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Revista Oficial de la Sociedad Española de Ginecología y Obstetricia Prog Obstet Ginecol 2019;62(1):72-78 Revisión de Conjunto

Update on vaginal infections: Aerobic and other vaginal abnormalities Actualización en infecciones vaginales: vaginitis aeróbica y otras alteraciones vaginales Gloria Martín Saco, Juan M. García-Lechuz Moya

Servicio de Microbiología. HGU Miguel Servet. Zaragoza

Abstract It is estimated that abnormal cannot be attributed to a clear infectious etiology in 15% to 50% of cases. Some women develop chronic vulvovaginal problems that are difficult to diagnose and treat, even by specialists. These disorders (, desquamative inflammatory vaginitis, , and cytolytic vaginosis) pose real challenges for clinical diagnosis and treatment. Researchers have established Key words: a diagnostic score based on phase-contrast microscopy. We review reported evidence on these entities and Vaginitis. present our diagnostic experience based on the correlation with Gram stain. We recommend treatment with Aerobic vaginitis. an that has a very low minimum inhibitory concentration against lactobacilli and is effective against Parabasal cells. enterobacteria and Gram-positive cocci, which are responsible for these entities (aerobic vaginitis and desqua- Diagnosis. mative inflammatory vaginitis).

Resumen Se estima que entre el 15 y el 50% de las mujeres que tienen trastornos del flujo vaginal, éstos no pueden atri- buirse a una etiología infecciosa clara. Algunas de ellas desarrollarán problemas vulvovaginales crónicos difíciles de diagnosticar y tratar, incluso por especialistas. Son trastornos que plantean desafíos reales en el diagnóstico Palabras clave: clínico y en su tratamiento como la vaginitis aeróbica, la vaginitis inflamatoria descamativa, la vaginitis atrófica y la vaginitis citolítica. Para diagnosticarlos, algunos investigadores han establecido una puntuación basada en la Vaginitis. Vaginitis aeróbica. observación microscópica mediante contraste de fases. En este artículo, se revisa la evidencia publicada sobre Microbiota estas entidades y presentamos nuestra experiencia en la correlación diagnóstica con la tinción de Gram. Se vaginal. Células recomienda el tratamiento con un antibiótico con una concentración mínima inhibitoria muy baja contra los lac- parabasales. tobacilos y eficaz contra las enterobacterias y los cocos grampositivos, responsables de estas entidades (vaginitis Diagnóstico. aeróbica y vaginitis inflamatoria descamativa).

Correspondencia: Recibido: 04/03/2018 Gloria Martín Saco Aceptado: 18/09/2018 Servicio de Microbiología HGU Miguel Servet Martín Saco G, García-Lechuz Moya JM. Update on vaginal infections: Aerobic vaginitis Paseo Isabel la Católica, 1-3 and other vaginal abnormalities. Prog Obstet Ginecol 2019;62(1):72-78. DOI: 10.20960/j. 50009 Zaragoza pog.00172 e-mail: [email protected] UPDATE ON VAGINAL INFECTIONS: AEROBIC VAGINITIS AND OTHER VAGINAL ABNORMALITIES 73

INTRODUCTION frequently colonize the in most cases are Lacto- bacillus iners (34%), crispatus (27%), Lac- Vaginitis is the term used to define disorders of the tobacillus gasseri (6%), Lactobacillus jensenii (5%), and vagina caused by infection, , or changes in a mixed group including Gardnerella vaginalis (27%) (3). normal . Lactobacilli act by protecting the vagina from coloniza- Vaginal problems are one of the main reasons women tion by in 3 ways (Fig. 1): seek medical attention. It is estimated that no clear infec- 1. By inhibiting the growth of other pathogens via tious etiology can be assigned in 15% to 50% of women competition for the substrate. Lactobacilli do this by (1). Some women develop chronic vulvovaginal disorders producing hydrogen peroxide and organic acids and that are difficult to diagnose and treat, even for specia- metabolizing glycogen, which depends on the pro- lists (2). Therefore, based on the well-known and complex duction of estrogens and accumulates in the squa- vaginal ecosystem, we aim to provide a review of less well- mous epithelium and in lactic acid, thus leading to a known vaginal disorders that go beyond microbiological vaginal pH of ≤4.5. concepts and generate real challenges in clinical diagnosis 2. By inhibiting the of other microorganisms and treatment. These disorders include aerobic vaginitis, through adhesion to epithelial cells and the muco- desquamative inflammatory vaginitis, atrophic vaginitis, sa to produce surfactants and binding to vaginal and cytolytic vaginitis. fibronectin. 3. Blocking the spread of other pathogens by binding to them (coaggregation). Vaginal ecosystem However, the absence of lactobacilli does not inevita- bly mean that the patient will develop a disease, since The "healthy" vaginal ecosystem, in which Lactobaci- other also produce lactic acid and help maintain llus is the predominant microorganism, plays a key role a healthy medium in the vagina (4). Not all strains of Lac- in the determination and prevention of various genital tobacillus species express these properties with the same infections (including sexually transmitted infections intensity, and there are considerable differences between [STIs]) and urinary infections. The species that most species, and even between strains of the same species.

Figure 1: a) Coaggregation; b) Production of biosurfactants; c) Production of bacteriocins and hydrogen peroxide; d) Regulation of toxin production; e) Competition for nutrients and surface receptors; f) Production of antimicrobial peptides (eg, defensins, lactoferrin, lysozyme, and alkaline phosphata- ses); g) On covering the surface of connections between cells, the lactobacilli prevent the penetration of other microorganisms. Adapted from Reference 5, Reid et al. Nature Rev Micro 2011.

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The intensity of these properties has led some strains to teria (Lactobacillus species) and, in contrast, facilitate be used as probiotics (5). the presence of others (eg, enterobacteria, Staphylococ- Lactobacilli live together with several species of cus species, anaerobes). Hormonal changes in the pre- microorganism in the vagina. Most are anaerobic (aerobic menarche are sometimes sudden and facilitate massive microorganisms are more common, in a proportion of 10 colonization byLactobacillus species. This usually leads to to 1) (6). These microorganisms make up the microbiota considerable desquamation of cells, which is often asso- of the healthy vagina: ciated with abundant secretions, leading the patient to ––Facultative anaerobes and aerobes: Gram-positive visit her doctor. Infections byCandida species are common bacilli (Lactobacillus species, 45%-88% of women; during this period. These represent the abovementioned Corynebacterium species, 14%-72%; Gardnerella changes (estrogens facilitate the expression of Candida vaginalis, 2%-58%); Gram-positive cocci Staphylo( - virulence factors) and the establishment of the microbiota coccus epidermidis, 34%-92%; Staphylococcus aureus, in adult women. During reproductive age, depending on 1%-32%; Group B Streptococcus 6%-22%; Entero- sexual activity and the regularity of the menstrual cycle, coccus species 32%-36%; nonhemolytic streptococ- the microbiota is made up mainly of lactobacilli and other ci, 14%-33%; α-hemolytic streptococci, 17%-36%); bacteria whose metabolic products enable pH to remain Gram-negative bacilli (Escherichia coli 20%-28%, below 4.5. and other Enterobacteriaceae in lower proportions); During the puerperium, in contrast with pregnancy, mollicutes ( hominis, 0%-22% and Urea- the vaginal microbiota undergoes dramatic changes, plasma urealyticum, 0%-58%). favoring the development of certain bacteria (anaero- ––Anaerobes: Gram-positive bacilli Lactobacillus( spe- bes and enterobacteria) to the detriment of species of cies, 10%-43%, Eubacterium species, 0%-7%, Bifido- lactobacilli. This is why this period is usually crucial for bacterium species, 8-10%, Propionibacterium species triggering and progress of an infection of the upper geni- 2%-5%, Clostridium 4%-17%); Gram-positive cocci tal tract. In postmenopausal women, the microbiota is (Peptococcus and Peptostreptococcus); Gram-negati- very variable owing to the reduction in hormone (estro- ve cocci and bacilli ( bivia, Porphyromonas gens) and common anatomical structural changes (eg, asaccharolytica, fragilis group Bacteroides, and Fuso- prolapse, episiotomy scars). In elderly women, epithelial bacterium species). atrophy leads to recurrences and reinfections that gene- ––Yeasts 15%-30%. rally involve low-virulence endogenous microorganisms The vaginal microbiota is not a static population but a (Table I and Figure 2). dynamic one, where types and levels of microbial popu- Furthermore, normal vaginal discharge is characterized lations fluctuate continuously within a changing environ- by vaginal wall transudate and cervical mucus that is clear, ment. The changes are produced by endogenous factors whitish, viscous, odorless, homogeneous and has a ph of (age, menstrual cycle, and pregnancy) and by exogenous < 4.5. It is also characterized by the presence of polymor- factors (sexual relations, , , contracep- phonuclear leukocytes (< 10 per field of x400 noncluste- tives, and vaginal hygiene habits) (7). red leukocytes) and polygonal epithelial cells with whole The anatomy, physiology, and ecology of the vagina borders and no perinuclear halo. are age-dependent. In infants and girls who have not yet In summary, under normal conditions, the vagina is a menstruated, the microorganisms that make up—both habitat where different species of bacteria are balanced transitorily and permanently—the vulvar and cutaneous in symbiosis with the host. This balance remains stable microbiota are established in the vagina. The lack of thanks to the presence of Lactobacillus (50%-90% of the estrogen and high pH limit colonization by certain bac- vaginal aerobic flora in most women) (8).

Table I. Status of vaginal homeostasis at different ages

Age Estrogens Epithelium Glycogen pH Microbiota

Neonatal +++ + 4.5 Lactobacillus spp

Prepubertal + - 7 Coliform

Reproductive age ++++ ++ 3.5-4 Lactobacillus spp

Menopause + - 7 Coliform

Dpto. Scienze Microbiologiche e Ginecologiche. Università di Catania (2002).

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It is difficult to define a healthy vagina and, therefo- ––In microbiological terms, it is characterized by re, diagnose and treat diseases such as vaginosis. There increased Gram-positive aerobic microorganisms have been reports of bacteria in some women that would such as Streptococcus agalactiae, Staphylococcus, normally lead to a diagnosis of , even Enterococcus, and Gram-negative microorganisms though the patient had no symptoms of vaginosis (9). It such as Enterobacteriaceae (particularly, Escheri- has even been suggested that variations in the composi- chia coli). tion of a woman’s vaginal microbiota, together with the ––In clinical terms, the infection is characterized by the composition of a man’s sperm, could lead the woman to presence of the following: be fertile with one man and infertile with another (10). -- Yellowish secretion -- Malodor (negative KOH test) -- High vaginal pH -- Vaginal reddening, itching, burning sensation, and different degrees of . The most common and well-known types of vaginitis Donders et al. (12) established a score based on micros- are candidal vaginitis, vaginitis caused by Trichomonas copic observations of phase contrasts (x400) of the num- vaginalis, and bacterial vaginitis, which account for 90% ber of Lactobacillus species, the number of leukocytes, of all cases of vaginitis. Available tools for diagnosis and the proportion of toxic leukocytes, the bacterial flora treatment are known to be effective. observed, and the proportion of parabasal cells. Each cri- The remaining 10% comprises much less well-known terion is scored from 0 to 2, with a maximum score of vaginal abnormalities that we do not find as easy to 10. The scores were as follows: Between 1 and 2, normal diagnose, namely, aerobic vaginitis, desquamative flora; between 3 and 4, mild aerobic vaginitis; between inflammatory vaginitis, cytolytic vaginitis, and atrophic 5 and 6, moderate aerobic vaginitis; and greater than 6, vaginitis. intense disease. A score of 8-10 indicated severe vaginitis or desquamative inflammatory vaginitis. Donders et al. studied 631 patients and found that 50 (7.9%) had signs Aerobic vaginitis of moderate or severe aerobic vaginitis. If we based the evaluation on Gram stain, we do not Aerobic vaginitis is a new disease that cannot be classi- take into account the criterion of toxic leukocytes, with a fied. It is neither specific vaginitis nor bacterial vaginosis maximum score of 8 instead of 10 (13) (Figure 4). (8,11). Tempera and Furneri (8) proposed treatment based on Aerobic vaginitis differs from bacterial vaginosis (Fig. 3 an antibiotic with a very high minimum inhibitory concen- a-c): tration againstlactobacillus , but that was effective against

Figure 2. Changes in the metabolism of vaginal structure and composition.

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a b c

Figure 3. a) Mild aerobic vaginitis. Parabasal cells with Gram stain. b) Bacterial vaginosis with clue cell. c) Normal epithelial cells and vaginal flora. G. Martín-Saco. HUMS. 2016. enterobacteria and gram-positive cocci. The authors con- The differential diagnosis should be made with atro- cluded that the 2 best options were topical quinolones phic vaginitis, lichen planus, pemphigus vulgaris, Behçet and kanamycin. Furthermore, the role of probiotics for disease, presence of foreign bodies, and secon- re-establishing vaginal flora with or without the help of dary to uterine leiomyoma or polyps (22). low-dose hormones has been investigated (14,15,16). In 2011, Sobel et al. (23) found that intravaginal As with vaginosis, aerobic vaginitis seems to have a hydrocortisone or clindamycin relieved symptoms in up negative effect on pregnancy, increasing the risk of pre- to 86% of cases, although with relapses before 6 weeks term birth, , and funisitis. There is also an increase in IL-1β, IL-6, and IL-8 associated with increa- sed prostaglandins during labor (17,18). The recommen- ded treatment during pregnancy is clindamycin and pro- biotics (19).

Desquamative inflammatory vaginitis

Desquamative inflammatory vaginitis was first described by Gray and Barnes (20) in 1965 as a rare chronic syndro- me of unknown etiology, although very exudative vagi- nitis had been reported in 1956 (21). This noninfectious inflammatory vaginitis with secondary bacterial superin- fection is present in 8% of cases of persistent vaginitis (2). It can occur at any age and is most common during the menopause and postpartum period. There is no specific associated microorganism, although Lactobacillus species is absent. As the condition has sometimes been associated with group A Streptococcus or Staphylococcus aureus, the authors recommend always performing bacterial culture and ruling out the presence of Trichomonas (21), although diagnosis may be by exclusion. It may be considered an extreme form of aerobic vaginitis (20). Diagnosis requires fulfillment of the following conditions: 1. Symptoms: yellow flow, dyspareunia, pruritus, bur- ning sensation, irritation 2. Vaginal inflammation 3. pH >4.5 4. Loss of usual lactobacilli 5. Increased leukocytes and parabasal cells at a ratio of Figure 4. Leukocytes > parabasal cells. Gram stain (x400) and (x1000). >1/1 G. Martín-Saco. HUMS. 2016 .

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in 32%. The recommended treatment is intravaginal can appear in premenopausal women, and is associated clindamycin 2% ointment twice weekly for 3 months or with risk factors such as antiestrogen drugs, radiothera- clindamycin 200 mg vaginal suppositories at the same py, and chemotherapy. The condition is characterized by frequency (longer treatments are more successful) or a loss of elasticity and thinning of the . hydrocortisone in 25-mg vaginal suppositories or oint- It progresses with irritation or a burning sensation in the ment 300-500 mg 2-3 times per week for 2 months with vagina, dyspareunia, and urinary symptoms. Vaginal flow gradual tapering. Clindamycin ointment and hydrocor- has a pH ≥ 5. Microscopy reveals parabasal cells, leuko- tisone suppositories can be combined (24). cytes, and absence of Lactobacillus, which are similar to the characteristics of desquamative inflammatory vaginitis. Treatment is with estrogens, which lead to recovery of Cytolytic vaginosis (noninfectious) the mucosa. The dose and route of administration are tailored according to the characteristics of the patient. Cytolytic vaginosis is characterized by excessive growth Antibiotic therapy is not necessary (27). of Lactobacillus species. Symptoms are similar to those of candidal vulvovaginitis, with which it is often confused (25) (pruritus, burning sensation, dyspareunia, dysuria), CONCLUSION with altered vaginal flow, which intensifies during the luteal phase (second phase of the menstrual cycle), with The less well-known vaginal diseases, whose frequen- a pH of 3.5 to 4.5. Microscopy reveals desquamated, rup- cy varies in the gynecology clinic, are more problematic tured epithelial cells with denuded nuclei (cytolysis). The in terms of diagnosis and management than infectious disease is a lactobacillosis, which is sometimes caused by vaginitis that causes sexually transmitted infections. The overtreatment with antibiotics or that leads to differential diagnosis of these complex diseases (see Table an imbalance in normal flora. It is not a genuine infection. II and Figure 5) requires specialist knowledge of epidemio- The recommended treatment is vaginal douching with logy, microbiology, and cytology. They are worthy of spe- sodium bicarbonate twice weekly for 2 weeks (26). cial attention because they tend to relapse and may even become chronic. Given that some of these conditions can intensify owing to the inappropriate use of antibiotics and Atrophic vaginitis (noninfectious) agents, it is very important to make a careful microbiologic diagnosis in order to rule out the presen- Atrophic vaginitis affects more than 40% of postmeno- ce or absence of specific infectious agents and to better pausal women. It is associated with estrogen deficiency, recognize the disease.

Table II. Comparison of the characteristics of the most frequent types of vaginitis

Normal Bacterial vaginosis Aerobic vaginitis Desquamative Cytolytic vaginosis inflammatory (noninfectious) vaginitis

Pruritus Pruritus Burning sensation Malodorous discharge Pruritus Burning sensation Symptoms - Similar to candidiasis Dyspareunia No dyspareunia Sporadic dyspareunia Dyspareunia Abnormal flow Abnormal flow

Erythema Erythema Smooth, white Signs - Edema Adherent discharge Edema Little erythema mucous discharge Fissuring Fissuring

pH < 4.5 4 - 4.5 > 4.5 > 4.5 > 4.5 Very acidic

Amine Negative Negative Positive Negative Negative Negative

Inflammatory Positive in Negative Positive or negative Negative Positive Generally negative response symptomatic patients

Leukocytes with Abundant Gram-positive Yeasts Toxic leukocytes Microscopy Guide cells increased parabasal bacilli and frayed, Cells Hyphae Parabasal cells cells (>1/1) ruptured cells

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Vaginal pH

>4.5 KOH (-) <4.5

CYTOLYTIC VAGINOSIS PMN/parabasal PMN/parabasal ATROPHIC cells >10 cells = I VAGINITIS DESQUAMATIVE AEROBIC INFLAMMATORY VAGINITIS VAGINITIS

Figure 5. Diagnostic algorithm for other types of vaginitis based on vaginal pH.

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