vaginitis, vulvitis
Vulvovaginitis is an inflammation of the vagina and vulva that may be triggered by bacteria, fungi, or parasites characterized by irritation, itching, vaginal discharge with odor, and a burning sensation. Vulvovaginitis occurs when the balance of the vaginal ecosystem is disturbed.
While vaginosis is an infection of the vagina, vaginitis is an inflammation of the vagina that may be due to vaginosis or other factors such as an allergy, irritant, or a decrease in the female hormone estrogen. Vaginosis is different from vulvovaginitis in that there is no inflammatory reaction, however there is overlap in symptoms between the two conditions.
The onset of signs and symptoms such as leukorrhea (whitish, yellowish, or greenish vaginal discharge), itching, burning and pain in the vulvovaginal area is a frequent occurrence in women’s life. The clinical status is supported by an alteration of the physiological vaginal flora, which can be due to a proliferation of common germs (vaginosis) or to the colonization by pathogenic microorganisms (specific vaginitis).
The most frequent causes of vaginitis/vaginosis (up to 90%) are infections due to:
Bacterial vaginitis (BV) is an inflammation of the vagina caused by several bacterial species including G. vaginalis and Mobiluncus curtisii. It is known to affect high number of women, and is usually associated with other complications such as, pelvic inflammatory disease, preterm labor, low birth weight among others.
BV may result from imbalance in the normal vaginal flora, due to the loss of lactobacilli from sexual intercourse with condoms, use of certain antibiotics, or excessive growth of anaerobic bacteria. BV may reoccur in about 60% of women from one to six months.
Bacterial vaginosis usually occurs in sexually active patients. Some of the other risk factors include multiple sexual partners, low socioeconomic status, lesbians, presence of intrauterine device and prior sexually transmitted disease (STD).
Candida (C. albicans) are the major cause of yeast infection and are present in the normal vaginal flora though in small numbers. Conditions that can alter their quantities might result in infection. The risk of developing vaginitis due to candidas can be increased by the presence of few or combination of the following; disease (diabetes), condition (pregnancy), agents (antibiotics and intrauterine device), weak body immunity, and use of clothing (underwear) that do not allow free flow of air.
Trichomoniasis (Pic. 1) is the commonest sexually transmitted disease worldwide. It was originally thought to be innocuous but has now been found to be associated with preterm labour, premature rupture of membranes, increased perinatal loss and pelvic inflammatory disease (PID).
The particular trichomonad responsible for vaginitis is T. vaginalis, which is the type found in the vagina. Other trichomonads found in the anal canal and rectum, are known but do not cause vaginal discharge because they cannot survive in the vagina. T. vaginalis has been demonstrated in the male urethra and prostate gland.
T. vaginalis is usually transmitted sexually. The organism may survive for several hours in urine, wet towels and even on toilet seats. The possibility of transmission by these routes had been suggested but not completely proven. Incubation period is 4–20 days with an average of 7 days. Males are usually asymptomatic, but they can easily infect treated female.
Definitive diagnosis requires laboratory procedures, including the vaginal pool wet mount examination, determination of the vaginal pH (Pic. 2), and the whiff test. Once a specific diagnosis is made, effective therapy can be prescribed.
A common therapeutic approach is to use local or systemic antibiotics with reduced impact on Lactobacilli (e.g. metronidazole or clindamycin); the use of local antiseptics and probiotics may be useful as well. The administration of antibiotics, however, although generally effective is not free from side effects, which make a repeated use difficult. For this reason, therapeutic alternatives have been proposed, including non-steroidal anti-inflammatory drugs (NSAIDs), plant extracts and agents active on the bacterial biofilm.
Symptoms
The following symptoms may indicate the presence of infection:
Associated diseases
Sexually transmitted infections
Women with vulvovaginitis are more likely to get sexually transmitted infections (STIs), such as HIV, trichomonas vaginitis, Chlamydia, gonorrhea, and herpes. Also, STIs can cause vulvovaginitis.
HIV
The Human Immunodeficiency Virus (HIV) is the virus that can result in Acquired Immune Deficiency Syndrome (AIDS) if left untreated. People who are diagnosed with HIV are said to be HIV positive, even if their infection has not progressed to AIDS. If HIV is left untreated, it may progress to AIDS.
If HIV is left untreated (usually many years), it can affect a person's immune system, leaving the body less able to protect itself from disease. When a person has undiagnosed or untreated HIV the immune system can be damaged and the person can get sick from related infections or cancers.
Theories include that vaginitis increases the number of immune cells at the site of infection, and HIV then infects those immune cells. Other theories suggest that trichomoniasis increases the amount of HIV genital shedding, thereby increasing the risk of transmission to sexual partners.
Human papillomavirus
Human papillomavirus (HPV) is a DNA virus that presents tropism for epithelial cells, causing infections of the skin and mucous membranes. Lesions induced by the human papillomavirus (HPV) are usually associated with vaginal infections.
Endometritis
Chronic endometritis (CE), a local inflammatory disease characterized by unusual plasmacytic infiltration in the endometrial stromal areas. CE frequently happens in the later stage of the infection or under repeated infection. It tends to be neglected in gynecologic practice because of its less apparent symptom and the requirement of time-consuming histopathologic examinations. In most cases, the diagnosis is made based on gynecological indications, such as abnormal uterine bleeding (AUB) and infertility.
Preeclampsia
Implantation is the first coordinated encounter between mother and baby. The abnormal implantation and placentation may lead to various dysfunctions through‐ out the pregnancy. Pre-eclampsia (PE) is a pregnancy-induced disorder characterized by hypertension (high blood pressure) and proteinuria (elevated proteins in the urine). It is estimated to affect about 8% of pregnancies and is thought to be unique to humans. The etiology of PE still remains poorly understood, but abnormal placentation is proved to be a major reason for this disease. In addition, local infection and immune responses are critically involved in the process of implantation.
Pelvic inflammatory disease
Pelvic inflammatory disease (PID), one of the most common infections in nonpregnant women of reproductive age, remains an important public health problem. Typically, PID results from the spread of microorganisms from the cervix and/or vagina into the upper genital tract. It is associated with major long-term sequelae, including tubal factor infertility, ectopic pregnancy, and chronic pelvic pain.
Athropic vaginitis
Atrophic vaginitis is caused by very low hormonal (estrogen) levels that may appear due to the exclusion of ovaries, radiation and menopause.
Complications
Many cases of acute vaginitis can be easily treated when correctly diagnosed, however, some women will have persistent or recurrent disease. Vaginal infections often have multiple causes (varies between countries between 20 and 40% of vaginal infections), which present challenging cases for treatment. Indeed, when only one cause is treated, the other pathogens can become resistant to treatment and induce relapses and recurrences. Therefore, the key factor is to get a precise diagnosis and treat with broad spectrum anti-infective agents (often also inducing adverse effects).
Bacterial vaginosis has been associated with several complications or is known to increase the risk of acquiring certain disease including sexually transmitted diseases (STDs) such as gonorrhea, chlamydial infection, trichomoniasis and human immunodeficiency virus (HIV), as well as reproductive complications.
Vaginal infections left untreated can lead to further complications, especially for the pregnant woman. Different studies have indicated the association between BV and pregnancy complications such as preterm labor and delivery, even miscarriage especially in young women. It has also been related to the reproductive problems such as infertility and pelvic inflammatory diseases, post-operative infection, cervicitis, cervical intraepithelial neoplasia as well as increased risk of STDs. A causative agent of BV (Mageeibacillus indolicus) found in the endocervix was reported to increase the clinical manifestation of cervicitis. Rather, BV has been strongly allied with female infertility, and may be a reason of unexplained infertility usually underestimated.
Similar to BV, trichomoniasis is associated with infertility, pregnancy complications, post-operative infections, and increased risk of other STDs. Candidiasis may also increase the risk of preterm birth.
Further, there are complications which lead to daily discomfort such as:
Risk factors
Many factors may influence occurrences of vulvovaginitis, including age, vaginal pH, hysterectomy, menstrual cycle phase, HPV (human papillomavirus) infection and skin color (elevated vaginal pH is prevalent among black women). Moreover, genetic factors can influence the susceptibility to infection.
Vaginal inflammation could be also caused by agents other than bacteria, fungus, or protozoa. This can happen by utilization of substances that can irritate the cervix such as spermicides, perfumes, soaps, certain antifungal drugs and creams, as well as condoms.
Prevention
Prevention of candidiasis, the most common type of vaginitis, includes using loose cotton underwear. The vaginal area should be washed with water. Perfumed soaps, shower gels, and vaginal deodorants should be avoided. Douching is not recommended. The practice upsets the normal balance of yeast in the vagina and does more harm than good. Prevention of bacterial vaginosis includes healthy diets and behaviors as well as minimizing stress as all these factors can affect the pH balance of the vagina. Prevention of trichomoniasis revolves around avoiding other people's wet towels and hot tubs, and safe-sex procedures, such as condom use.
Presumptive treatments (metronidazole and miconazole) have been reported to reduce the incidence of vaginal infections including bacterial vaginosis and complications of STDs associated with bacterial vaginosis.
Frequent consumption of probiotics has also been shown to reduce the occurrence and reoccurrence of bacterial vaginosis by normalizing the vaginal flora and pH. These products can be taken orally (metronidazole) or administered directly to the vagina (Lactobacilli impregnated vaginal tampons). Prevention and reduction in the occurrence of BV will consequently reduce the development of its related complications and risks.
Vulvovaginitis occurs when the balance of the vaginal ecosystem is disturbed. Infection either in peripheral or directly in vagina can arouse strong immune/inflammatory reaction systematically or locally. The released cytokines and chemokines then act on the pituitary gland and reproductive organs, which may finally lead to menoxenia (abnormal menstruation), irregular ovulation, and infertility. These mediators have an important role in the control of reproductive neuroendocrine, ovarian physiology, fetal implantation and development, and placenta function.
Premature ovarian failure
Female mammals are born with a finite number of oocytes that gradually decreases during prepubertal development and adult life. Each oocyte is encircled by somatic granulosa cells (GCs) to form the basic functioning unit of the ovary - the follicle. The size of the oocytes at birth and the rate of endowment depletion dominate the ovarian functional lifespan. On the other hand, programmed cell death (apoptosis) has been considered one of the most prevalent mechanisms that contribute to the age-related exhaustion of oocytes. Therefore, a precise balance has to be achieved between prosurvival and proapoptotic molecules to maintain the final destiny of the follicle.
It is well recognized that immune/inflammatory response participates in many aspects of reproductive physiology, such as ovulation, menstruation, and implantation. Recent studies suggest that the inflammatory stress caused by infection may also affect ovarian reserve and cyclicity in women.
If properly treated, vaginal infections itself do not cause infertility. However, these infections might interfere with the women’s reproductive health if left undiagnosed or untreated, being commonly associated with many obstetric conditions such as pelvic inflammatory disease, premature rupture of membranes (PROM), prematurity, and infertility and also increasing the risk of HIV transmission.
