Skip to main content
SpringerLink
Log in

Management of Vaginosis

Prevention and Treatment

  • Published:
Drug Investigation Aims and scope Submit manuscript

Summary

Although trichomoniasis and bacterial vaginosis represent opposite ends of the clinical spectrum (vaginitis versus vaginosis) and are due to entirely different pathogenic mechanisms, they nevertheless share several characteristics. Common manifestations include a malodorous vaginal discharge, a massive disruption of the normal lactobacillus-dominant flora, elevated pH, and overgrowth of vaginal anaerobes. What these 2 conditions have most in common is an exquisite susceptibility to nitroimidazole agents. For many years, oral multidose metronidazole was the only available nitroimidazole for the indication; however, the recent availability of single dose, long-acting secnidazole offers a useful alternative to conventional therapy. Moreover, although several new options are now available for the treatment of bacterial vaginosis, namely vaginal clindamycin and metronidazole gel, no vaginal regimens are available for the treatment of trichomoniasis. Finally, while clindamycin availability ensures safe treatment of bacterial vaginosis in pregnancy, nitroimidazole therapy is not endorsed for use in the first trimester of pregnancy, and this therapeutic need remains unanswered.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Rein M, Muller M. Trichomonas vaginalis and trichomoniasis. In: Holmes KK. editor. Sexually transmitted diseases. 2nd ed. New York: McGraw Hill, 1989: 581–92

    Google Scholar 

  2. Honigberg B. Trichomonas of importance in human medicine. In: Krieger JP, editor. Parasitic protozoa, vol. 2. New York: Academic Press, 1978: 275

    Google Scholar 

  3. Latif AS, Mason PR, Marowa E, et al. Urethral trichomoniasis in men. Sex Transm Dis 1987; 14: 9

    Article  PubMed  CAS  Google Scholar 

  4. Weston TET, Nicol CS. Natural history of trichomonal infection in males. Br J Vener Dis 1963; 39: 251

    PubMed  CAS  Google Scholar 

  5. Wolner-Hanssen P, Krieger JN, Stevens CE, et al. Clinical manifestations of vaginal trichomoniasis. JAMA 1989; 261: 571

    Article  PubMed  CAS  Google Scholar 

  6. Krieger JN, Jenny C, Verdon M, et al. Clinical manifestations of trichomoniasis in men. Ann Intern Med 1993; 118: 844–9

    PubMed  CAS  Google Scholar 

  7. Barbone F, Austin H, Louv WC, et al. A follow-up study of methods of contraception, sexual activity. and rates of trichomoniasis, candidiasis, and bacterial vaginosis. Am J Obstet Gynecol 1990; 163: 510–4

    PubMed  CAS  Google Scholar 

  8. Dykes JR. Single dose metronidazole for trichomonal vaginitis. N Engl J Med 1975; 293: 23

    Article  Google Scholar 

  9. Lossick JG. Treatment of sexually transmitted vagnosis/vaginitis. Rev Infect Dis 1990; 12: S665

    Article  PubMed  Google Scholar 

  10. Lossick JG, Muller M, Gorell TE. In vitro drug susceptibility and doses of metronidazole required for cure in cases of refractory vaginal trichomoniasis. J Infect Dis 1986; 153: 948

    Article  PubMed  CAS  Google Scholar 

  11. Centers for Disease Control. Sexually transmitted diseases treatment guidelines. Sept 1993. Morb Mortal Wkly Rep 1993; 42: 70

  12. Fleury FJ, Van Bergan WS, Prentice RL, et al. A single dose of two grams of metronidazole for Trichomonas vaginalis vaginitis. Am J Obstet Gynecol 1977; 128; 320

    PubMed  CAS  Google Scholar 

  13. Hager WD, Brown ST, Kraus SJ, et al. Metronidazole for vaginal trichomoniasis; seven day vs single dose regimens. JAMA 1980; 244: 1219–20

    Article  PubMed  CAS  Google Scholar 

  14. Alvarez AB, Quiroz RT, Léon DF. Tratamiento de la vaginitis par tricomonas con secnidazol em dosis única. Invest Med Int 1978; 5/5: 476–82

    Google Scholar 

  15. Machado D, Machado KE. A single dose of secnidazole in the treatment of vaginal trichomoniasis: a comparative study of morning and evening doses. In: Katz N, Willis AT, editors. Secnidazole: a new approach in 5-nitroimidazole therapy. Proceedings of the 16th International Congress of Chemotherapy; 1989 Jun 11-16; Jerusalem. Amsterdam: Excerpta Medica, 1989: 71–7

    Google Scholar 

  16. Siboulet A, Catalàn F, Videau D, et al. Latrichomase urogénitale essais d’un imidazole à demi-vie prolongée: le secnidazole. Méd Mal Infect 1977; 7: 400–9

    Article  Google Scholar 

  17. Muller M, Lossick JG, Gorrell TE. In vitro susceptibility of Trichomonas vaginusis to metronidazole and treatment outcome in vaginal trichomoniasis. Sex Transm Dis 1988; 15: 17–24

    Article  PubMed  CAS  Google Scholar 

  18. Schmitt C, Sobel JD, Meriwether C. Bacterial vaginosis: treatment with clindamycin cream versus oral metronidazole. Obstet Gynecol 1992; 79: 1020

    PubMed  CAS  Google Scholar 

  19. Dombrowski MP, Sokol RJ, Brown WJ, et al. Intravenous therapy of metronidazole-resistant Trichomonas vaginalis. Obstet Gynecol 1987: 69: 524–5

    PubMed  CAS  Google Scholar 

  20. Rabbie MO, Sweet RL. Metronidazole use in obstetrics and gynecology: a review. Am J Obstet Gynecol 1983; 145: 865

    Google Scholar 

  21. Goldman P. Metronidazole. N Engl J Med 1979; 301: 519

    Article  Google Scholar 

  22. Redondo-Lopez V, Meriwether C, Schmitt C, et al. Vulvovaginal candidiasis complicating recurrent bacterial vaginosis. Sex Transm Dis 1990; 17: 51–3

    PubMed  CAS  Google Scholar 

  23. Eschenbach DA, Davick PR, Williams BL, et al. Prevalence of hydrogen peroxide-producing Lactobacillus species in normal women and women with bacterial vaginosis. J Clin Microb 1989; 27: 251–6

    CAS  Google Scholar 

  24. Hill GB. The microbiology of bacterial vaginosis. Am J Obstet Gynecol 1993; 169: 450

    PubMed  CAS  Google Scholar 

  25. Eschenbach DA, Hillier S, Critchlow C, et al. Diagnosis and clinical manifestation of bacterial vaginosis. Am J Obstet Gynecol 1988; 158: 819–28

    PubMed  CAS  Google Scholar 

  26. Hill LH, Ruparelia H, Embil JA, et al. Non-specific vaginitis and other genital infections in three clinic populations. Sex Transm Dis 1983; 3: 114–118

    Google Scholar 

  27. Gravett MG, Hummel D, Eschenbach DA, et al. Preterm labor associated with subclinical amniotic fluid infection and with bacterial vaginosis. Obstet Gynecol 1986; 67: 229–37

    Article  PubMed  CAS  Google Scholar 

  28. Martius J, Eschenbach DA. The role of bacterial vaginosis as a cause of amniotic fluid infection, chorioamnionitis and prematurity - a review. Universitats-Frauenklinik Wurzburg, FRG. Arch Gynecol Obstet 1990; 247: 1

    Article  PubMed  CAS  Google Scholar 

  29. Amsel R, Totten P, Spiegel C, et al. Nonspecific vaginitis: diagnostic criteria and microbiotic and epidemiologic associations. Am J Med 1983; 74: 14–22

    Article  PubMed  CAS  Google Scholar 

  30. Spiegel CA, Amsel R, Eschenbach D, et al. Anaerobic bacteria in nonspecific vaginitis. N Engl J Med 1980; 303: 601

    Article  PubMed  CAS  Google Scholar 

  31. Gardner HL, Dukes CD. Haemophilus vaginalis vaginitis. A newly defined specific infection previously classified ‘nonspecific’ vaginitis. Am J Obstet Gynecol 1955; 69: 962

    PubMed  CAS  Google Scholar 

  32. McCormack WM, Hayes WM, Rosner CM, et al. Vaginal colonization with Corynebacterium vaginale (Haemophilus vaginalis). J Infect Dis 1977; 136: 740–54

    Article  PubMed  CAS  Google Scholar 

  33. Pheifer TA, Forsyth PS, Durfee MA, et al. Nonspecific vaginitis: role of Haemophilus vaginalis and treatment with metronidazole. N Engl J Med 1978; 298: 1429

    Article  PubMed  CAS  Google Scholar 

  34. Bump RC, Buesching III WJ. Bacterial vaginosis in virginal and sexually active adolescent females: evidence against exclusive sexual transmission. Obstet Gynecol 1988; 158: 935

    CAS  Google Scholar 

  35. Hooton TM, Fihn SD, Johnson C, et al. Association between bacterial vaginosis and acute cystitis in women using diaphragms. Arch Intern Med 1989; 149: 1932–6

    Article  PubMed  CAS  Google Scholar 

  36. Eschenbach DA. Treatment of vaginitis. In: Horowitz BJ, Mardh P-A, editors. Vaginitis and vaginosis. New York: Wiley-Liss, 1991: 195

    Google Scholar 

  37. Malouf M, Fortier M, Morin G, et al. Treatment of Haemophilus vaginalis vaginitis. Obstet Gynecol 1981; 57: 711–4

    PubMed  CAS  Google Scholar 

  38. McGregor JA, French JI, Richter R, et al. Cervica vaginal microflora and pregnancy outcome: results of a double-blind, placebo controlled trial of erythromycin treatment. Am J Obstet Gynecol 1990; 163: 1580

    PubMed  CAS  Google Scholar 

  39. Ralph ED. Comparative antimicrobial activity of metronidazole and the hydroxy metabolite against Gardnerella vaginalis. Scand J Infect Dis 1983; 40: 115

    CAS  Google Scholar 

  40. Jones BM, Geary I, Alawattegama AB, et al. In vitro and in vivo activity of metronidazole against Gardnerella vaginalis, Bacteroides sp. and Mobiluncus sp. in bacterial vaginosis. J Antimicrob Chemother 1985; 16: 189–97

    Article  PubMed  CAS  Google Scholar 

  41. Larsson PG, Platz-Christensen JJ, Thejls H. Incidence of pelvic inflammatory disease after first trimester legal abortion in women with bacterial vaginosis after treatment with metronidazole: a double-blind, randomized study. Am J Obstet Gynecol 1992; 166: 100–3

    PubMed  CAS  Google Scholar 

  42. Spiegel CA. Susceptibility of Mobiluncus species to 23 antimicrobial agents and 15 other compounds. Antimicrob Agents Chemother 1987; 31: 249

    Article  PubMed  CAS  Google Scholar 

  43. Piot P. Bacterial vaginosis. An evaluation of treatment. Scand J Urol Nephrol 1985; 87Suppl.: 229

    Google Scholar 

  44. Balsdon MJ. Treatment of the Gardnerella vaginalis syndrome with a single 2 gram oral dosage of metronidazole. Scand J Infect Dis 1983; 40: 101

    CAS  Google Scholar 

  45. Eschenbach DA, Critchlow CW, Watkins H, et al. A dose-duration study of metronidazole for the treatment of nonspecific vaginosis. Scand J Infect Dis Suppl 1983; 40: 73–80

    PubMed  CAS  Google Scholar 

  46. Swedberg J, Steiner JF, Deiss F, et al. Comparison of single dose versus one week course of metronidazole for symptomatic bacterial vaginosis. JAMA 1985; 254: 1046–9

    Article  PubMed  CAS  Google Scholar 

  47. Larsson PG. Treatment of bacterial vaginosis. Int J STD AIDS 1992; 3: 239

    PubMed  CAS  Google Scholar 

  48. Hillier S, Krohn MA, Watts H. Microbiologic efficacy of intravaginal clindamycin cream for the treatment of bacterial vaginosis. Obstet Gynecol 1990; 76: 407–13

    PubMed  CAS  Google Scholar 

  49. Lugo-Miro VI, Green M, Mazur L. Comparison of different metronidazole therapeutic regimens for bacterial vaginosis. A meta-analysis. JAMA 1992; 268: 92

    Article  PubMed  CAS  Google Scholar 

  50. Hegg R, Ribeiro RM, Bagnoli VR, et al. Treatment of non-specific vaginitis with secnidazole and metronidazole. In: Katz N, Willis AT, editors. Secnidazole: a new approach in 5-nitroimidazole therapy. Proceedings of the 16th International Congress of Chemotherapy; 1989 Jun 11-16: Jerusalem. Amsterdam: Excerpta Medica, 1989: 65–70

    Google Scholar 

  51. Brenner WE, Dingfelder JR. Metronidazole-containing vaginal sponges for the treatment of bacterial vaginosis. Adv Contracept 1986; 2: 363

    Article  PubMed  CAS  Google Scholar 

  52. Bro F. Metronidazole pessaries compared with placebo in the treatment of bacterial vaginosis. Scand J Prim Health Care 1990: 8: 219

    Article  PubMed  CAS  Google Scholar 

  53. Edelman DA, North BB. Treatment of bacterial vaginosis with intravaginal sponges containing metronidazole. J Reprod Med 1989; 34: 341

    PubMed  CAS  Google Scholar 

  54. Hillier S, Lipinski C, Briselden AM. Efficacy of intravaginal 0.75% metronidazole gel for treatment of bacterial vaginosis. Obstet Gynecol 1993; 81: 963

    PubMed  CAS  Google Scholar 

  55. Alper MM, Barwin N, McClean WM, et al. Systemic absorption of metronidazole by the vaginal route. Obstet Gynecol 1985; 65: 781–84

    PubMed  CAS  Google Scholar 

  56. Fredricsson B, Hagstrom B, Word CE, et al. Systemic concentrations of metronidazole and its main metabolites after intravenous, oral and vaginal administration. Gynecol Obstet Invest 1987; 24: 200–7

    Article  PubMed  CAS  Google Scholar 

  57. Plosker GL. Possible interaction between ethanol and vaginally administered metronidazole. Clin Pharm 1987; 6: 189

    PubMed  CAS  Google Scholar 

  58. Greaves WL, Chungafung J, Morris B, et al. Clindamycin versus metronidazole in the treatment of bacterial vaginosis. Obstet Gynecol 1988; 72: 799–802

    PubMed  CAS  Google Scholar 

  59. McGregor JA, French JI, Seo K. Adjunctive clindamycin therapy for preterm labor: results of a double-blind, placebo-controlled trial. Am J Obstet Gynecol 1991; 165: 867

    PubMed  CAS  Google Scholar 

  60. Livengood CH, Thomason JL, Hill GB. Bacterial vaginosis: treatment with topical intravaginal clindamycin phosphate. Obstet Gynecol 1990; 76: 118

    PubMed  Google Scholar 

  61. Stein GE, Christensen SL, Mummaw NL, et al. Placebo-controlled trial of intravaginal clindamycin 2% cream for the treatment of bacterial vaginosis. Ann Pharmacother 1993; 27: 1343–5

    PubMed  CAS  Google Scholar 

  62. Higuera F, Hidalgo H, Sanchez CJ. Bacterial vaginosis: a comparative, double-blind study of clindamycin vaginal cream versus oral metronidazole. Curr Ther Res 1993; 54: 98–110

    Article  Google Scholar 

  63. Thomason JL, Gelbart SM, Scaglione NJ. Bacterial vaginosis: current review with indications for asymptomatic therapy. Am J Obstet Gynecol 1991; 265: 1210

    Google Scholar 

  64. Bump RC, Zuspan FP, Buesching WJ, et al. The prevalence, six-month persistence, and predictive values of laboratory indicators of bacterial vaginosis (non-specific vaginitis) in asymptomatic women. Am J Obstet Gynecol 1986: 150: 917–24

    Google Scholar 

  65. Hillier SL, Martius J, Krohn M, et al. Case-control study of chorioamnionic infection and chorioamnionitis in prematurity. N Engl J Med 1988: 319: 972–8

    Article  PubMed  CAS  Google Scholar 

  66. Kurki T, Sivonen A, Renkonen OV, et al. Bacterial vaginosis in early pregnancy and pregnancy outcome. Obstet Gynecol 1992; 80: 173–7

    PubMed  CAS  Google Scholar 

  67. Newton ER, Prihoda TJ, Gibbs RS. A clinical and microbiologic analysis of risk factors for puerperal endometritis. Obstet Gynecol 1990; 75: 402

    PubMed  CAS  Google Scholar 

  68. Riduan JM, Hillier SL, Utomo B, et al. Bacterial vaginosis and prematurity in Indonesia: association in early and late pregnancy. Am J Obstet Gynecol 1993; 169: 175–8

    PubMed  CAS  Google Scholar 

  69. Soper DE, Bump RC, Hurt WG. Bacterial vaginosis and trichomoniasis vaginitis are risk factors for cuff cellulitis after abdominal hysterectomy. Am J Obstet Gynecol 1990; 163: 1016

    PubMed  CAS  Google Scholar 

  70. Watts DH, Krohn MA, Hillier SL, et al. Bacterial vaginosis as a risk factor for postcesarean endometritis. Obstet Gynecol 1990: 75: 52–8

    PubMed  CAS  Google Scholar 

  71. Holst E, Wathne B, Mårdh P-A. Bacterial vaginosis: microbiological and clinical findings. Eur J Clin Microbiol 1987; 6: 536–41

    Article  PubMed  CAS  Google Scholar 

  72. Holst E. Reservoir of four organisms associated with bacterial vaginosis suggests lack of sexual transmission. Department of Clinical Microbiology, Lund University Hospital, Sweden. J Clin Microbiol 1990; 28: 2035

    PubMed  CAS  Google Scholar 

  73. Moi H, Erkkola R, Jerve F, et al. Should male consorts of women with bacterial vaginosis be treated? Genitourin Med 1989; 65: 263

    PubMed  CAS  Google Scholar 

  74. Blackwell A, Phillips I, Fox AR, et al. Anaerobic vaginosis (nonspecific vaginitis): clinical, microbiological and therapeutic findings. Lancet 1983; 2: 1379–82

    Article  PubMed  CAS  Google Scholar 

  75. Hillier S, Holmes KK. Bacterial vaginosis. In: Holmes KK, Mårdh P-A, Sparling PF et al, editors. Sexually transmitted diseases, 2nd ed. New York: McGraw-Hill. 1990: 547

    Google Scholar 

  76. Cook RL, Redondo-Lopez V, Schmitt C, et al. Clinical, microbiological, and biochemical factors, in recurrent bacterial vaginosis. J Clin Microbial 1992; 30: 870–7

    CAS  Google Scholar 

  77. Holst E, Brandberg A. Treatment of bacterial vaginosis in pregnancy with a lactate gel. Scand J Infect Dis 1990; 22: 625

    Article  PubMed  CAS  Google Scholar 

  78. Metronidazole (Flagyl) interactions. In: Hansten PO, Horn JR, editors. Drug interactions and updates. Vancouver WA: Applied Therapeutics, 1993: 239

Download references

Author information

Authors and Affiliations

  1. Division of Infectious Diseases, Wayne State University School of Medicine, Detroit Medical Center, Suite 202 Harper Professional Bldg, 4160 John R, Detroit, Michigan, 48201, USA

    Jack D. Sobel

Authors
  1. Jack D. Sobel
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sobel, J.D. Management of Vaginosis. Clinical Drug Investigation 8 (Suppl 1), 26–34 (1994). https://doi.org/10.1007/BF03260002

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03260002

Keywords

Search

Navigation