Cytolytic vaginosis: misdiagnosed as candidal vaginitis

Scoping review of cytolytic vaginosis literature

BACKGROUND

Cytolytic vaginosis (CV) is a little-known, controversial condition that is typically not considered for women presenting with vulvovaginitis symptoms. Objective: The objective of this scoping review was to identify and compile the global evidence on CV.

METHODS

A medical librarian searched Prospero, Wiley Cochrane Library, Ovid Embase, Ovid Medline, EBSCO CINAHL, ProQuest Dissertations and Theses Global, and Scopus, from inception to April 4, 2019 and updated to October 17, 2021. Studies were eligible if they discussed CV. Two independent reviewers conducted study selection and data extraction.

RESULTS

Sixty-four studies were identified, with 67% of studies (n = 43) published since 2007. Studies were from around the world, including the United States (28%, n = 18), Brazil (11%, n = 7), Portugal (11%, n = 7), and China (11%, n = 7). Fifty percent of studies (n = 32) were reviews; the remainder were observational; and of these, 78% (n = 25) were cross-sectional. The most frequent topics included: diagnosis (19%, n = 12), prevalence (17%, n = 11), and overview of CV (50%, n = 32). Evidence for prevalence in symptomatic women (median prevalence of 5%, interquartile range 3%-8%) was based only on 16% of studies (n = 10) with minimal evidence on prevalence in asymptomatic women and across different geographic regions. Microbiological findings, including abundant lactobacilli and fragmented epithelial cells, were found useful to distinguish between CV and vulvovaginal candidiasis, and Lactobacillus crispatus was noted to dominate the vaginal flora in women with CV. Most studies used subjective criteria to diagnose CV as the condition lacks gold-standard microscopic criteria. The suggested primary treatment (baking soda irrigations) was largely based on expert opinion, and there was minimal evidence on associations between CV and other conditions.

CONCLUSION

Knowledge gaps currently exist in all realms of CV research. Additional research is needed to confirm the validity of CV and ensure that women are diagnosed and treated effectively.

Roles of the Microbiota of the Female Reproductive Tract in Gynecological and Reproductive Health

The microbiome of the female reproductive tract defies the convention that high biodiversity is a hallmark of an optimal ecosystem. Although not universally true, a homogeneous vaginal microbiome composed of species of Lactobacillus is generally associated with health, whereas vaginal microbiomes consisting of other taxa are generally associated with dysbiosis and a higher risk of disease. The past decade has seen a rapid advancement in our understanding of these unique biosystems. Of particular interest, substantial effort has been devoted to deciphering how members of the microbiome of the female reproductive tract impact pregnancy, with a focus on adverse outcomes, including but not limited to preterm birth. Herein, we review recent research efforts that are revealing the mechanisms by which these microorganisms of the female reproductive tract influence gynecologic and reproductive health of the female reproductive tract.

A Clinicopathological Diagnostic and Therapeutic Approach to Cytolytic Vaginosis: An Extremely Rare Entity that may Mimic Vulvovaginal Candidiasis

Objectives:

Cytolytic vaginosis is a very rare entity that may be clinically misdiagnosed as vulvovaginal candidiasis. The aim of this study was to determine the incidence of cytolytic vaginosis in patients displaying symptoms similar to vulvovaginal candidiasis and to develop a clinicopathological diagnostic and therapeutic approach.

Materials and Methods:

In total, 3000 cervical smear samples were evaluated at our center between 2015 and 2018. Patients whose PAP smears demonstrated significant epithelial cytolysis, naked nuclei, excessive increase in lactobacilli population, absent or minimal neutrophils and no microorganisms were subjected to a symptom assessment questionnaire and had their vaginal pHs measured. They were classified into two groups according to their complaints, symptoms and vaginal pHs: Cytolytic vaginosis and Asymptomatic intravaginal lactobacillus overgrowth. A standardized NaHCO3 Sitz bath therapy was applied to the cytolytic vaginosis group.

Results:

Fifty-three of the patients (1.7%) were diagnosed as cytolytic vaginosis. After Sitz bath therapy, there was a statistically significant decrease in the cytolysis and lactobacillus scores of the patients. Vaginal discharge of 43 (81%) patients ceased completely while that of the remaining 10 (19%) patients decreased after the therapy. The improvement was statistically significant (P < 0.001). There was a complete resolution in 28 (96%) patients with severe; and in 21 (94%) patients with intermediate vaginal discomfort, after the therapy. Dyspareunia was resolved in 35 (97%) patients (P < 0.001).

Conclusion:

Cytolytic vaginosis is a rare entity that can be diagnosed with the help of cytopathology and has a therapy based on the modulation microbiota by decreasing the vaginal pH.

Laboratorial Aspects of Cytolytic Vaginosis and Vulvovaginal Candidiasis as a Key for Accurate Diagnosis: A Pilot Study

OBJECTIVE

 To identify clinical, microscopic, and biochemical characteristics that differentiate cytolytic vaginosis (CV) from vulvovaginal candidiasis (VVC).

METHODS

 The present cross-sectional study analyzed the vaginal contents of 24 non-pregnant women aged 18 to 42 years who were attended at the Genital Infections Clinic at Centro de Atenção Integral à Saúde da Mulher da Universidade Estadual de Campinas (CAISM-UNICAMP). They were diagnosed either with (CV = 8, VVC = 8) or without vulvovaginitis or vaginal dysbiosis (controls). The socio-demographic, clinical, and gynecological data were obtained from a detailed patient interview. Samples of the vaginal contents were collected for analysis of vaginal pH, gram stain, and specific fungal culture. The Kruskal-Wallis and Fisher exact tests were used to compare the differences between the groups. Odds ratios were used to compare the categorical variables. The significance level was considered at p < 0.05.

RESULTS

 Both women with CV and VVC had a lumpy vaginal discharge (p = 0,002) and vaginal hyperemia (p = 0.001), compared with controls. The inflammatory process was more intense in the VVC group (p = 0.001). In the CV group, there was statistical significance for the lactobacillus amount (p = 0.006), vaginal epithelium lysis (p = 0.001), and vaginal pH (p = 0.0002).

CONCLUSION

 Cytolytic vaginosis and VVC diagnoses rarely differ on clinical characteristics but have different laboratorial findings. The present study highlights the importance of conducting an accurate investigation through laboratory tests rather than clinical criteria to avoid misdiagnosis.

Variation of the Vaginal Lactobacillus Microbiome in Cytolytic Vaginosis

OBJECTIVE

This pilot study aimed to evaluate whether different microbial compositions cause symptoms in patients with Lactobacillus overgrowth and to investigate the variation in Lactobacillus microbiome in cytolytic vaginosis (CV).

MATERIALS AND METHODS

Lactobacillus species were identified from the vaginal fluid of 70 healthy women and 79 patients with CV using molecular analysis of the 16S rRNA gene. χ and Fisher exact tests were used to compare the isolated rates of Lactobacillus species between the 2 groups. The capabilities of dominant Lactobacillus strain to produce acid in the 2 groups were analyzed by repeated measures analysis of variance.

RESULTS

The isolation of 2 or more Lactobacillus species per vaginal sampling was significantly less common in the CV group (1.3%) compared with the healthy control (HC) group 12.2% (p = .013). Significant differences in Lactobacillus species were observed between the 2 groups (p < .001). Lactobacillus crispatus was more often found in the CV group (88.7%) than in the HC group (56.4%, p < .001). Compared with that in the HC group, the dominant L. crispatus strain in the CV group tended to produce more acid.

CONCLUSIONS

The CV group carried a less diverse Lactobacillus species, vaginally. Lactobacillus crispatus was common to both CV and HC groups but demonstrated enhanced acid-producing capability in the CV group. The pathogenesis of CV may be based, in part, on an overgrowth of L. crispatus with enhanced acid-producing capability.

Characterization of the vaginal microbiome during cytolytic vaginosis using high-throughput sequencing

BACKGROUND

Cytolytic vaginosis (CV) is a common disease that results in pruritus, dyspareunia, and vulvar dysuria. However, the pathological mechanisms of the disease are still unclear. Compared to traditional methods, high-throughput sequencing can obtain more accurate qualitative and quantitative information on the microbiome.

METHODS

We collected 75 samples from 32 healthy women (average age 44 ± 8) and 43 patients with CV (average age 38 ± 8). We used high-throughput sequencing of the 16S rRNA V3-V4 region to characterize and compare the vaginal microbiota of patients with CV and healthy women and to identify potential biomarkers for CV.

RESULTS

The vaginal pH of patients with CV was ≤3.8, and the vaginal concentration of H2 O2 was ≥2 μmol/L. Colony densities of Lactobacillus spp. in patients with CV ranged from +++ (5-30) to ++++ (>30) and were significantly higher than those in healthy women. High-throughput sequencing showed that Lactobacillus was the most prominent genus both in patients with CV and in healthy women, with abundances of 83.8% and 97.2%, respectively (P < 0.001). Lactobacillus crispatus was more abundant in patients with CV, whereas Lactobacillus sp. L-YJ was more abundant in healthy women, with area under the curve (AUC) values of 0.9375 and 0.8379, respectively.

CONCLUSION

The abundance of Lactobacillus spp. in CV patients was significantly different from that of healthy patients. Two suitable biomarkers, L. crispatus and Lactobacillus sp. L-YJ, were identified. These results will be useful for the identification of women at risk of serious illness before they develop obvious symptoms.

Vaginal lipidomics of women with vulvovaginal candidiasis and cytolytic vaginosis: A non-targeted LC-MS pilot study

Objective

To characterize the lipid profile in vaginal discharge of women with vulvovaginal candidiasis, cytolytic vaginosis, or no vaginal infection or dysbiosis.

Design

Cross-sectional study.

Setting

Genital Infections Ambulatory, Department of Tocogynecology, University of Campinas, Campinas, São Paulo–Brazil.

Sample

Twenty-four women were included in this study: eight with vulvovaginal candidiasis, eight with cytolytic vaginosis and eight with no vaginal infections or dysbiosis (control group).

Methods

The lipid profile in vaginal discharge of the different study groups was determined by liquid chromatography-mass spectrometry and further analyzed with MetaboAnalyst 3.0 platform.

Main outcome measures

Vaginal lipids concentration and its correlation with vulvovaginal candidiasis and cytolytic vaginosis.

Results

PCA, PLS-DA and hierarchical clustering analyses indicated 38 potential lipid biomarkers for the different groups, correlating with oxidative stress, inflammation, apoptosis and integrity of the vaginal epithelial tissue. Among these, greater concentrations were found for Glycochenodeoxycholic acid-7-sulfate, O-adipoylcarnitine, 1-eicosyl-2-heptadecanoyl-glycero-3-phosphoserine, undecanoic acid, formyl dodecanoate and lipoic acid in the vulvovaginal candidiasis group; N–(tetradecanoyl)-sphinganine, DL-PPMP, 1-oleoyl-cyclic phosphatidic, palmitic acid and 5-aminopentanoic acid in the cytolytic vaginosis group; and 1-nonadecanoyl-glycero-3-phosphate, eicosadienoic acid, 1-stearoyl-cyclic-phosphatidic acid, 1-(9Z,12Z-heptadecadienoyl)-glycero-3-phosphate, formyl 9Z-tetradecenoate and 7Z,10Z-hexadecadienoic acid in the control group.

Conclusions

Lipids related to oxidative stress and apoptosis were found in higher concentrations in women with vulvovaginal candidiasis and cytolytic vaginosis, while lipids related to epithelial tissue integrity were more pronounced in the control group. Furthermore, in women with cytolytic vaginosis, we observed higher concentrations of lipids related to bacterial overgrowth.

Vaginitis: Beyond the Basics

Vaginal complaints are one of the most common reasons women seek the advice of a health care provider. Uncomplicated infections such as vulvovaginal candidiasis, bacterial vaginosis, or trichomoniasis are easy to diagnose and treat. However, about 8% of patients will have a more complicated course with failure to respond to treatment or rapid recurrence of symptoms. Understanding the need for a methodical, diagnostic approach to help these women with recurrent or refractory cases of vaginal symptoms will aid the clinician achieve successful patient outcomes.

The human vaginal microbial community

Monopolization of the vaginal econiche by a limited number of Lactobacillus species, resulting in low pH of 3.5-4.5, has been shown to protect women against vaginal dysbiosis, sexually transmitted infections and adverse pregnancy outcomes. Still, controversy exists as to which characteristics of lactobacilli are most important with regard to colonization resistance and to providing protection. This review addresses the antimicrobial and anti-inflammatory roles of lactic acid (and low pH) and hydrogen peroxide (and oxidative stress) as means of lactobacilli to dominate the vaginal econiche.

Epidemiology and clinico-investigative study of organisms causing vaginal discharge

BACKGROUND

Abnormal vaginal discharge is a common clinical problem in reproductive age group. It is the second most common problem after abnormal uterine bleeding. It is a neglected health problem, most commonly caused due to vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis (BV).

OBJECTIVES

The present study was conducted to determine the prevalence of common organisms causing vaginal discharge and also to know the variety of clinical presentation.

MATERIALS AND METHODS

A cross-sectional descriptive study was conducted in the Skin and STD Outpatient Department of Vinayaka Mission Kirupananda Variyar Medical College Hospital, Salem, who presented with abnormal vaginal discharge between September 2012 and September 2014. A total of 100 women in the reproductive age group who had symptoms of vaginitis were examined. Data were coded and analyzed.

RESULTS

Out of the 100 patients examined, 77 (77%) cases were organism positive. Among the positive cases, BV (27%) was the most common microbiological cause of abnormal vaginal discharge, followed by trichomoniasis (25%), vaginal candidiasis (22%), combined infection (Candida and BV) (3%), and nonspecific cases (23%).

CONCLUSION

Out of 100 cases, few cases showed discordance between clinical and laboratory diagnosis. This discordance can be due to pitfalls in identifying the causative agent clinically or obscuring of the findings due to improper treatment received for other ailments. Thus, clinico-investigative correlation is more important than other clinical findings alone.

Epidemiology and clinico-investigative study of organisms causing vaginal discharge

BACKGROUND

Abnormal vaginal discharge is a common clinical problem in reproductive age group. It is the second most common problem after abnormal uterine bleeding. It is a neglected health problem, most commonly caused due to vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis (BV).

OBJECTIVES

The present study was conducted to determine the prevalence of common organisms causing vaginal discharge and also to know the variety of clinical presentation.

MATERIALS AND METHODS

A cross-sectional descriptive study was conducted in the Skin and STD Outpatient Department of Vinayaka Mission Kirupananda Variyar Medical College Hospital, Salem, who presented with abnormal vaginal discharge between September 2012 and September 2014. A total of 100 women in the reproductive age group who had symptoms of vaginitis were examined. Data were coded and analyzed.

RESULTS

Out of the 100 patients examined, 77 (77%) cases were organism positive. Among the positive cases, BV (27%) was the most common microbiological cause of abnormal vaginal discharge, followed by trichomoniasis (25%), vaginal candidiasis (22%), combined infection (Candida and BV) (3%), and nonspecific cases (23%).

CONCLUSION

Out of 100 cases, few cases showed discordance between clinical and laboratory diagnosis. This discordance can be due to pitfalls in identifying the causative agent clinically or obscuring of the findings due to improper treatment received for other ailments. Thus, clinico-investigative correlation is more important than other clinical findings alone.

Primary care management of women with persistent vaginal discharge

Vaginal discharge is a common complaint managed by NPs in ambulatory settings. This article reviews noninfectious etiologies of vaginal discharge with diagnostic criteria and recommended treatment to aid the NP in correctly managing these patients.

Differential expression of lactic acid isomers, extracellular matrix metalloproteinase inducer, and matrix metalloproteinase-8 in vaginal fluid from women with vaginal disorders

OBJECTIVE

Do metabolites in vaginal samples vary between women with different vaginal disorders.

DESIGN

Cross-sectional study.

SETTING

Campinas, Brazil.

SAMPLE

Seventy-seven women (39.9%) with no vaginal disorder, 52 women (26.9%) with vulvovaginal candidiasis (VVC), 43 women (22.3%) with bacterial vaginosis (BV), and 21 women (10.9%) with cytolytic vaginosis (CTV).

METHOD

Concentrations of D- and L-lactic acid, extracellular matrix metalloproteinase inducer (EMMPRIN), and matrix metalloproteinase-8 (MMP-8), and the influence of Candida albicans on EMMPRIN production by cultured vaginal epithelial cells, were determined by enzyme-linked immunosorbent assay (ELISA). Associations were determined by the Mann-Whitney U-test and by Spearman's rank correlation test.

MAIN OUTCOME MEASURES

Metabolite levels and their correlation with diagnoses.

RESULTS

Vaginal concentrations of D- and L-lactic acid were reduced from control levels in BV (P < 0.0001); L-lactic acid levels were elevated in CTV (P = 0.0116). EMMPRIN and MMP-8 concentrations were elevated in VVC (P < 0.0001). EMMPRIN and L-lactic acid concentrations (P ≤ 0.008), but not EMMPRIN and D-lactic acid, were correlated in all groups. EMMPRIN also increased in proportion with the ratio of L- to D-lactic acid in controls and in women with BV (P ≤ 0.009). Concentrations of EMMPRIN and MMP-8 were correlated in controls and women with VVC (P ≤ 0.0002). Candida albicans induced EMMPRIN release from vaginal epithelial cells.

CONCLUSIONS

Vaginal secretions from women with BV are deficient in D- and L-lactic acid, women with VVC have elevated EMMPRIN and MMP-8 levels, and women with CTV have elevated L-lactic acid levels. These deviations may contribute to the clinical signs, symptoms, and sequelae that are characteristic of these disorders.

The effect of pH and viscosity on bovine spermatozoa motility under controlled conditions

Infertility in a large proportion of infertile couples is due, in part, to the male factor. Spermatozoa must survive the unique environment of the female reproductive tract in their path to fertilize the ovum. This fact is even more problematic for men with oligospermia. Of the many environmental factors that effect sperm motility in the female reproductive tract, we have decided to concentrate on the effect of pH and viscosity on bovine spermatozoa in the laboratory setting. Follicular fluid was harvested from heifer ovaries to serve as a chemo-attractant. Through image analysis, our data shows trends of sperm motility as a function of pH and viscosity. There is a significant increase in the number of immotile sperm seen as pH decreases from 6.5 to 6.0. Furthermore, an exponential relationship between sperm speed and environmental viscosity was observed in vitro. This suggests that modulating vaginal pH and vaginal secretion viscosity could greatly affect spermatozoa motility and therefore male fertility.

Definition and classification of abnormal vaginal flora

Studying the vaginal microflora is not only fascinating, with many discoveries to be made, it is also a very practical way to help women get rid of bothersome and sometimes dangerous infections. Gram-stained vaginal preparations, Pap smears, specific cultures, and nucleic acid detection techniques can be used to diagnose the constituents of the vaginal flora, but in trained hands office-based microscopy of a fresh vaginal smear, preferably using a x400 magnification phase-contrast microscope, allows almost every diagnosis and combination of diagnoses imaginable. In this chapter I will address the pros and cons of the tools that are in use to study vaginal flora, and discuss the different types of bacterial flora and the difficulties encountered in reaching the correct diagnosis of pathological conditions. The 'intermediate flora' is addressed separately, and a new entity--'aerobic vaginitis'--is discussed. Future research should focus on the interaction between infecting microorganisms and host defence mechanisms, as both together generate the pathogenicity of these conditions.