Vaginal Diseases and Vulvular Disorders: Bacterial Vaginosis, Vulvitis and more

Table of Contents

Image: “at obstetrics and gynecology” by seapachi. Licence: CC BY-SA 2.0

Colpitis

Colpitis (or vaginitis) refers to the inflammation of the vagina. The pathological vaginal discharge and epithelial reddening are typical symptoms.

The pH-value of the vaginal milieu is normally acidic. It is between 3.8 and 4.5. This way, an excessive proliferation of pathogenic germs is inhibited. Lactic acid bacteria are responsible for this milieu. They are called Döderlein’s bacteria and produce lactic acid based on estrogen.

Accordingly, the vaginal flora is disturbed if, for instance, lactic acid bacteria are inhibited. Cervical mucous and menstrual blood can lead to alkalization. Other irritations can be caused by lack of estrogen, diabetes mellitus, foreign bodies (e.g. tampons), vaginal douches, sexual contacts, or antibiotics.

Pathogens of Colpitis

An inflammation of the vagina can have several reasons. The most frequent causes are:

Bacterial infections (bacterial vaginosis)
Fungal infections with candida (vaginal thrush)
Trichomoniasis

Bacterial Vaginosis

One major form of colpitis is bacterial vaginosis, which is—as the name suggests—a vaginosis caused by bacteria.

Pathogens of Bacterial Vaginosis

Microscopic view of Gardnerella vaginalis (License: Public Domain)

In the vaginal secretion of symptom-free, sexually active women, Gardnerella vaginalis can be found. It is assumed that the transmission occurs via vaginal intercourse. Additionally, bacteria from the perianal region and bacteria of sexual partners can change the vaginal flora. This can promote the proliferation of anaerobes like Gardnerella vaginalis. They then replace the lactic acid bacteria.

Clinical Presentation of Bacterial Vaginosis

Usually in this inflammation, neither reddening nor itching is present. Specific findings are the grey-white, very thin, sometimes foamy vaginal discharge and its fishy smell in the alkaline area. As a complication, an ascending infection can develop.

Diagnostics of Bacterial Vaginosis

Clinical examination	White-grey, foamy, thin vaginal discharge, fishy smell, pH of 4.8 – 5.5
Direct microscopic examination	Vaginal secretion with leukocytes, numerous bacteria, clue cells (= epithelial cells fully covered with Gardnerella vaginalis and other bacteria)
Cultivation	Not recommended as in most cases, mixed infections are present

Treatment of Bacterial Vaginosis

Once diagnostics are completed, treatment should be commenced. Administration of 5-nitroimidazole (metronidazole 2 x 400 mg for 5 days) is the established treatment. The healing rate is roughly 95%. Simultaneous treatment of sexual partners is not recommended.

Vaginal Thrush

Candida glabrata (License: Public Domain)

Vaginal thrush refers to a fungal infection that leads to colpitis. In over 80% of the cases, theses fungal infections are caused by Candida albicans. In rare cases, they are caused by Candida glabrata. Frequently, candida are already colonizing vulva and vagina.

Therefore, vaginal thrush normally is an endogenous infection. If the vaginal flora is disturbed, the proliferation of germs is promoted. Hormonal fluctuation (e.g., pregnancy or oral contraceptives), antibiotic therapy, or immunodeficiency can also promote an infection.

Clinical Presentation of Vaginal Thrush

Itching, burning, pain, and discharge are typical symptoms of vaginal thrush. Vaginal thrush normally occurs together with vulvitis.

Diagnostics of Vaginal Thrush

Clinical examination	White crumbly discharge
Microscopic direct specimen	Confirmation through pseudo-mycelia. The detection of sprout-cells only shows colonization of yeasts.
Microbiological detection	Only if clinical exam and direct specimen yield no significant results.

Treatment of Vaginal Thrush

A first step is the local treatment with nystatin- and imidazole medication in the vagina and on the vulva; 5 – 7 days can be sufficient.

If the vaginal thrush is recurrent, systemic therapy with fluconazole becomes necessary. Treatment of the partner is not necessary since it is an endogenous infection. However, the rate for recurrences is quite high.

In case of a chronic recurrent vaginal thrush, high-dosage administration with fluconazole for several weeks is recommended. Also, regularly performed prophylactic antimycotic treatment can be reasonable.

Trichomoniasis

Bild: “Micrograph showing Trichomoniasis” von NEphron. Lizenz: CC BY-SA 3.0

Trichomoniasis is caused by Trichomonas vaginalis. It is a facultative pathogenic protozoon. It affects the vagina, glandular ducts, urethra, and less frequently also the bladder, rectum, and cervix.

Transmission occurs via sexual contacts. Risk for infections amounts to 70%. In the last years, the number of infections has severely regressed and is now below 1%.

Clinical Presentation of Trichomoniasis

A characteristic sign of trichomoniasis is a severe, liquid, foamy discharge, which sometimes is green-yellow. Also, symptoms like burning, itching, and sometimes dysuria and reddening can be observed.

A potential complication of trichomoniasis is an accompanying bacterial vaginosis.

Diagnostics of Trichomoniasis

Clinical examination	Foamy vaginal discharge, pungent smell, reddening
Microscopic direct specimen	Moving trichomonads with surrounding leucocytes
Cytological cervical smear

Treatment of Trichomoniasis

Systemic administration of 5-nitroimidazoles (1×2 g metronidazole) has a healing rate of 90%. Treatment of the partner is necessary. Condoms can prevent transmission.

Unspecific Colpitis

Unspecific colpitis cannot be traced to one particular pathogen.

Vulvitis

Vulvitis is defined as dermatitis of the labia of women. In almost all cases, it is accompanied by a form of vaginitis.

Etiology of Vulvitis

Image: “ Candida albicans ” from GrahamColm. License: CC BY 3.0

Primary causes of the disease can be fungi, bacteria, or viruses. Secondarily, an inflammation of the outer genitals can also be caused by mechanical causes or by hormonal changes.

Pathogens of Vulvitis

With 95% of the cases, the fungus Candida albicans is the most frequent pathogen of vulvitis. Bacteria like A-streptococci, Staphylococcus aureus, and Treponema pallidum are the second most frequent cause. Viruses like herpes simplex and varicella zoster as triggers are rather rare.

Secondary causes can be mechanical; for example, maceration, which is a consequence of obesity. An inflammation of the outer genital can also be caused by chemical irritation of the skin due to vaginal douches or detergents. Vulvitis can also be a secondary consequence ofpregnancy and of estrogen deficiency during post-menopause. In patients with diabetes mellitus, infections with Candida albicans are frequent.

Clinical Presentation of Vulvitis

There are three main symptoms that should be known. They are the most prominent manifestations of inflammations of the outer genitalia:

Vaginal discharge
Pruritus: The scratching caused by the strong itching often worsens the infections. If children present with this kind of itching, worms should be considered as a differential diagnosis.
Burning and pain during walking, urination, and cohabitation.

Examination shows the typical signs of inflammation; reddened and swollen skin is visible. Candidosis is often accompanied by clumpy white discharge. The native specimen and Sabourand agar show evidence of the fungal infection. In herpes genitalis infections, fine vesicles can be seen. If an inflammation of the hair follicle is present (i.e., folliculitis), one often observes a small red area that is painful and sensitive to pressure.

Treatment of Vulvitis

Against fungal infections, clotrimazole, which is an antimycotic, is applied locally. Bacterial vulvitis can be treated locally with antiseptical povidone iodine and orally with cephalosporin. If a S. aureus infection is left untreated, folliculitis can develop into an abscess. This must be opened surgically. For relief of pain and itching, the patients can apply cortison balm and chamomile hip baths.

Bartholinitis

Image: “Bartholin’s cyst of the right side” from Medimage. License: CC BY 3.0

Bartholin glands are located on the inside of the inner labia. Their excretory duct lies in the introitus area. Bartholinitis is an inflammation of the Bartholin gland that leads to painful swelling. In most cases, it is unilateral. If the excretory ducts are obstructed due to a stasis of the glandular secretion (Bartholin cyst), an infection with intestinal germs can occur.

Etiology of Bartholinitis

Neisseria gonorrhea
Staphylococcus aureus
Escherichia coli
Anaerobe bacteria (bacteroides, peptococci, peptostreptococci)

Clinical Presentation of Bartholinitis

If the secretory ducts are obstructed, swelling occurs, which can reach the size of a ping-pong ball. This cyst is painful when infected and can even lead to problems walking.

Treatment of Bartholinitis

In case of a large cyst or an abscess, treatment consists in marsupialization, which is performed under general anesthesia. If the bartholinitis is recurrent, extirpation of the Bartholin gland can be performed.

Condylomata Acuminata

Image: “genital warts” from SOA-AIDS Amsterdam. License: CC BY 3.0

Condylomata accuminata are papillary, pointy epitheliomas, which mainly affect the vulva, vagina, porta uteri, and the anal region.

Etiology of Condylomata Acuminata

An infection with HPV (human papilloma virus) can trigger the formation of condylomata acuminata. Serotypes 6 and 11 are responsible for changes like pointy condylomas. Infection with papilloma viruses HPV-16 and -18 can lead to the formation of cervical or anal carcinoma.

Clinical Presentation of Condylomata Acuminata

Examination shows pointy, papillary changes of epithelial cells. They are arranged in a cockscomb-like manner.

Histology shows koilocytes. These are squamous epithelial cells with a perinuclear halo, which means that these cells have a bright halo around their nucleus. Koilocytes are a sign of HPV infection.

Treatment of Condylomata Acuminata

Treatment options depend on the severity of the disease. A first step is topical treatment. In cases of mild infestation, denaturation using podophyllin cream or 60% tricholoric acetic acid is possible. For extreme infestations, surgical treatment using electric sling abrasion or a CO2laser has to be performed.

Lichen Sclerosus: Vulvar Itching

Image: “Lichen sclerosus on an 82 year old woman, showing an ivory white coloring in the vulva, also stretching downward to the perineum.” from Mikael Häggström. License: CC BY 1.0

Lichen sclerosus is a chronic disease and a degenerative change of the dermis. It consists in a shrinking of the vulva and sclerotization of subcutaneous fat tissue.

Etiology of Lichen Slerosus

Lichen sclerosus is caused by skin shrinking due to a lack of estrogen.Older women often suffer from estrogen deficiency in post-menopause.

Clinical Presentation of Lichen Sclerosus

Due to the unbearable pruritus, scratch defects sometimes occur. Examination shows depigmentation, scratch defects, and superinfection. The shrinking is accompanied by shiny vulvar skin.

Diagnostics of Lichen Sclerosus

Histological examination involving punch biopsy or excision should be performed in order to exclude vulvar carcinoma and vulvar intra-epithelial dysplasia.

Treatment of Lichen Sclerosus

Lichen sclerosus is treated with cortison creams for at least 4 weeks exceeding the point at which the patient is free of complaints. Fatty ointments should be applied before any event of skin stress (urination, defecation, cohabitation). Treatment with corticoids is supposed to prevent skin shrinking and synechia (adhesion of the labia).

As long as there is no contraindication, systemic administration of estrogen should be considered. In any case, however, local estrogen treatment should occur. When symptoms persist, laser therapy or surgical interventions like denervation can be necessary.