• The vagina is not a sterile organ and contains most of the vaginitis factors in its normal flora. In women between puberty and menopause, the most abundant bacteria in the vagina physiologically are Gram (+), anaerobic or microaerophilic hydrogen peroxide producing Döderlein bacilli (Lactobacilli).
• Estrogen increases the glycogen content in the squamous epithelium and this glycogen is converted by lactobacilli to monosaccharide, glucose and lactic acid, thus keeping the pH at an acidic level ( < 4.5).
• Epithelial desquamation, trauma, decrease in estrogen, increase in progesterone, menstruation, frequent coitus, vaginal douching disrupt the flora by increasing the vaginal pH.
Bacterial Vaginosis (BV) / Gardnerella Vaginitis
• The most common vaginal infection in women of all ages is bacterial vaginosis. The term vaginosis denotes a decrease in polymorphonuclear leukocytes (PMNL) in objective examination despite increased vaginal secretion. This indicates that there is no actual inflammatory process. The term bacterial refers to the presence of an abnormal number of bacteria in the vagina. In short, bacterial vaginosis is a condition in which the infection cannot be documented objectively, despite the presence of an abnormal number of bacteria in the vagina.
• There is loss of lactobacilli in BV. Lactobacilli are replaced by facultative microorganisms and generally anaerobes, Bacteriodes spp., peptostreptococci, Mobiluncus spp., Mycoplasma hominis and Gardnerella vaginalis. Normally, anaerobes are present in less than 1% of the vaginal flora; but increased 100-1000 times in BV.
• Vaginal alkalinization caused by frequent sexual intercourse and vaginal douching is held responsible for the development of BV.
bacterial vaginosis risk factors
• Oral sex
• Intrauterine device
• Vaginal douche
• Coitus at an early age
• Black race
• New or multiple sexual partners
• Cigarette
• Lesbian intercourse
• Coitus during menstruation
Clinic
► Clinical findings in BV are also included in the Amsel criteria used in diagnosis. The presence of 3 of the Amsel criteria establishes the diagnosis of BV.
Amsel criteria
1. There is a gray-white, watery discharge adhered to the vaginal wall.
2. Vaginal pH is above 4.5.
3. Clue cell (>20%) and very few leukocytes are seen in the Gram staining of the discharge in the fresh preparation. There are abundant Gram-negative bacilli or coccobacillus adhered to epithelial cells. These cells, called Clue cells, are the name given to the microscopic appearance of bacteria adhering to the superficial vaginal epithelial cells and the disappearance of the sharp cell border. It is the most reliable criterion in the diagnosis of BV.
4. A fishy odor occurs when 10% KOH solution is dripped into the vaginal secretions (Whiff Test). The reason for this is the formation of abundant amines in the vagina. There is a fishy odor that becomes evident especially after coitus.
Culture has no place in the diagnosis of bacterial vaginosis
Treatment
► Metronidazole (oral or vaginal)
► Clindamycin (oral or vaginal)
Since bacterial vaginosis is not an STD, there is no need for co-treatment.
Complications of Bacterial Vaginosis
1. Pelvic inflammatory disease
2. Vaginal cuff infection after hysterectomy
3. Premature rupture of membranes
4. Preterm labor and delivery
5. Chorioamnionitis
6. Endometritis after cesarean section
7. Second trimester abortions
8. Endometritis
9. Endometritis after abortion
Trichomoniasis
• It is the most common among non-viral and non-chlamydial sexually transmitted diseases. The causative agent, Trichomonas vaginalis, is a motile protozoan with flagella. The parasite creates an anaerobic environment. Bacterial vaginosis accompanies the picture in 60% of patients with trichomonas. Therefore, complications of bacterial vaginosis can also be seen in trichomonas.
Clinic
► Often asymptomatic
► Vaginal discharge (abundant, excessively foamy, purulent, foul-smelling)
► Vulvar pruritus
► Vaginal pH is usually above 5.0.
► Vaginal erythema and strawberry appearance on the cervix (colpitis macularis = subepithelial petechial hemorrhage) are seen in cases where the organism concentration is intense.
► Whiff test may be positive.
Diagnosis
► It is put by seeing the flagellated organism with the fresh preparation. The leukocytes are observed to be increased. The frequent presence of bacterial vaginosis causes clue cells to be seen in microscopic examination.
Treatment
► Oral Metronidazole or Tinidazole. Since it is an STD, co-treatment is absolutely necessary.
Vulvovaginal Candidiasis
• Candida albicans is the causative agent in 85-90% of the cases. Other types of vulvovaginitis, C.glabrata and C.tropicalis, are generally resistant to treatment.
• Predisposing factors to vulvovaginal candidiasis: COC use, systemic steroid use, broad spectrum antibiotics, diabetes, synthetic underwear, pregnancy, hot climate, obesity and immunosuppression
Clinic
Vaginal and/or vulvar itching is the main symptom. Widespread itching despite minimal invasion of lower genital epithelial cells suggests that an extracellular toxin or enzyme is involved in the pathogenesis.
The discharge is in the form of milk curd-white cheese.
The patient has external dysuria (burning sensation when urinating on contact with the inflamed vulvar skin).
Whiff test is negative in cases.
The cervix is usually normal.
It is the only vaginitis with a normal vaginal pH.
Vulvovaginal candidiasis is clinically divided into complicated and uncomplicated.
Uncomplicated vulvovaginal candidiasis
• Sporadic
• Mild or moderate symptoms
• Candida albicans
• Cases with intact immunity
Complicated vulvovaginal candidiasis
• Recurrence
• Severe symptoms
• Non-Candida albicans
• Cases with impaired immunity (diabetes mellitus, AIDS, malignancy)
Diagnosis
► It is placed by adding 10% KOH to the sample taken from the side wall of the vagina and seeing typical fungal spores under the microscope. Culture can also be used for diagnosis.
Treatment
► Topical and/or oral azoles (fluconazole) are used in the treatment. Another alternative is topical nystatin. These drugs can also be used safely in pregnant women.
Inflammatory Vaginitis (Desquamative)
• It is a picture characterized by abundant purulent exudative discharge and epithelial cell shedding. When Gram staining is performed, it is seen that lactobacilli have disappeared and replaced by streptococci and other Gram (+) cocci.
• Symptoms are purulent vaginal discharge, vulvar burning and dyspareunia. Itching is very rare. Vaginal pH is above 4.5.
• Vaginal 2% clindamycin cream is used in the treatment.
Atrophic Vaginitis
• As a result of the withdrawal of estrogen from the environment in menopausal women, the normal vaginal flora is disrupted and an inflammatory vaginitis develops, resulting in purulent vaginal discharge. Vaginal pH is above 4.5 due to the absence of estrogen in the environment. There is an increase in parabasal cells and leukocyte dominance.
• The treatment is estrogen creams used intravaginally.