In this article we are speaking about one of the most important parts of gynecology, the vaginitis.

The VAGINA is a virtual channel (distensible) that communicates externally with external genitalia and internally with the Cervix; reproductive organ pelvic and median learn specifically devoted to sexuality and the passage of the fetus during birth.

It is a body “estrogen-dependent” and is influenced by a lot of hormonal conditions that characterize the different periods of women’s lives. With a pH ranging from neutral (6-7) in childhood and old age, to acidic values (4-5) in adolescence and adulthood; the pH varies during the cycle with values tending to neutrality around the menstrual period and slightly alkaline (by virtue of the cervical mucus dl) during the ovulatory period. Even sperm (slightly alkaline) can temporarily change vaginal PH and unmask some latent infections.

An acid pH protects against infection and promotes the growth of Doderlein lactobacilli, symbiotic bacteria that produce lactic acid and help to maintain a healthy vaginal environment and healthy body fluids.

The VAGINAL FLUOR is in fact a vaginal physiological secretion too often mistaken for pathology and instead has a function of lubrication and protection of the vaginal ecosystem; this secretion may increase in an entirely physiological period like ovulatory period, during pregnancy, or during sexual arousal.

TABLE 1: incidence of the most frequent vaginitis
  • Bacterial Vaginosis 40-45% (the most frequent)
  • Candida Vaginitis 20-25%
  • Trichomonas Vaginitis (Trichomoniasis) 15-20%

With these small but important premises of Anatomy and Physiology kind, I can now describe the main VAGINAL INFECTIONS.

VAGINITIS is a vaginal inflammation and can be recognized due to mechanical, chemical, or infectious causes.

I will discuss in this article of Infectious vaginitis in distinguishing them three main groups: Bacterial vaginosis, the Vaginitis Candida and Trichomonas vaginitis. TABLE 1 shows the respective percentages of incidence.

BACTERIAL VAGINOSIS is the most common cause of vaginal infection. The term “vaginosis” means the lack of a true full-blown inflammatory state even in the presence of abnormal vaginal discharge and complete disruption of the resident bacterial flora with a predominance of Gardnerella vaginalis. The irritation can therefore be minimal or absent, but abundant vaginal discharge and bad odor (typically similar to that of rotten fish) are very frequent and are characteristic elements. Symptoms sometimes worsen after menstruation or sexual intercourse.

The cause seems originated in a reduction of the Lactobacilli population that plays an important defensive role also through the production of hydrogen peroxide, bactericidal for anaerobic bacteria. Although often associated with multiple sexual partners and sexual infectious diseases it is currently not considered a sexually transmitted disease.

The presence of bacterial vaginosis has been associated with major diseases such as premature membrane rupture, preterm birth, low birth weight infants, uterine and pelvic infections, infection complications of surgical procedures on the reproductive system, increased susceptibility to get sexually transmitted diseases and HIV .

The most widely used drugs for the treatment are metronidazole, tinidazole, clindamycin.

The diagnosis is based on standardized criteria of Amsel and then on detection of at least 3 of the following: pH> 4.5, the presence of special cells at the microscopic “fresh” examination called “clue cells”, positive amine test , homogeneous vaginal discharge grayish-white, non-viscous, whitish uniformly adherent to the vaginal walls.

Usually, embarrassment because of the smell of rotten fish pushes patients them to the consultation. Bacterial vaginosis must be thought always in the presence of particularly abundant vaginal discharge (leukorrhea). Early identification (including pregnancy) of the disease can prevent the serious complications related.

CANDIDA VAGINITIS (VULVOVAGINAL VAGINITIS) is one of the most frequent pathologies in women of fertile age and it is estimated vaginal candidiasisthat at least 75% of adult women have had at least one episode of vaginitis or vulvovaginitis by Candida. Unfortunately, approximately 40-50% of women who had a first episode is likely to present a recurrence and 5% may present a form of “recurring” characterized by at least three or more episodes of infection per year.

Candida albicans is responsible for 80-95% of the mitotic vaginal and vulvovaginal infections while the remaining percentage belongs to the so-called forms of “non-albicans” as the Glabrata and Tropicalis (forms, however, steadily progressive increasing).

The Vaginal Candida albicans comes from the outside, often from the vulvar skin and intestine where very often lies in high concentrations (intestinal reservoir). The moisture, skin folds and mucous membranes, changes in microflora normally resident are undoubtedly factors contributing to its spread and replication. But Candida albicans can also be considered a common commensal vulvar and vaginal skin flora being present in low concentrations and without any symptoms in many adult women (at least 20%) with a fine balance between welfare and disease where the immune system certainly plays a very important role.

The symptoms of the fungal Candida infection are essentially characterized by vaginal and vulvar itching of varying intensity and always present, whitish vaginal secretions and typically dense and gritty similar to the “curdled milk”; sometimes there is redness and edema (swelling) of the genital mucosa and in particular the labia minora and vaginal Introit.

The symptoms can be so intense to impede sexual activity and create an extreme discomfort.

Candida vaginitis is not considered typical sexually transmitted infection although this possibility can not be excluded in all cases and should be considered in any case in recurring forms (many men are asymptomatic carriers).

The diagnosis is fairly easy: Vulva is often reddened and Thin Lips are swollen; Vagina can also be reddened but the most typical sign is the presence of a thick whitish not smelly discharge with lumps like curdled milk. The acidity of the vaginal environment in the course of Candida Vaginitis normally fluctuates between 4.0 and 4.7. Microscopic “fresh” examination practicable during the visit allows you to highlight the characteristics of pseudohyphae and blastospores while the crop is used to identify various fungal less frequent.

Favorable conditions:

  • Antibiotic therapy, in particular when they are broad-spectrum (for reduction of microbial competition) or treatment with corticosteroids (they reduce the immune system)
  • Some habits such as wearing tight-fitting (skinny jeans) or synthetic (increase temperature and humidity favoring fungal growth)
  • Diabetes
  • Pregnancy, as well as taking oral contraceptives (increased glycogen and modification of Ph).

The treatment of vaginal candidiasis is a very important topic. This fungus has particular tendency to adhere to the mucous membranes and take advantage of any element that leads to a reduction of the immune system tends to have a very high percentage of recurrences.

The drugs most commonly used are Fluconazole, Miconazole, Tioconazole, Nystatin, Boric Acid. Treatment regimens that include general and local therapy and occasionally repeat patterns of treatment. The eradication of a first episode of infection is very important but also the prevention has a strategic role that must be studied on the basis of the clinical condition of the patient. As we have seen the resident bacterial flora is important but it is also important to break down the fungal load in potential reservoirs like the Intestine.

Drugs, rules of hygiene and diet, elimination of risk factors, compared with vulvar and vaginal eco system cutaneous are strategies that should be studied in an increasingly integrated cure.

The treatment of the partner is not a routine procedure and should always be considered after prior assessment or dermatological and urological consultation with the doctor in symptomatic patients or in the presence of recurrences.

TRICHOMONAL VAGINITIS (TRICHOMONIASIS). Etiological agent of this infection is Trichomonasvaginal trichomoniasis Vaginalis, an anaerobic protozoan with flagella wide in its front portion and a rear tail hooked. Featuring vibrant motility, it is transmitted mainly through sexual intercourse (probably currently the most common sexually transmitted disease) and only rarely through contaminated objects (towels, other undergarments, bathing ..). Its incidence varies depending on the geographical areas: 5-25% of the population having the infection. However, in most cases (especially in humans) it is asymptomatic. In women, the disease affects more frequently between 20 and 40 years old and is quite rare (although epidemiological factors) before puberty and postmenopausal age. The symptoms are mainly characterized by vaginal discharge with gray or greenish-yellow fluid rather frothy, foul-smelling, intense itching, edema and Vaginal Wall Erythema, Cervix redness. The sensation of itching, burning (heat) can sometimes be really very busy and associated with dyspareunia and postcoital bleeding, pelvic pain and urinary symptoms.

Even for Trichomoniasis are not uncommon relapsing forms that create a serious physical disorder and can even psychological problems and sometimes unexplainable pelvic pain. There is also a good percentage of chronic patients carriers of Trichomonas Vaginalis therefore able to infect multiple partners. The diagnosis is not difficult and in cases of doubt, “fresh” microscopy (possibly in phase contrast) made directly during the visit without special preparation of the sample letting you easily find flagellate protozoa recognizable for their motility. With examination mirror (typical instrument used during the visit) is easily detectable by its typical secretion and the presence of gas bubbles. Conditions favoring the development of Trichomonas are heat, humidity, and all those conditions that elevate the vaginal PH; In fact, this protozoan grows optimally at pH 5.5. While Candida causes “chemistry” inflammation, Trichomonas has a destructive mechanism linked to the mechanical action towards the mucosa and the release of toxins.

Trichomonas vaginitis has been associated with:

  • Tubal infertility, endometritis and pelvic inflammatory disease (sometimes subtle because they are not symptomatic);
  • Abnormal Pap test and higher incidence of carcinoma of the uterine cervix;
  • Pregnancy complications such as ectopic settlement, premature rupture of membranes, preterm birth, low birth weight, postpartum endometritis.

The Metronidazole is the drug of first choice and always has to be involved partner, obviously after specialist examination, to assess any contraindications and coexisting medical conditions.

SENILE ATROPHIC VAGINITIS. This kind of vaginal inflammation recognizes estrogen deficiency as the atrophic vaginitisroot cause. Estrogens are important for the normal trophism of the vaginal mucosa. The Ph, glandular secretions, hydration, the resident bacterial flora are affected, sometimes in a dramatic way, by physiological decrease in estrogen following Menopause period. The vaginal mucosa is reduced and loses glycogen, thus becoming brittle and very susceptible to opportunistic infections. Even the vaginal elasticity is compromised and all this results in a clinical picture characterized by feeling of dryness, burning, itching sometimes. The treatment of vaginitis in addition to these opportunistic eradication of the germ is based on the use of lubricants, topical estrogen, Lactobacillus and its objective is to restore the integrity of the mucosa and lower the Ph.

A FINAL CONSIDERATION. The subject of vaginitis is too often overlooked and the National Health System does not recognize the extension to many of the topical treatments needed, certainly does not help the eradication of diseases that I wrote which may have significant complications. Do not neglect any change in vaginal secretions and always pay attention to the health status of the partner. Avoiding intercourse during therapy is a good thing (the sperm changes the Ph). Therapies should never forget the physiological basis of the vaginal ecosystem and never aim solely on the action of drugs; hygiene and behavioral measures are

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Filiberto Di Prospero
Medical Doctor, Consultant in Gynecology and Obstetrics, Endocrinology and Metabolism. Director of Gynecologic Endocrinology Unit at Civitanova Marche General Hospital (Italy). Private clinics in Civitanova Marche, Rome and Milan.

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