Noncandidal vaginitis: a comprehensive approach to diagnosis and management

Characterization of a Lactobacillus gasseri strain as a probiotic for female vaginitis

Vaginitis, a prevalent gynecological condition in women, is mainly caused by an imbalance in the vaginal micro-ecology. The two most common types of vaginitis are vaginal bacteriosis and vulvovaginal candidiasis, triggered by the virulent Gardnerella vaginalis and Candida albicans, respectively. In this study, a strain capable of inhibiting G. vaginalis and C. albicans was screened from vaginal secretions and identified as Lactobacillus gasseri based on 16S rRNA sequences. The strain, named L. gasseri VHProbi E09, could inhibit the growth of G. vaginalis and C. albicans under co-culture conditions by 99.07% ± 0.26% and 99.95% ± 0.01%, respectively. In addition, it could significantly inhibit the adhesion of these pathogens to vaginal epithelial cells. The strain further showed the ability to inhibit the enteropathogenic bacteria Escherichia coli and Salmonella enteritidis, to tolerate artificial gastric and intestinal fluids and to adhere to intestinal Caco-2 cells. These results suggest that L. gasseri VHProbi E09 holds promise for clinical trials and animal studies whether administered orally or directly into the vagina. Whole-genome analysis also revealed a genome consisting of 1752 genes for L. gasseri VHProbi E09, with subsequent analyses identifying seven genes related to adhesion and three genes related to bacteriocins. These adhesion- and bacteriocin-related genes provide a theoretical basis for understanding the mechanism of bacterial inhibition of the strain. The research conducted in this study suggests that L. gasseri VHProbi E09 may be considered as a potential probiotic, and further research can delve deeper into its efficacy as an agent which can restore a healthy vaginal ecosystem.

Clinical Performance and Safety of Vaginal Ovules in the Local Treatment of Nonspecific Vaginitis: A National, Multicentric Clinical Investigation

PURPOSE

Nonspecific vaginitis is a distinct clinical entity with particular microscopic and immunologic features. There is currently no standard of care for women with nonspecific vaginitis. The aim of our study was to assess the change in vaginal symptoms score after 3 months of treatment with an intravaginal medical device in participants with abnormal vaginal discharge and specific signs and symptoms. As secondary objectives, the study analyzed other clinical and microscopic features, such as vaginal discharge aspect, change in vaginal pH, change in vaginal microbiome, and vaginal inflammation.

METHODS

The study population included 47 participants with symptomatic vulvovaginitis, distinct from candidiasis, trichomoniasis, or bacterial vaginosis. The study design included 2 research sites from Romania. The treatment protocol consisted of 1 ovule per day inserted intravaginally during 15 consecutive days. The total study duration was 3 months.

FINDINGS

The intravaginal medical device had a positive impact on the vaginal symptoms score for 72.34% of the study participants. Topical administration of the ovules balanced vaginal pH values and significantly reduced signs of inflammation between study visits.

IMPLICATIONS

This intravaginal medical device had curative effects that support its use as a stand-alone treatment in women with nonspecific vaginitis. A second clinical investigation is ongoing to evaluate the clinical efficacy of the device in postoperative care of cervical and vaginal wounds traumatic or secondary to surgical interventions.

CLINICALTRIALS

gov identifier: NCT04735705.

Hypervalent Iodine-Mediated Synthesis of Sulfinimidate Esters from Sulfenamides

In this study, we present a novel and efficient approach for the oxidative esterification of sulfenamides using phenyliodonium diacetate, enabling the synthesis of sulfinimidate esters and sulfilimines under mild and metal-free conditions, with yields reaching up to 99%. The protocol is readily scalable and compatible with a diverse range of substrates and functional groups, and we demonstrate its potential for late-stage functionalization of pharmacologically relevant molecules. Furthermore, we propose a plausible reaction mechanism to account for the observed sequence of events.

Therapeutic effects of fenticonazole on bacterial vaginosis in mice

Bacterial vaginitis (BV) is a syndrome of increased vaginal discharge, fishy smelling leucorrhea, and itching and burning vulva caused by the microecological imbalance in the vagina induced by mixture of Gardnerella vaginalis (GV) and some anaerobic bacteria. Fenticonazole, an imidazole derivative and antimicrobial compound, has been demonstrated to exert effective therapeutic effects in mixed vaginitis. Accordingly, our study was designed to explore the potential role of fenticonazole in GV-infected BV mouse models. Female C57/BL6 mice were injected intraperitoneally with β-estradiol 3 days before and on the day of GV infection to maintain a pseudoestrus state. On the day of infection, mice were intravaginally inoculated with 20 µl of a suspension of GV (6 × 106 CFU/ml). Fenticonazole was administered as 2% vaginal cream (0.2 mg each mouse) by intravaginal application once a day for 3 days beginning the day of infection. At day 3 postinfection, the mice were sacrificed and vaginal washes were harvested. GV proliferation and Lactobacillus content were calculated in the vaginal lavage. Neutrophil counts in the vaginal lavage were observed through Pap staining. Myeloperoxidase (MPO) activity and proinflammatory cytokine (TNF-α, IL-1β, IL-6, iNOS, COX2, and NF-κB) levels in vaginal tissues were measured by ELISA and western blotting. Vaginal tissues were stained by hematoxylin and eosin (H&E) to examine the exfoliation of vaginal epithelial cells. GV infection increased GV proliferation and neutrophil counts but reduced Lactobacillus content in the vaginal lavage, as well as enhanced MPO activity, proinflammatory cytokine levels, and the exfoliation of vaginal epithelial cells in vaginal tissues of BV mouse models. However, administration of fenticonazole significantly ameliorated the above phenomena. Fenticonazole greatly improves the symptoms of GV-induced BV in mouse models.

Inhibitory effect of Lactobacillus gasseri CCFM1201 on Gardnerella vaginalis in mice with bacterial vaginosis

Gardnerella vaginalis is the core pathogen of bacterial vaginosis (BV), the most common vaginal infection in women. G. vaginalis exerts pathogenicity through various factors, such as biofilm formation and the local host immune response stimulation. Therefore, this study aimed to evaluate the inhibitory effect of Lactobacillus gasseri CCFM1201 on G. vaginalis using experimental BV models. We evaluated L. gasseri in vitro to inhibit pathogen biofilm formation and adhesion capacity in HeLa cells using crystal violet staining. Further in vivo studies were conducted to assess the inhibitory effects of L. gasseri CCFM1201 on BV induced by G. vaginalis. L. gasseri exhibited strain-specific adhesion and inhibition of pathogen biofilm formation in vitro. L. gasseri CCFM1201 significantly reduced G. vaginalis in mice (p < 0.05), inhibited sialidase activity, modulated tumor necrosis factor-α and interleukin-1β expression, and reduced myeloperoxidase activity (p < 0.05). Histopathological examination indicated that L. gasseri CCFM1201 improved inflammatory cell infiltration of vaginal tissue and restored its structure. Vaginal epithelial cell exfoliation, the main clinical feature of BV, was significantly improved by L. gasseri CCFM1201 intervention (p < 0.05). Thus, L. gasseri CCFM1201 is a potential candidate for treating G. vaginalis-induced vaginal diseases.

Vaginal pH Value for Clinical Diagnosis and Treatment of Common Vaginitis

In modern society, 75% of all women worldwide have had vaginitis at least once in their lives. The vagina has a dynamic microbial ecosystem with varying vaginal pH levels. An imbalance in that ecosystem can alter the vaginal pH and tip the scale to the point of causing issues, such as vaginitis, that require medical attention. Although vaginitis is not an incurable disease, it causes discomfort and pain that disrupt women's daily lives. The most common causes of vaginitis include bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis. In this review, we discuss the causes, diagnostic methods, and symptoms of different types of vaginitis, the relationship of vaginitis to the prevalence of other diseases, issues associated with recurrent vaginitis and the immune system, and a variety of effective available treatments. In our article, we summarize the relationship of pH with the vaginal ecosystem, discuss the associated factors of vaginal pH, and finally introduce the different available vaginal pH self-test products.

Recurrent Bacterial Vaginosis: An Unmet Therapeutic Challenge. Experience With a Combination Pharmacotherapy Long-Term Suppressive Regimen

BACKGROUND

Recurrence of bacterial vaginosis (RBV) is a major challenge to effective therapy. Women experiencing intractable and frequent recurrences are ill-served by available treatment options, such as both antimicrobial and use of probiotics.

METHODS

One hundred five women with RBV failing all recommended regimens seen in the clinic were prescribed combination oral nitroimidazole 500 mg twice a day for 7 days and simultaneous boric acid 600 mg daily per vagina therapy for 30 days; thereafter, they were prescribed twice-weekly vaginal metronidazole gel for 5 months in an attempt to prevent recurrence and followed by a 6-month observation period. Results reflect standard of clinic care in this uncontrolled retrospective cohort analysis.

RESULTS

An initial regimen of nitroimidazole and simultaneous but prolonged vaginal boric acid achieved a satisfactory response (BV cure ≤2 Amsel criteria) in 92 of 93 available patients. Thereafter, a maintenance metronidazole gel prevented symptomatic BV recurrence in 69.6% of compliant patients at 6-month follow-up. Long-term cure at a 12-month follow-up was demonstrated in almost 69% of women reaching the 6-month observation phase. Vaginal candidiasis frequently complicated prolonged antibiotic prophylaxis requiring frequent antifungal rescue or prophylaxis. Frequent loss to follow-up in this long-term study influenced efficacy evaluation.

CONCLUSIONS

In the absence of new antimicrobials or proven probiotic regimens, women with RBV may benefit from a prolonged drug-intensive antimicrobial regimen incorporating antibiofilm activity until newer measures are available. Additional randomized, control studies are needed.

Vaginal discharge during pregnancy and associated adverse maternal and perinatal outcomes

Objectives:

To observe the effects of vaginal discharge during pregnancy on maternal and fetal outcomes.

Methods:

This observational study was undertaken form June 2018 to 31 May 2019 period in the Department of Obstetrics and Gynaecology at Liaquat University of Medical and Health Sciences hospital Jamshoro Unit IV. Data were collected from a convenience sample of 85 pregnant women. All the pregnant women with vaginal discharge were included in the study, while the women with bleeding and other medical disorders during pregnancy were excluded. Data was analyzed.

Results:

Women’s mean age as 27.4 (±4.7) years and most were 28-35 weeks pregnant (n=29, 34%) and primigravida (n=35, 41%). Seventy six women (89%) presented with vaginal discharge while nine women (11%) reported no vaginal discharge. Of those with vaginal discharge,53 women (69.7%) had vaginal infections: bacterial vaginosis (n=21, 39.6%), vaginal candidiasis (n=17, 32.1%) and vaginal trichomoniasis (n=15, 28.3%). Pathological vaginal discharge (PVD) was associated with vaginal irritation (n=30, p<0.0001), vaginal pain (n=50, p<0.0001), fever (n=12, p=0.015), uterine contractions (n=31, p<0.0001), premature membrane rupture (n=29, p<0.0001), abortion (n=13, p=0.009), pre-term delivery (n=24, p<0.0001) and post-partum endometritis (n=19, p=0.0006). PVD was associated with neonatal outcomes i.e. low birth weight (n=24, p<0.0001), low Apgar score at birth (n=22, p=0.0001), neonatal respiratory distress syndrome (n=21, p=0.0002), neonatal intensive care hospitalisation (n=20, p=0.002) and early neonatal death (n=16, p=0.003).

Conclusion:

Pathological vaginal discharge (PVD) during pregnancy is more frequent and is associated with adverse maternal and perinatal outcomes.

Telemedicine in Urogynecology

Telemedicine, which provides safe, equitable, patient-centered care, has gained significant momentum in recent years. Success using telemedicine has been seen across diverse groups of patients for a variety of diagnoses, including older adults and gynecology patients. In response to the coronavirus disease 2019 pandemic, federal and local governments have issued provisions to improve reimbursement and accessibility to telemedicine. In urogynecology, virtual care is growing in popularity, along with a growing body of literature in support of this method of providing care. Providers should use clinical judgment and existing data to guide them on which clinical conditions are appropriate for virtual care.

Vulvovaginal candidiasis and current perspectives: new risk factors and laboratory diagnosis by using MALDI TOF for identifying species in primary infection and recurrence

Vulvovaginal candidiasis (VVC), considered the second cause of genital infection among women, has pathogenic mechanisms still to be elucidated and unknown risk factors. Prevalence studies with laboratory diagnosis (at first diagnosis and recurrence) are uncommon, especially using MALDI TOF, used in this clinical, epidemiological, and laboratory study for evaluating candidiasis, and identifying unknown risk factors. To obtain clinical and epidemiological data, patients were questioned, and there was material collection. Samples collected were identified by using phenotypic and presumptive methods and confirmed by MALDI TOF. This study analyzed 278 patients, divided into symptomatic (n = 173) and asymptomatic (n = 105) groups. Regarding the main candidiasis symptoms (discharge, itching, and burning), only 50.3% of patients described these concomitant symptoms, showing a positive predictive value of 67.8%. Regarding the risk factors investigated, there was a statistical correlation between candidiasis and dairy products, gut transit, contraceptive use, respiratory allergy, and panty liners, describing new risk factors related to intestinal and vaginal dysbiosis. After Candida species analysis and confirmation, the primary prevalence was 80.9% (Candida albicans), 15.2% (non-albicans), 1% (Rhodotorula mucilaginosa), and 1.9% (unidentified species). In recurrence, the prevalence was 66.7% (C. albicans) and 33.3% (non-albicans). The presence of symptoms has low positive predictive value for the diagnosis of candidiasis, even when considering the classic triad of symptoms. Laboratory identification of yeast species is essential for correct treatment, preventing the resistance to antifungals and the high recurrence. In addition, dairy products and bowel habits, both related to intestinal and vaginal dysbiosis, may be associated with VVC.

Vaginal leukocyte counts for predicting sexually transmitted infections in the emergency department

BACKGROUND

The use of vaginal white blood cell (WBC) counts to predict sexually transmitted infections (STIs) in the emergency department (ED) is incompletely characterized.

OBJECTIVES

Our objective was to assess the relationship between vaginal wet preparation WBC counts and STIs and to determine whether WBC counts of at least 11 WBCs per high-power field (HPF) could be useful for identifying STIs in women in the ED.

METHODS

Female ED patients 18 years or older who were evaluated in a single health system between April 18, 2014, and March 7, 2017, and had a genital wet preparation WBC result were retrospectively examined using univariable and multivariable analysis.

RESULTS

Vaginal wet preparation WBC counts were examined for 17,180 patient encounters. Vaginal WBC counts of at least 11 WBCs/HPF were associated with increased odds of having gonorrhea, chlamydia, or trichomoniasis. When this threshold was used for the diagnosis of each STI, sensitivity ranged from 48.2% to 53.9%, and specificity ranged from 67.2% to 68.8%.

CONCLUSION

Women with STIs are more likely to have higher vaginal WBC counts. However, higher vaginal wet preparation WBC counts in isolation have limited diagnostic utility for gonorrhea, chlamydia, and trichomoniasis. Incorporation of age, urine leukocyte esterase results, and vaginal WBC counts provided a better predictor of an STI than vaginal WBC counts alone.

Development and characterization of chitosan nanoparticles loaded nanofiber hybrid system for vaginal controlled release of benzydamine

Vaginal infections caused by various pathogens such as fungi, viruses and protozoa are frequently seen. Systemic and local treatments can be applied to eliminate these infections. Novel vaginal drug delivery systems can be used to provide local treatment. Vaginal drug delivery systems prevent systemic side effects and can provide long-term drug release in the vaginal area. Nanofibers and nanoparticles have a wide range of applications and can also be preferred as vaginal drug delivery systems. Benzydamine is a non-steroidal anti-inflammatory and antiseptic drug which is used for treatment of vaginal infections. The aim of this study was to compare the nanofiber and gel formulations containing lyophilized benzydamine nanoparticles with nanofiber and gel formulations containing free benzydamine, and to provide prolonged release for protection from the vaginal infections. Ionic gelation method was used for the preparation of benzydamine loaded nanoparticles. To produce benzydamine nanoparticles loaded nanofiber formulations, polyvinylpyrrolidone (PVP) solutions were prepared at 10% concentrations and mixed with nanoparticles. Hydroxypropyl methylcellulose (HPMC) was used as a gelling agent at the concentration of 1% for the vaginal gel formulation. Nanoparticles were characterized in terms of zeta potential, polydispersity index and particle size. Viscosity, surface tension and conductivity values of the polymer solutions were measured for the electrospinning. Mechanical properties, contact angle and drug loading capacity of the fibers were determined. Scanning electron microscopy (SEM), differential scanning calorimetry (DSC), transmission electron microscopy (TEM), fourier-transform infrared (FT-IR) spectroscopy, mucoadhesion, ex vivo permeability studies and in vitro release studies were performed for the selected formulations. Ex vivo permeability studies were performed using Franz diffusion cell method. SEM and TEM images showed that fiber diameters increased with loading of nanoparticles. DSC studies showed no interaction between excipients used in the formulation. Tensile strength and elongation at break values of the fibers increased with the loading of nanoparticles, and the contact angle values of the fibers were found to be 0°. Addition of benzydamine nanoparticles to gel and nanofiber formulations increased mucoadhesion compared to free benzydamine loading formulations. Benzydamine nanoparticle loaded gel and nanofiber formulations penetrated slower than that of free benzydamine gel and fiber formulations. The results demonstrated that benzydamine and benzydamine nanoparticle loaded fibers and gels could be a potential drug delivery system for the treatment of vaginal infections. Chitosan nanoparticle loaded nanofiber formulations are offered as an alternative controlled release vaginal formulations for vaginal infections.

Frequency of Coinfection on the Vaginal Wet Preparation in the Emergency Department

Introduction

Vaginal infections are common in the emergency department (ED) but the frequency of vaginal coinfections identified on wet preparation is unknown.

Methods

The study examined a data set of 75,000 ED patient encounters between April 18, 2014, and March 7, 2017, who had received testing for gonorrhea, chlamydia, or trichomonas or had received a urinalysis and urine culture during the ED encounter. From this data set we reviewed 16,484 patient encounters where a vaginal wet preparation was performed on women age 18 years and older. Findings from the vaginal wet preparation and ED discharge diagnoses were examined to evaluate the frequency of vaginal coinfections with vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis.

Results

Among the women who had wet preparations, 4,124 patient encounters (25.0%) had a diagnosis of bacterial vaginosis, 625 (3.8%) had a diagnosis of vulvovaginal candidiasis, and 1,802 (10.9%) were infected with Trichomonas vaginalis. Twenty encounters (0.1%) had a diagnosis of vulvovaginal candidiasis and trichomoniasis; 150 (0.9%), bacterial vaginosis and trichomoniasis; 136 (0.8%), vulvovaginal candidiasis and bacterial vaginosis; and 10 (0.1%), trichomoniasis, bacterial vaginosis, and vulvovaginal candidiasis. On vaginal wet preparation, the mean white blood cell count was 13.0 per high-power field. Clue cells were found in 6,988 wet preparations (42.4%); 1,065 wet preparations (6.5%) had yeast and 1,377 (8.4%) had T. vaginalis. T. vaginalis was identified in 2.5% (266/10,542) of urinalyses and 8.4% (406/4,821) of nucleic acid amplification tests.

Conclusions

Vaginal coinfections were uncommon among women receiving a vaginal wet preparation in the emergency department. The most common vaginal coinfection was bacterial vaginosis and trichomonas.

Guidance for gynecologists utilizing telemedicine during COVID‐19 pandemic based on expert consensus and rapid literature reviews

Background

COVID‐19 has impacted delivery of outpatient gynecology and shifted care toward use of telemedicine.

Objective

To rapidly review literature and society guidelines and create expert consensus to provide guidance regarding management of outpatient gynecology scenarios via telemedicine.

Search strategy

Searches were conducted in Medline and Cochrane databases from inception through April 15, 2020.

Selection criteria

Literature searches were conducted for articles on telemedicine and abnormal uterine bleeding, chronic pelvic pain, endometriosis, vaginitis, and postoperative care. Searches were restricted to available English language publications.

Data collection and analysis

Expedited literature review methodology was followed and 10 943 citations were single‐screened. Full‐text articles and relevant guidelines were reviewed and narrative summaries developed.

Main results

Fifty‐one studies on the use of telemedicine in gynecology were found. Findings were reported for these studies and combined with society guidelines and expert consensus on four topics (abnormal uterine bleeding, chronic pelvic pain and endometriosis, vaginal discharge, and postoperative care).

Conclusions

Guidance for treating gynecological conditions via telemedicine based on expedited literature review, review of society recommendations, and expert consensus is presented. Due to minimal evidence surrounding telemedicine and gynecology, a final consensus document is presented here that can be efficiently used in a clinical setting.

Guidance for gynecologists using telemedicine during COVID‐19 based on rapid literature review, review of society recommendations, and expert consensus in accessible format.

Mucoadhesive Chitosan Delivery System with Chelidonii Herba Lyophilized Extract as a Promising Strategy for Vaginitis Treatment

Chelidonium majus (also known as celandine) contains pharmacologically active compounds such as isoquinoline alkaloids (e.g., chelidonine, sanguinarine), flavonoids, saponins, carotenoids, and organic acids. Due to the presence of isoquinoline alkaloids, Chelidonii herba extracts are widely used as an antibacterial, antifungal, antiviral (including HSV-1 and HIV-1), and anti-inflammatory agent in the treatment of various diseases, while chitosan is a biocompatible and biodegradable carrier with valuable properties for mucoadhesive formulations preparation. Our work aimed to prepare mucoadhesive vaginal drug delivery systems composed of Chelidonii herba lyophilized extract and chitosan as an effective way to treat vaginitis. The pharmacological safety of usage of isoquinoline alkaloids, based on MTT test, were evaluated for the maximum doses 36.34 ± 0.29 µg/mL and 0.89 ± 1.16 µg/mL for chelidonine and sanguinarine, respectively. Dissolution rate profiles and permeability through artificial membranes for chelidonine and sanguinarine after their introduction into the chitosan system were studied. The low permeability for used save doses of isoquinoline alkaloids and results of microbiological studies allow confirmation that system Chelidonii herba lyophilized extract chitosan 80/500 1:1 (w/w) is a promising strategy for vaginal use. Ex vivo studies of mucoadhesive properties and evaluation of tableting features demonstrated that the formulation containing Chelidonii herba lyophilized extract (120.0 mg) with chitosan (80/500—100.0 mg) and polymer content (HPMC—100.0 mg, microcrystalline cellulose—50.0 mg, lactose monohydrate—30.0 mg and magnesium stearate—4.0 mg) is a vaginal dosage form with prolonging dissolution profile and high mucoadhesion properties (up to 4 h).