Edit concept Create issue ticket

Cytolytic Vaginosis

Cytolytic vaginosis occurs due to overgrowth of Lactobacillus species and subsequent lysis of epithelial cells in a highly acidic environment. Dysuria, dyspareunia and whitish discharge are main symptoms and the diagnosis is made based on microbiological findings from vaginal smears. Douching with sodium bicarbonate solutions to increase vaginal pH is the mainstay of therapy.


Presentation

The clinical presentation is strikingly similar to candidal vaginosis, characterized by dyspareunia, dysuria, abundant whitish discharge and pruritus [1] [2]. A cyclical appearance of symptoms, most likely during the luteal phase of the menstrual cycle is observed [1].

Vaginal Discharge
  • Fungal cultures, 10% potassium hydroxide (KOH) and Gram stained preparations and pH measurements were performed on the vaginal discharge material of each patient.[ncbi.nlm.nih.gov]
  • The pH was 3.5 to 5.5 and the clinical symptoms were profuse vaginal discharge (VD) especially whitish-cheesy vaginal discharge and other symptoms of vaginal candidiasis.[ncbi.nlm.nih.gov]
  • Vaginal discharge was collected and made into smear. The morphological characteristics of these vaginal smears with Gram staining were observed under the microscope.[ncbi.nlm.nih.gov]
  • The most important diagnostic aides are microscopic examination of the vaginal discharge and culture for Trichomonasvaginalis and Candida (). Interestingly, there are relatively few white blood cells (WBC) present in the vaginal discharge.[sexualhealthmedicine.com]
Cheesy Vaginal Discharge
  • The pH was 3.5 to 5.5 and the clinical symptoms were profuse vaginal discharge (VD) especially whitish-cheesy vaginal discharge and other symptoms of vaginal candidiasis.[ncbi.nlm.nih.gov]
  • The women presenting with cytolytic vaginosis complain of a thick or thin white cheesy vaginal discharge, pruritus, dyspareunia, vulvar dysuria, and a cyclic increase in symptoms that are more pronounced in the luteal phase ( 11 , 37 , 49 ).[ispub.com]

Workup

A presumptive diagnosis can be made based on clinical findings and reported complaints, but because numerous pathogens may cause a similar presentation, it is necessary to perform a vaginal smear and subsequent microscopic examination [1]. The proposed criteria for cytolytic vaginosis are evidence of cytolysis, abundance of lactobacilli, absence of Trichomonas vaginalis, Gardnerella vaginalis or Candida sp. on wet smear and pH of the smear between 3.5-4.5 [4].

Gram-Positive Rods
  • rods, now referred as lactobacillus species.[ncbi.nlm.nih.gov]
  • Definition / general Presence of gram positive rods (lactobacilli) with cytolysis of intermediate cells Terminology Also known as bacillus vaginalis , bacillus Doderlein Epidemiology Lactobacilli are the most abundant bacteria found in normal vaginal[pathologyoutlines.com]
  • Historical Perspectives In 1892, Doderlein first identified the presence or absence of gram-positive rods in normal vaginal flora ( 16 ). He named these organisms Doderlein's bacilli.[ispub.com]
Gram-Positive Bacteria
  • Clindamycin will also have an inhibitory effect on Gram-positive bacteria, except the enterococci. Additionally, clindamycin would not have a suppressive effect on the Gram-negative facultative bacteria.[sexualhealthmedicine.com]

Treatment

Once the diagnosis is confirmed, the main goal of therapy is elevation of vaginal pH through douching with sodium bicarbonate solution or through the use of a vaginal sodium bicarbonate suppository [1] [4]. In most cases, intravaginal douching is performed for twice weekly for 2-3 weeks, while antibiotic therapy is not necessary [1].

Prognosis

The condition is self-limiting and easy to treat, but the diagnosis is often made erroneously as chronic candidal vulvovaginitis that does not respond to therapy [3], which is why the diagnostic workup should be properly conducted [2] [6].

Etiology

Lysis of vaginal epithelial cells is caused by overgrowth of lactobacilli, but the exact cause remains unclear [2].

Epidemiology

The exact rates of this condition in women is unknown, but cytolytic vaginosis is almost exclusively encountered in women during childbearing age [2]. Because lactobacilli convert glucose to lactic acid, it is hypothesized that women suffering from diabetes mellitus are more prone to this condition due to a higher circulating level of glucose [1].

Sex distribution
Age distribution

Pathophysiology

Under physiological conditions, Lactobacilllus species provide numerous beneficial effects as normal vaginal flora, predominantly by acidification of the local environment through production of lactic acid from glucose and the influence of estrogen [1]. An additional function is the production of hydrogen peroxide (H2O2), a potent free radical that prevents the ability of pathogenic microogranisms, such as Escherichia coli, Gardnerella vaginalis, but also Candida sp., to grow and cause an infection [2] [5]. Competition for nutrients and secretion of acidolin, which also inhibits growth of other organisms, are additional mechanism of protection [2]. In some women during reproductive age, however, a phenomenon of Lactobacillus overgrowth in this environment can occur and cause lysis of vaginal epithelial cells due to excessive acidification [1].

Prevention

Apart from adequate hygiene, no other preventive measures are currently known regarding prevention of vaginal infections.

Summary

Cytolytic vaginosis is a term that describes lysis of vaginal epithelial cells as a result of abundant growth of Lactobacillus sp., which normally reside in the vagina as normal flora [1]. As a protective mechanism against harmful pathogens, lactobacilli produce hydrogen peroxide (H2O2) and preserve the vaginal microenvironment, but for still undisclosed reasons, abundant growth of this bacterial organism can occur in women during childbearing age and cause marked lysis of epithelial cells, primarily due to profound acidification during the process of glucose conversion to lactic acid [1]. The clinical presentation includes dysuria, whitish discharge, dyspareunia and pruritus, with symptoms most commonly appearing in cyclic fashion [1] [2]. To make the diagnosis, it is necessary to obtain a vaginal smear and perform a microscopic examination that will exclude other pathogens that present with similar complaints, most notable being Trichomonas vaginalis, Gardnerella vaginalis and Candida species [3] [4]. Cytolytic vaginosis is treated by increasing pH, most commonly through the use of sodium bicarbonate, either in the form of vaginal suppositories or douching [1].

Patient Information

Cytolytic vaginosis is a condition characterized by overgrowth of Lactobacillus species, which normally comprise normal vaginal flora and protect from various harmful microorganisms via several mechanisms. For some reason, abundant growth of this bacteria reduces normal pH of the vagina, causing a profoundly acidic environment in which destruction of epithelial cells (cytolysis) occurs. Symptoms such as painful urination, itching, whitish discharge and pain during intercourse are most frequently reported. This condition is almost exclusively seen in women during childbearing age and symptom often appear in cyclical fashion. The diagnosis can be made by obtaining a vaginal swab for microscopic examination. Increasing vaginal pH is the main principle of therapy, which is achieved by douching with sodium bicarbonate or use of vaginal suppositories containing sodium bicarbonate for 2-3 weeks. Cytolytic vaginosis is self-limiting and does not pose a risk for women, but it is often not recognized due to striking similarities of more common conditions such as vulvovaginitis caused by Candida, which is why careful examination is necessary to make the right diagnosis.

References

Article

  1. Suresh A, Rajesh A, Bhat RM, Rai Y. Cytolytic vaginosis: A review. Indian J Sex Transm Dis. 2009;30(1):48-50.
  2. Cerikcioglu N, Beksac MS. Cytolytic vaginosis: misdiagnosed as candidal vaginitis. Infect Dis Obstet Gynecol. 2004;12(1):13-16.
  3. Hu Z, Zhou W, Mu L, Kuang L, Su M, Jiang Y. Identification of cytolytic vaginosis versus vulvovaginal candidiasis. J Low Genit Tract Dis. 2015;19(2):152-155.
  4. Cibley LJ, Cibley LJ. Cytolytic vaginosis. Am J Obstet Gynecol. 1991;165(4 Pt 2):1245-1249.
  5. Hillier SL, Krohn MA, Klebanoff SJ, Eschenbach DA. The relationship of hydrogen peroxide-producing lactobacilli to bacterial vaginosis and genital microflora in pregnant women. Obstet Gynecol. 1992;79(3):369-373.
  6. Demirezen S. Cytolytic vaginosis: examination of 2947 vaginal smears. Cent Eur J Public Health. 2003;11(1):23-24.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-22 03:52