Vol. 15 •Issue 2 • Page 45
Cytolytic Vaginosis And Lactobacillosis
Consider These Conditions With All Vaginosis Symptoms
A 35-year-old woman presents with complaints of vulvovaginal itching and thick, white discharge that started 9 months earlier. She reports that the itching and discharge increase in severity during the 2 weeks prior to her menstrual period. She says she is in a monogamous relationship and that she sometimes experiences introital pain with intercourse. Her medication history includes an initial attempt to self-treat with an over-the-counter vaginal antimycotic treatment. It provided only temporary relief. The patient then sought diagnosis and treatment from multiple health care providers. She received prescriptions for fluconazole (Diflucan) and metronidazole (Flagyl), but these provided little relief. One provider suggested that she seek psychiatric counseling.
Vulvovaginal complaints are the most frequent gynecologic reason that U.S. women visit their health care providers.1 Bacterial vaginosis, trichomoniasis and vulvovaginal candidiasis account for approximately 90% of vulvovaginal diagnoses.2 Although knowledge of these common diagnoses, as well as normal findings, is fundamental, it is also imperative that nurse practitioners consider the differential diagnoses for the remaining 10%. Recent research suggests that two conditions characterized by lactobacilli overgrowth, cytolytic vaginosis and lactobacillosis, may account for as much as 5% of vulvovaginal complaints.3 Although the body of evidence about these conditions is immature, nurse practitioners and their patients will benefit from an increased awareness of their existence and recommended treatment regimens.
Etiology and Background
More than 80 species of lactobacilli, the predominant bacteria in the healthy vagina, have been identified. Select anaerobic species of lactobacilli have a protective effect against the overgrowth of potentially pathogenic indigenous flora and common infectious vaginal microorganisms by maintaining an acidic vaginal pH between 4.0 and 4.5.4 Lactobacilli contribute to this acidic environment by producing lactic acid and hydrogen peroxide as byproducts of glucose and glycogen synthesis.5,6 In cytolytic vaginosis and lactobacillosis, however, a disruption in this vaginal equilibrium occurs. Although these conditions are characterized by an overgrowth of lactobacilli, a direct causal relationship has not been identified.7,8 Therefore, the etiology of these conditions remains unknown.
What is known is that the lactobacilli overgrowth in cytolytic vaginosis appears to trigger the cytolysis of intermediate vaginal epithelial cells, first described in the early 1890s as Dsderlein's cytolysis.7,9 In 1991, two researchers determined that this was a misnomer because it excluded the various species of lactobacilli that cause the cytolysis, leading to the more appropriate label of cytolytic vaginosis.7
Like cytolytic vaginosis, the etiology of lactobacillosis is unknown. Unlike cytolytic vaginosis, however, no cytolysis of vaginal epithelial cells occurs with lactobacillosis. An association with recent antimycotic treatment may exist, but no evidence has proved a direct causal link.8,10
Cytolysis is a somewhat common finding on Pap smear specimens in patients with symptoms typically attributed to vulvovaginal candidiasis.5,7,11 A study of the rate of cytolysis on 2,947 Pap smears determined that 54 (1.83%) had microscopic findings consistent with cytolytic vaginosis.5 In a study of 101 women with cyclic vaginal discharge, 5% had cytolytic vaginosis based on microscopic findings.3 Based on these limited studies, 1% to 5% of patients who present with vaginal complaints may have cytolytic vaginosis.
The incidence of lactobacillosis has not been quantified. It seems reasonable to hypothesize that, due to the inaccuracy of patient self-diagnosis and the increased over-the-counter availability of mycolytic therapy during the last decade, the incidence of lactobacillosis may have increased.12
The typical patient complaints associated with cytolytic vaginosis and lactobacillosis include pasty, odorless, white vaginal discharge, pruritus and vulvar dysuria (Table 1).8,10 A low-grade vulvar burning or discomfort may occur and increase with sexual activity, especially with cytolytic vaginosis.13,14 These symptoms are often cyclical in nature, being more pronounced during the luteal phase and reaching a peak shortly before menses.10,13 In addition, the patient frequently presents with a lengthy history of these symptoms.8 It is clear why these conditions, based on presentation alone, are frequently misdiagnosed as vulvovaginal candidiasis.
As a result of self-diagnosis and then blind diagnosis by providers, patients with these conditions typically present with numerous partially used medications that have neither cured nor alleviated the symptoms.7 The most frequently administered medications are mycolytic because the patient or provider assumes that yeast is the causative organism.8 Recommendations for psychiatric counseling to address the chronic vaginal complaints have also been reported by these patients.7
On physical examination, the cervix, uterus, adnexa, vulva and vaginal tissues typically appear normal.8 Vulvar and vaginal tissues may, however, be diffusely erythematous and slightly edematous. The introitus may be mildly tender with speculum insertion. The discharge may be thick, opaque, paste-like or flocculent, and it is typically odorless.9
Microscopic examination and pH analysis are key for accurate diagnosis. Microscopic findings for cytolytic vaginosis by saline wet preparation include a large number of intermediate epithelial cells - present in greater numbers during the luteal phase of the menstrual cycle - as well as copious amounts of lactobacilli of varying lengths. These lactobacilli sometimes adhere to the epithelial cells, which then may be mislabeled as false clue cells. Cytoplasmic debris, including bare or naked nuclei from cytolyzed epithelial cells, is also visible. In addition, a low pH (3.5 to 4.5) is typical. Pseudohyphae, spores, trichomonads and clue cells are absent, and leukocytes are scarce or absent.10,13 Although leukocytes are generally absent, a mislabeling of the bare or naked nuclei as white blood cells may also occur, which would lead to misdiagnosis.
In lactobacillosis, intermediate epithelial cells are also visible on microscopy, with few leukocytes.8,10 A similar pH range of 3.6 to 4.7 is typical.14 However, cytoplasmic debris is not present because of the absence of cytolysis. Lactobacillosis also differs from cytolytic vaginosis in that the lactobacilli appear as long, segmented chains (also known as leptothrix) and are less abundant.8,11
The length of these lactobacilli chains is six times greater than the lactobacilli found in a normal vaginal sample. Whereas normal rods of lactobacilli are between 5 and 15 microns in length, many long serpiginous, nonbranching chains of lactobacilli ranging from 40 to 60 microns in length are present in lactobacillosis.8,14 To make an accurate diagnosis, the provider must be able to accurately identify the clue cells, pseudohyphae, leukocytes, bare nuclei and lactobacilli overgrowth.
If the patient has risk factors for sexually transmitted infections, obtain cervical cultures in addition to vaginal microscopy. Consider obtaining a vaginal yeast culture to rule out candidal infection.9,14 Because the Pap smear is diagnostic for detecting cytolytic vaginosis, advise the patient with a cytolysis result to return to the clinic to confirm the diagnosis and be treated appropriately.5
Diagnosing cytolytic vaginosis and lactobacillosis is inexpensive and uncomplicated based on the subjective and objective assessments previously discussed. Diagnostic criteria for cytolytic vaginosis and lactobacillosis (Table 2) include the presence of pasty, odorless, white vaginal discharge. The vulvar and vaginal tissues are normal or slightly erythematous and may also be edematous. On saline wet preparation, trichomonads, clue cells and hyphae are absent, and few leukocytes are present. The pH is 3.5 to 4.5. Diagnostic criteria specific to cytolytic vaginosis include evidence of cytolysis with bare or naked intermediate nuclei and copious amounts of lactobacillus rods of varying lengths, possibly adhered to the intermediate epithelial cells.
In lactobacillosis, the lactobacillus rods are more sparse and markedly longer than those found in cytolytic vaginosis. Trichomoniasis, bacterial vaginosis, vulvovaginal candidiasis and cervicitis may all be excluded with these findings and appropriate vaginal and cervical cultures.
Symptom relief, achieved by restoring vaginal equilibrium, is the goal of treatment. Decreasing the amount of lactobacilli in cytolytic vaginosis and lactobacillosis will lead to a reduction in vaginal acidity and an increase in the pH, producing symptom relief.13 The scientific evidence is sparse at best regarding treatment regimens for these conditions. However, significant empirical evidence has been published in the literature.
Discontinuing tampon use may be the only necessary measure to decrease vaginal acidity in cytolytic vaginosis, since menstrual flow may sufficiently raise the pH.9 If this measure does not provide relief, suggest the use of sodium bicarbonate (baking soda) in a sitz bath or douche to achieve this pH elevation (Table 3).9,13 Both regimens have proven to be effective, but the sitz bath should be recommended as first-line treatment.9 Recommending a douche treatment regimen to the patient who has previously been encouraged to discontinue douching will require specific patient education about the disease process. Encourage the patient who experiences recurrence to begin the sitz baths or douching 24 to 48 hours prior to the typical onset of symptoms.7,13
Lactobacillosis does not disappear spontaneously. One study found that the sitz bath and douche were not consistently efficacious in the treatment of lactobacillosis, but beta lactamase antibiotic therapy (Augmentin) was found to be effective.8 When beta lactamase antibiotic therapy is contraindicated due to penicillin sensitivity or is ineffective as initial treatment, doxycycline (Doryx) is recommended.
In rare cases, cytolytic vaginosis may occur concurrently with vulvovaginal candidiasis. In such cases, recommend a 7-day regimen consisting of an antimycotic agent inserted intravaginally at bedtime and douching with the sodium bicarbonate mixture every morning.9
When an accurate diagnosis is made and appropriate treatment is recommended, relief of symptoms is generally achieved, and follow-up and referral are unnecessary. In recalcitrant cases, referral to a collaborating physician or a gynecologist may be warranted.
Patient education should begin with an explanation of the diagnosis. Advise the patient that symptom resolution may require two to three treatment cycles.9 Instruct her to discontinue any pharmacologic treatments or homeopathic remedies, including yogurt and acidophilus supplements. As previously discussed, menstrual flow through the vagina may aid in raising vaginal pH; therefore, the patient should discontinue the use of tampons except during physical activity or swimming. This use should be limited to 1 or 2 hours. Instead of tampons, she should use nondeodorant sanitary pads. A return to tampon use may be considered only after the patient is symptom free for at least 6 months.9
Basic vulvovaginal care instructions are also important for patients with cytolytic vaginosis or lactobacillosis. Advise the patient to wear white, all-cotton underwear laundered in mild soap and hot water and to avoid using soap to cleanse the genital area.9 Recommend abstinence from sexual activity when symptoms are present and during initial therapy. Finally, educate the patient about the importance of douching only when symptomatic, to avoid creating a more alkaline vaginal environment conducive to bacterial vaginosis.
Putting It Into Practice
Although vulvovaginal complaints are the most frequent gynecologic reason women visit health care providers, clinical studies addressing the etiology of vaginal microflora imbalance have been outnumbered by an emphasis on other areas of women's health. As a result, the body of evidence on cytolytic vaginosis and lactobacillosis is immature. Nurse practitioners should include these conditions in the list of differential diagnoses for vulvovaginal complaints, thus optimizing clinical outcomes and enhancing quality of life for patients. As awareness of these conditions increases, quantitative research studies should focus on the etiology, incidence and effective treatment options for these conditions.
1. Stewart EG. Developments in vulvovaginal care. Curr Opin Obstet Gynecol. 2002;14(5):483-488.
2. Reis AJ. Treatment of vaginal infections: candidiasis, bacterial vaginosis, and trichomoniasis. J Am Pharm Assoc. 1997;NS37:563-569.
3. Wathne B, et al. Vaginal discharge: comparison of clinical, laboratory and microbiological findings. Acta Obstet Gynecol Scand. 1994;73(10):802-808.
4. Redondo-Lopez V, Cook RL. Emerging role of lactobacilli in the control and maintenance of the vaginal bacterial microflora. Rev Infect Dis. 1990;12(5):856-872.
5. Demirezen S. Cytolytic vaginosis: examination of 2947 vaginal smears. Cent Eur J Publ Health. 2003;11(1):23-24.
6. Overman BA. The vagina as an ecologic system: current understanding and clinical applications. J Nurse Midwifery. 1993;38(3):146-151.
7. Cibley LJ, Cibley LJ. Cytolytic vaginosis. Am J Obstet Gynecol. 1991;165(4Pt2):1245-1249.
8. Horowitz BJ, et al. Vaginal lactobacillosis. Am J Obstet Gynecol. 1994;170(3):857-61.
9. Secor RM. Cytolytic vaginosis: a common cause of cyclic vulvovaginitis. Nurse Pract Forum. 1992;3(3):145-148.
10. Paavonen J. Vulvodynia: a complex syndrome of vulvar pain. Acta Obstet Gynecol Scand. 1995;74(4):243-247.
11. Bibbo M, Harris MJ. Leptothrix. Acta Cytol. 1972;16(1):2-4.
12. Ferris DG, et al. Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis. Obstet Gynecol. 2002;99(3):419-425.
13. Hutti MH, Hoffman C. Cytolytic vaginosis: an overlooked cause of cyclic vaginal itching and burning. J Am Acad Nurse Pract. 2000;12(2):55-57.
14. Korenek P, et al. Differentiation of the vaginoses - bacterial vaginosis, lactobacillosis, and cytolytic vaginosis. Internet J Adv Nurs Pract. 2003;6(1). Available at: http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijanp/vol6n1/vaginosis.xml. Accessed Oct. 26, 2006.
Robin Hills is a women's health nurse practitioner and certified menopause clinician who is a clinical instructor at Virginia Commonwealth University School of Nursing in Richmond.