Download Symptoms of Cytolytic Vaginosis and Lactobacillosis8,10,13,14

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
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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