Gardnerellosis – Symptoms and Treatment

Definition of the Disease. Causes of the Illness

Gardnerellosis is an inflammatory disease of the genitourinary organs, caused by the growth of the conditionally pathogenic bacterium Gardnerella vaginalis.

Gardnerella vaginalis are small gram-negative (bacteria that do not stain purple when using the Gram method) or gram-variable (can stain or not stain using the Gram method) non-capsulated immobile rods measuring 1.0-2.0 μm in length, 0.3-0.6 μm in thickness, often exhibiting polymorphism (variety of structure and form), producing amino acids and acetic acid.

Gardnerellosis is classified as a sexually transmitted disease, however, its epidemiology (the occurrence and spread of the disease) remains unclear. The presence of Gardnerella in healthy women allows them to be identified as part of the normal vaginal biocenosis (a unique and balanced ecosystem). That is, Gardnerella is a facultative (possible, not obligatory) anaerobe, which is a conditionally pathogenic microorganism and in small quantities does not cause significant harm to the human body.
Both women and men can suffer from gardnerellosis. Normally, women have an acidic environment in the vagina, which is created and maintained by lactobacilli, constituting the majority (95-98%) of all present microflora. With the development of gardnerellosis, there is an increase and multiplication of bacteria, while the normal vaginal microflora is destroyed.
During its life cycle, Gardnerella produces special substances, under the influence of which the acidic environment of the vagina becomes alkaline. This causes inflammation, reduces protective functions, local immunity, creating a favorable environment for the attachment and multiplication of other pathogenic microorganisms.
In men, Gardnerella is usually present in the body only in 10% of cases and typically does not cause any symptoms. However, a man with asymptomatic carriage is a source of Gardnerellosis transmission. Sometimes the presence of Gardnerella in men causes urethritis (inflammation of the urethra) and cystitis (inflammation of the bladder).

Factors Contributing to Gardnerellosis Development

Changes in the normal healthy vaginal microflora occur under the influence of the following factors:

  • Unprotected sexual intercourse with frequent changes of partners (reacting to unfamiliar microflora, where each new partner may carry additional infection).
  • Hormonal and physiological changes: puberty, menopause, pregnancy.
  • Self-administration of antibiotics for an extended period without medical supervision.
  • Surgical operations on the organs of the small pelvis.
  • Frequent improper use of personal hygiene products (daily pads, tampons). The adhesive layer in pads, which allows attaching the product to underwear, prevents oxygen penetration. Prolonged use of pads contributes to the development of an anaerobic (oxygen-free) environment in the vagina, favorable for bacterial overgrowth. Daily pads should be changed every three hours and should not be used during nighttime sleep. It is advisable to choose pads with a interrupted adhesive layer to allow more oxygen to reach the skin. Tampons have the same drawback—using them for an extended period (more than 2 hours) leads to the accumulation of secretions and the development of unfavorable vaginal microflora with the appearance of harmful bacteria.
  • Use of an intrauterine device for more than 5 years.
  • Menstrual cycle disturbances (associated with hormonal imbalances, prolonged bleeding leading to anemia).
  • Decrease in the body’s immunity during stress, exhaustion, heavy physical exertion.

On one hand, these factors suggest an endogenous (internal) origin of gardnerellosis (prolonged use of an intrauterine device or oral contraceptives, pregnancy and postpartum period, abortions, and menopause). On the other hand, the disease also exhibits signs of a sexually transmitted infection:

  • Gardnerella is detected in infected women and their sexual partners.
  • There is a risk of reinfection in women whose sexual partners have not undergone treatment.
  • There is a likelihood of bacterial vaginosis (one type of gardnerellosis) occurring after unprotected sexual contact with a carrier of Gardnerella.

If considering gardnerellosis as a sexually transmitted infection, it’s important to identify its transmission routes.

Transmission Routes of Gardnerella:

  • Penile-genital sexual contact is the primary mode of transmission of Gardnerella vaginalis. There are suggestions that transmission may also occur through oral-genital contact and anal intercourse (oral-anal contact followed by oral-genital) among lesbians, as in some cases, vaginal Gardnerella has been detected in swabs from the rectum and the posterior wall of the throat.
  • Vertical transmission from mother to newborn girl. This mode of transmission is subject to doubt, as Gardnerella is rarely detected in girls, despite the absence of lactobacillary flora in premenstrual girls. This is because both vaginal lactobacilli and vaginal Gardnerella use the same nutrient substrate—glycogen from vaginal epithelial cells. Its level is regulated by the hormone estrogen, and in girls before menstruation, estrogen levels are low.
  • Household contact transmission is presumed due to registered cases of bacterial vaginosis with detection of vaginal Gardnerella in virgins.

Symptoms of Gardnerellosis

There are two clinical variants of Gardnerellosis: asymptomatic and symptomatic.

In asymptomatic cases, there are no clinical manifestations, meaning patients have no complaints and no specific symptoms, although laboratory signs of the disease are present.

In the second variant (with clinical manifestations), patients report moderate to copious white or grayish vaginal discharge. These discharges are often accompanied by an unpleasant odor, especially after sexual intercourse or during menstruation. Some women experience discomfort during intercourse, as well as mild itching or burning sensation. In the progressive acute process, the discharges become yellowish-green, thicker, more viscous, and sticky, sometimes foamy, evenly distributed along the vaginal walls. Such discharges are associated with increased activity of conditionally pathogenic bacteria: the more bacteria, the thicker and more opaque the discharge.

Gardnerellosis often accompanies conditions such as colpitis, cervical ectopy, less commonly leukoplakia, cervicitis, adnexitis, endometriosis, cystitis, and pyelonephritis.

The situation is exacerbated by the fact that the inflammatory process practically does not cause any symptoms and is detected late, when tissue structure changes occur.

In men, Gardnerellosis mainly progresses asymptomatically, although it can sometimes cause itching in the urethra (urethral canal) and burning during urination.

Clinical Picture in Men:

Urethritis is most commonly seen in males, characterized by a mild course. There are usually no subjective symptoms, but itching and scanty serous-mucous discharge of whitish color from the urethra may occur. Gardnerella can be detected in individuals without signs of urethritis and may spontaneously disappear (transient carriage).

Clinical Picture in Women:

Typically, women develop vaginitis (inflammation of the vaginal mucosa), during the acute course of which discomfort in the genital area, itching, and burning of the vulva are noted, as well as copious vaginal discharge and redness of the mucous membranes. Discharges with a “fishy” odor usually accumulate in the posterior vault of the vagina and envelop almost the entire cervix with a film. Hyperemic (reddened) and swollen labia of the urethra cause cystitis with frequent and painful urination and a burning sensation.

In the mild course of Gardnerellosis, only brief itching is noted, and the discharges become scanty. In typical cases, there is minimal discharge, which is grayish-white or watery.

Pathogenesis of Gardnerellosis:

Lactobacilli, constantly present in the vaginal environment, form a stable healthy ecological barrier that prevents the proliferation of conditionally pathogenic microorganisms. The stability of normal flora is due to the secretion of lactic acid (which maintains a low pH), antimicrobial substances, adhesins, and hydrogen peroxide. Under unfavorable conditions, the number of lactobacilli decreases, leading to an increase in vaginal pH, which results in the proliferation of conditionally pathogenic microorganisms, including Gardnerella, in the urethra and other anatomical structures of our body.

Rapidly proliferating anaerobes in the human body can produce amino acids and fatty acids. It is because of these substances that an unpleasant odor, reminiscent of rotten fish, appears. Additionally, Gardnerella forms a protective biological film that prevents the restoration of the natural vaginal microflora. Many scientific studies have shown that such a biological film can persist even after medical treatment of the disease.

Although Gardnerellosis is not officially classified as a venereal disease, sexual activity in women may increase the risk of vaginal dysbiosis. Frequent ejaculation in the vaginal area may also play an important role in the development of the disease, as semen has an alkaline environment.

Classification and Stages of Gardnerellosis Development:

Acute Stage (infection duration up to two months):

Acute – with pronounced clinical symptoms:

  • abundant serous-purulent discharge from the genital organs;
  • hyperemia, swelling of the mucous membranes;
  • frequent and painful urination, burning, itching;
  • sharp pains in the lower abdomen, etc.

Subacute – with blurred manifestations:

  • scanty serous discharge from the genital organs;
  • slight hyperemia and swelling of the mucous membranes;
  • discomfort during urination, burning, itching;
  • pulling pains in the lower abdomen, etc.

Torpid – practically asymptomatic (minor symptoms are present).

Chronic Stage (infection duration more than two months) – symptoms of the disease are weakly expressed or absent.

Incubation period – from 5 days to 3 weeks (on average 7-10 days).

For the characterization of clinical signs of urogenital pathologies caused by anaerobic infection, scientists have created a special scientific classification, which includes various forms of Gardnerellosis:

  • Bacterial vaginosis;
  • Bacterial lesions of the upper genital tract (uterus, ovaries, and fallopian tubes);
  • Gardnerellosis of the urinary tract in women (urethra, bladder, ureters, kidneys);
  • Gardnerellosis of the urinary tract in men (urethra, prostate, bladder, ureters, kidneys);
  • Gardnerellosis in pregnant women.
Complications of Gardnerellosis:

In women, Gardnerellosis can lead to the following complications:

  • Inflammation of the pelvic organs;
  • Urethral syndrome (inflammation of the urethra);
  • Postpartum endometritis (inflammation of the uterus after childbirth);
  • Infertility;
  • Intraepithelial cervical neoplasia (cervical dysplasia – a precancerous condition of the cervix);
  • Bartholin’s gland abscess;
  • Miscarriages, stillbirths.

During pregnancy, immunity decreases physiologically, increasing the likelihood of massive Gardnerella infections in a woman’s urogenital system. Gardnerellosis in this case can lead to miscarriages at different stages, premature births, the birth of low-weight babies, and complicated pathological deliveries.

Recently, it has become known that anaerobic microorganisms, such as Gardnerella, can produce nitrosamines, which serve as cofactors for carcinogenesis (the initiation and development of tumors) and can cause the development of dysplastic and dystrophic processes in the cervix. It has been proven that nitrosamines can cause various pathologies, including malignant cell neoplasms. The decisive role in the onset of the infectious process is played by the general condition of the body, the intensity of infection, and the virulence (degree of pathogenicity) of the microbial agent.

In men, Gardnerellosis can cause:

  • Non-gonococcal urethritis (urethritis caused by non-gonococcal infection);
  • Chronic prostatitis;
  • Cystitis;
  • Balanoposthitis (inflammation of the skin of the penis head and the inner layer of the foreskin).

Complications of urethritis often occur, such as epididymitis (inflammation of the epididymis). Its feature is a sudden acute onset followed by a sluggish course. There are general malaise, weakness, subfebrile temperature (37.1–38.0°C), and a dull pain syndrome in the perineal area.

The diagnosis of Gardnerella infection involves various methods:
  1. Microscopy of vaginal smears stained with Gram’s method to detect “clue cells” – superficial epithelial cells covered with bacteria (their presence in more than 20% is characteristic of Gardnerella infection).
  2. pH measurement of vaginal secretions to determine pH levels (values above 4.5 indicate bacterial vaginosis).
  3. Use of the amine test – an express method based on the detection of a strong fishy odor when mixing vaginal secretions with potassium hydroxide solution.
  4. Instrumental methods such as microscopy, microbiological, and molecular genetic studies:
  • Gram staining.
  • Examination of native material.
  • Immunofluorescence reaction (IFR).
  • DNA hybridization and polymerase chain reaction (PCR).
  • Staining with aqueous brilliant green.
  1. Materials for research include secretions from the vagina, cervical canal, urethra, and urine, collected by various methods.
  2. Assessment of vaginal biocenosis according to the Nugent scale, where scores from 0 to 10 determine the degree of microflora dysbiosis in the vagina. The diagnosis of “bacterial vaginosis” is made when more than six points are scored.
  3. Using the Hayes-Aison scale to classify the results of microscopic examination of smears into five levels of vaginal microflora dysbiosis.

These methods of diagnosing Gardnerella infection help establish an accurate diagnosis and select the most effective treatment.

Treatment of Gardnerella

Treatment of Gardnerella infection should be comprehensive, aimed at eliminating the cause of the disease, addressing its pathogenesis, and managing symptoms. It typically involves three stages:

  1. Decontamination of Gardnerella: This stage aims to reduce the quantity of Gardnerella in the vagina. Antibiotics are commonly used for this purpose, such as metronidazole, ornidazole, and local treatments like “Terzhinan” or “Neo-penotran” vaginal suppositories. In some cases, local treatment alone may be used, although its effectiveness compared to systemic treatment is not as high. After completing the primary treatment course, a follow-up analysis of vaginal secretions is usually conducted.
  2. Restoration of normal vaginal microbiota: This involves prescribing eubiotics and probiotics, which are beneficial live microorganisms that restore and maintain the intestinal microflora. They can be obtained from bacteria-enriched foods or dietary supplements. After antibiotic therapy, it’s essential to undergo a mandatory course of vaginal suppositories containing lacto- and bifidobacteria to restore vaginal flora. Probiotic treatment is administered only in the absence of candidal vulvovaginitis. To regulate dysbiotic processes and enhance the body’s immune response, supplements such as “Acylact,” “Gynoflor E,” “Bifidumbacterin,” “Vagilac,” and “Biovestin” may be used. They promote the growth of native vaginal lactoflora, reduce the recurrence rate of the disease, and enhance the protective properties of the vagina.
  3. Boosting local and systemic immunity: Immune modulators and multivitamins are vital components of comprehensive Gardnerella treatment. They improve the effectiveness of medications, shorten treatment duration, facilitate the restoration of immune parameters, expedite symptom relief, eradicate pathogenic flora more efficiently, and are crucial for managing bacterial infections. Therefore, immune system correction using appropriate immunotropic medications is essential for effectively combating bacterial growth. All medications should be prescribed by a doctor based on microbiological test results, the presence or absence of underlying conditions, and individual patient characteristics.

Both partners should undergo treatment simultaneously (the man taking oral and local medications), and during this period, sexual intercourse should be avoided or barrier contraception methods (condoms) should be used.

Forecast. Prevention

To reduce the risk of Gardnerella infection and prevent disease recurrence, it is advisable to follow some recommendations:

  • • Avoid casual sexual relations;
  • • Timely consult a doctor in case of other urogenital diseases;
  • • Choose underwear made only from natural fabrics;
  • • Do not constantly use daily pads and tampons;
  • • Use protection during doubtful sexual contacts, and it is not redundant to treat external genital organs with special antiseptic preparations within 1-1.5 hours after the sexual act;
  • • Observe personal hygiene rules;
  • • Maintain immunity;
  • • Undergo a preventive gynecological examination every six months.
  • • Avoid hypothermia, excessive physical exertion, and stress.
  • • Normalize sleep, walk more, eat properly, in other words, lead a healthy lifestyle.
  • Until the end of treatment, it is important to avoid sexual contacts with partners without a condom. Unfortunately, treatment of men does not reduce the frequency of Gardnerella recurrence in women.

Many medical specialists, for the prevention of Gardnerella recurrence, recommend abstaining from daily douching, as these procedures can cause allergic reactions. In addition, douching can irritate the vaginal mucosa, washing away natural lubrication and disrupting vaginal acidity, which ultimately leads to changes in natural microflora.

With adequate modern and timely treatment of Gardnerella, normal vaginal microflora is fully restored within 2-3 weeks. Without treatment, the pathological process spreads further and can provoke inflammation of the uterine appendages, various complications during pregnancy, and the development of female infertility.