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Women’s Health vovaginal 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 Döderlein’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 Incidence 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 Table 1 Symptoms of Cytolytic Vaginosis and Lactobacillosis8,10,13,14 Cytolytic Vaginosis Lactobacillosis • thick, paste-like, white luteal phase vaginal discharge • vulvar pruritis • vulvar dysuria • low-grade dyspareunia • thick, paste-like, white luteal phase vaginal discharge • vulvar pruritis • vulvar dysuria Table 2 Diagnostic Criteria8-10,13,14 Cytolytic Vaginosis Lactobacillosis • normal or slightly erythematous or edematous vulvar and vaginal tissues • thick, opaque, paste-like or flocculent white vaginal discharge • normal cervix, uterus and adnexa • copious lactobacilli of varying lengths (5-15 microns), often adhered to the epithelial cells • cytoplasmic debris (naked nuclei) • pH as low as 3.5 or normal • no clue cells • few or absent white blood cells • no hyphae • normal or slightly erythematous or edematous vulvar and vaginal tissues • thick, opaque, paste-like or flocculent white vaginal discharge • normal cervix, uterus and adnexa • long, serpiginous lactobacilli chains (40-60 microns) • pH as low as 3.6 or normal • no clue cells • few or absent white blood cells • no hyphae 46 FEBRUARY 2007 • ADVANCE FOR NURSE PRACTITIONERS • WWW.ADVANCEWEB.COM/NP 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 Assessment 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 Laboratory Workup 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 (Figure