The effect of introduction of a guideline on the management of vaginal discharge and in particular bacterial vaginosis in primary care

Background. Bacterial vaginosis (BV) is the commonest cause of vaginal disc harge, and its association with obstetric and gynaecological complications is being recognized increasingly. It was our impression that BV was poorly understood and underdiagnosed in family practice. Objective. The aim of this study was to explore the management of patients with vaginal symptoms by family practitioners and to see if the management changed after the assimilation of best practice guidelines. Method. Family practitioners were invited to complete a baseline questionna ire of their perceived practice, and to record actual practice when consult ed about vaginal symptoms, for a minimum of 4 weeks. Consensus best practic e guidelines were then provided and practice recorded for a similar period. Results. Baseline data was received from 34 practitioners and suggested tha t the symptoms and signs of different vaginal infections were not well know n. Most symptomatic patients were only investigated at re-presentation with unresolved symptoms or at recurrence, and 43% of respondents treated with empirical antifungals as a first line approach. Pregnant patients were only occasionally asked about symptoms and only occasionally examined if sympto matic. Preguideline practice data from 30 practitioners showed 1.2 patient consultations/week, of which 60% were examined and 55% had a high vaginal s wab (HVS) sent. Only 2% had near-patient tests done. Post-guideline data fr om 23 family practitioners showed a lower recorded consultation rate at 0.7 /week, but 90% of these were examined, 77% had an HVS sent and 69% had near -patient tests done. Of the 36 HVS examined by Gram stain, 19 (53%) showed Lacrobacillus predominant flora and 10 (28%) suggested BV. Seven (19%) were borderline or ungradable. Only three (8%) showed yeasts, one of which also showed BV. Conclusions. Baseline data supported our impression that BV was under-recog nized, Guidelines appeared to improve the rate of investigation of women co nsulting with vaginal symptoms.