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Image: A female patient and nurse walking in the obstetrics and gynecology department. By: seapachi. Licence: CC BY-SA 2.0


Colpitis

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

The pH of the vaginal milieu is normally acidic (3.84.5). This way, the 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, the lactic acid bacteria are inhibited. Cervical mucus and menstrual blood can lead to alkalinization. Other irritations can be caused by a lack of estrogen, diabetes mellitus, foreign bodies (e.g. tampons), vaginal douches, sexual contact, or antibiotics.

Pathogens of colpitis

Inflammation of the vagina can be due to 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, as the name suggests, is vaginosis caused by bacteria.

Pathogens of bacterial vaginosis

Microscopic view of Gardnerella vaginalis

Microscopic view of Gardnerella vaginalis

Gardnerella vaginalis can be found in the vaginal secretion of symptom-free, sexually active women. It is assumed that the transmission of this microorganism 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, such as G. vaginalis, which replace the lactic acid bacteria.

Note: Bacterial vaginosis is the most frequent form of colpitis, being present in 5–8% of women. G. vaginalis is the most common cause of bacterial vaginosis.

Clinical presentation of bacterial vaginosis

Reddening and itching are not present in bacterial vaginosis. Specific findings are a white-gray, very thin, sometimes foamy vaginal discharge and its fishy smell, with an alkaline pH. An ascending infection can develop as a complication.

Diagnostics for bacterial vaginosis

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

Treatment of bacterial vaginosis

Once tests are completed, treatment should be commenced. The administration of 5-nitroimidazole (metronidazole 2 × 400 mg for 5 days) is the established treatment. The healing rate is approx. 95%. The simultaneous treatment of sexual partners is not recommended.

Vaginal Thrush

Candida glabrata

Candida glabrata (License: Public Domain)

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

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

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

Treatment of vaginal thrush

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

If the vaginal thrush is recurrent, systemic therapy with fluconazole becomes necessary. Treating the partner is not necessary since vaginal thrush is an endogenous infection. However, the rate of recurrence is relatively high.

In the case of chronic recurrent vaginal thrush, high-dose fluconazole for several weeks is recommended. Further, regular prophylactic antimycotic treatment is indicated in some cases.

Trichomoniasis

Micrograph showing Trichomoniasis

Image: “Micrograph showing Trichomoniasis”, By: Nephron. License: CC BY-SA 3.0

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

Transmission occurs via sexual contact. The risk of infections is 70%. Recently, the number of infections has notably regressed and is now below 1%.

Clinical presentation of trichomoniasis

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

Note: In 90% of men and women, trichomoniasis can be asymptomatic.

A potential complication of trichomoniasis is accompanying bacterial vaginosis.

Diagnostics for trichomoniasis

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

Treatment of trichomoniasis

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

Nonspecific Colpitis

Nonspecific 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

Candida albicans

Image: Candida albicans. By: 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 due to mechanical causes or hormonal changes.

Pathogens of vulvitis

In 95% of the cases, the fungus C. 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 are rare triggers.

Secondary causes can be mechanical; for example, maceration, which is a consequence of obesity. Inflammation of the outer genitalia can also be caused by chemical irritation of the skin due to vaginal douches or detergents. Vulvitis can also be a secondary consequence of pregnancy and estrogen deficiency after menopause. In patients with diabetes mellitus, infections with C. albicans are frequent.

Note: Herpes genitalis causes the most painful vulvitis.

Clinical presentation of vulvitis

There are 3 main symptoms of vulvitis, and they are the most prominent features of inflammations of the outer genitalia:

  • Burning pain during walking, urination, and sexual intercourse
  • 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

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

Treatment of vulvitis

Clotrimazole, which is an antimycotic, is applied locally for fungal infections. Bacterial vulvitis can be treated locally with the antiseptic povidone-iodine and orally with cephalosporin. If an S. aureus infection is left untreated, folliculitis can develop into an abscess. Folliculitis must be surgically managed. For the relief of pain and itching, patients can apply cortisone balm and chamomile hip baths.

Bartholinitis

Bartholinitis

Image: “Bartholin’s cyst of the right side”. By: 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 which leads to painful swelling. In most cases, the inflammation is unilateral. If the excretory ducts are obstructed due to stasis of the glandular secretion (Bartholin cyst), an infection with intestinal germs can occur.

Etiology of bartholinitis

  • Neisseria gonorrhoeae
  • S. aureus
  • Escherichia coli
  • Anaerobe bacteria (Bacteroides, Peptococcus, and Peptostreptococcus)
Note: Primary infection with a pathogen is much less common than infection due to an obstructed duct.

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 involves marsupialization, which is performed under general anesthesia. If the bartholinitis is recurrent, extirpation of the Bartholin gland can be performed.

Condylomata Acuminata

genital warts

Image: Genital warts. By: SOA-AIDS Amsterdam. License: CC BY 3.0

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

Etiology of condylomata acuminata

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

Note: Almost 20% of sexually active women are HPV-positive with serotypes 6 and 11.

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. Koilocytes are a sign of HPV infection.

Treatment of condylomata acuminata

Treatment options depend on the severity of the disease. The first step is topical treatment. In cases of mild infection, denaturation using podophyllin cream or 60% trichloroacetic acid is possible. For extreme infections, surgical treatment using electric sling abrasion or CO2 laser has to be performed.

Note: All therapeutic measures have a recurrence risk of 25%.

Lichen Sclerosus: Vulvar Itching

Lichen sclerosus

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

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

Etiology of lichen sclerosus

Lichen sclerosus is caused by skin shrinking due to a lack of estrogen. Older women often experience estrogen deficiency in the postmenopausal period.

Clinical presentation of lichen sclerosus

Because of the marked pruritus, scratch defects can be noted. Examination shows depigmentation, scratch defects, and superinfection. The shrinking is accompanied by shiny vulvar skin.

Diagnostics for lichen sclerosus

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

Treatment of lichen sclerosus

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

As long as there is no contraindication, systemic estrogen should be considered. In any case, local estrogen treatment should occur. If symptoms persist, laser therapy or surgical interventions such as denervation may be necessary.

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