multiple number of sexual partners in the prior 12 months [2],

Signs and symptoms cannot reliably diagnose BV. The diagnosis is made by the presence of at least three of the following Amsel criteria: (1) an adherent, white, nonfloccular, homogenous discharge; (2) a positive amine test, with release of fishy odor on addition of 10% KOH to vaginal secretions; (3) a vaginal pH > 4.5; and (4) the presence of clue cells on light microscopy (the most reliable predictor). These criteria are simple, reliable, and easy to test.

At least 20% of observed epithelial cells should be clue cells, the exfoliated vaginal squamous epithelial cells covered with G. vaginalis, for this finding to be of diagnostic significance. The fishy odor may be apparent during the physical examination or the “whiff” (i.e., amine) test. A Gram stain of vaginal secretions is valuable in making the diagnosis, with a sensitivity of 93% and specificity of 70% [7].

Although cultures for G. vaginalis are positive in almost all cases of BV, the organism also may be detected in 50–60% of women who do not meet the diagnostic criteria for the disease [7]. Vaginal cultures are not used to diagnose BV.

Poor efficacy has been observed in the treatment of BV with triple sulfa creams, erythromycin, fiuoroquinolone, ampiciHin, tetracycline, acetic acid gel, and providoneiodine vaginal douches [8]. The most successful oral therapy is metronidazole. Multiple divideddose regimens of metronidazole at 800–1200 mg/day for 1 week achieved clinical cure rates in excess of 90% immediately and of approximately 80% at 4 weeks [8]. Although singledose therapy with 2 g of metronidazole achieved similar immediate clinical response rates, higher recurrence rates have been reported. The beneficial effect of metronidazole results primarily from its antianaerobic activity and its hydroxymetabolites.

Topical therapy with 2% clindamycin (once daily for 7 days) cream or suppositories, or metronidazole gel 0.75% (once daily for 5 days) has been shown to be as effective as oral metronidazole in eliminating BV without the side effects of the oral medication. Singledose vaginal clindamycin in a bioadhesive preparation is also available.

In the past, asymptomatic BV was not treated because patients often improved spontaneously over several months. However, the growing evidence linking asymptomatic BV with numerous obstetric and gynecologic complications involving the upper reproductive tract has prompted a reassessment of this policy, especially with the availability of convenient topical therapies [6].

Asymptomatic BV should be treated before pregnancy, in women with cervical abnormalities, and before elective gynecologic surgery. Routine screening and treatment for asymptomatic BV in pregnancy is controversial. Some controlled studies have shown that treatment of BV with topical clindamycin and oral metronidazole may reduce preterm labor and prematurity, but only in women with a past history of preterm labor. At present, this category of women seems most suited for screening [9]. Despite indirect evidence of its sexual transmission, no study has documented reduced recurrence rates of BV in women whose partners have been treated with a variety of regimens, including metronidazole. Accordingly, most clinicians do not routinely treat the male partners of affected women.

After treatment with oral metronidazole, symptoms of BV recur within 3 months in approximately 30% of patients who initially respond [7]. The reasons for such recurrence are unclear; possibilities include reinfection or vaginal relapse due to failure to eradicate the offending organisms and concurrent failure of the Lactobacillus-dominant vaginal flora to reestablish itself. Management of symptoms of acute BV during relapse includes treatment with oral or vaginal metronidazole or topical clindamycin, usually prescribed for a longer (10–14 days) period than the initial treatment regimen.

A recent study found that long-term suppressive maintenance therapy with twice weekly metronidazole gel (0.75%) is an effective prophylaxis, but long-term cure occurred in < 50% [10]. Attempts to prevent relapse by use of exogenous Lađobacilluspiepnmtions have been reasonably successful but remain controversial [11],

Epidemiology

Studies estimate that 3–5 million American women contract trichomoniasis annually, with a worldwide distribution of approximately 180 million cases each year [ 12]. The prevalence of trichomoniasis correlates with the overall level of sexual activity of the group of women studied, with the disease diagnosed in approximately 5% of women in family-planning clinics, 13–25% of women in gynecology clinics, 50–75% of sex workers, and 7–35% of women in STI clinics. Recent surveys indicate a decline in the incidence of trichomoniasis in many industrialized countries [12],