Cytolytic vaginosis, also referred to as Doderlein cytolysis, appears to be a common alteration in the vaginal ecosystem. Cytolytic vaginosis is similar in gross appearance to the discharge that is seen with vaginal candidiasis. When examining a patient with cytolytic vaginosis, physicians often do not see yeast but still treat the patient with an anti-fungal agent, and the patient’s condition does not resolve.

Clinical Presentation and Diagnosis

The external genitalia do not undergo any changes with cytolytic vaginosis, unlike with candidiasis. The patient with vaginal candidiasis often has vulvar involvement, i.e. the labia and crural folds are erythematous, pruritic, and/or burn. However, the patient with cytolytic vaginosis can complain of vaginal pruritis and burning, dyspareunia, and vulvar burning when micturating (vulvar dysuria). The patient’s symptoms intensify during the luteal phase of the menstrual cycle. The microflora of patients with cytolytic vaginosis does not shift to a flora dominated by facultative or obligate anaerobes but is dominated by Lactobacillus. In fact, there appears to be an overgrowth of lactobacilli. The pH of the vagina and the vaginal discharge remains between 3.5 and 4.5. The hydrogen ion concentration is maintained by the growth of lactobacilli. Production by lactobacilli of lactic acid and other organic acids maintains this hydrogen ion concentration and suppresses the growth of other bacteria. The most common Lactobacillus species found in the vagina are Lactobacillus crispatus, L. gasseii, L.jensenii, and L. iners .

The physical findings of vaginal discharge are quite distinct in patients with cytolytic vaginosis (Table Characteristics of cytolytic vagionis). The most important diagnostic aides are microscopic examination of the vaginal discharge and culture for Trichomonasvaginalis and Candida (). Interestingly, there are relatively few white blood cells (WBC) present in the vaginal discharge. This is important because it implies that there is a low probability that the patient has acute cervicitis or endometritis. However, to be complete, if the patient’s history places her at risk for possible infection with Chlamidia trachomatis and Neisseriagonorrhoeae, specimens for detection of these organisms should be obtained from the endocervix.

Table Characteristics of cytolytic vagionis

1. Vulva appears normal, i.e. no erythema, swelling edema,, or excoriations
2. Vaginal discharge is white and tends to be thick or pasty
3. Thew it no odd associated with (he discharge. If a whiff test is performed it is negative
4. The vaginal epithelium can appear slightly erythematous
5. pH < 4.5
6. Microscopic examination of the vaginal discharge reveals:
Numerous [abundant) squamous ceils
Squamous cells lhal are well eslragenized
Many squamous celts that appear disrupted
Cellular debris and naked nuclei from squamous cells
Rare to few white blood cells
An abundance of la*fie bacillary nnorpholypes {Laclobaatlvi)
The absence of other bacterial mcrtphotypes
Laclobacilli adhering to squamous cells (false clue cells)
The absence of J. vaginalis and Candida

Treatment for Cytolytic Vaginosis

Cibley and Cibley recommend vaginal douching with sodium bicarbonate, 30 — 60 g in a liter of water, two to three times a week. Once there appears to be improvement, the douching frequency should be tapered off to once a week as needed. However, douching should be done with little pressure and preferably in the sitting or standing position, which helps reduce the possibility of douching solution entering the upper genital tract. Some investigators believe that there is an association between douching and the development of pelvic infection.

The goal of treatment is not to significantly increase the pH since this can result in a decrease in Lactobacillus growth and an increase in the growth of other bacteria. Therefore, it would be detrimental to maintaining a balanced vaginal ecosystem to raise the pH above 4.5. Perhaps the administration of intravaginal clindamycin cream (2%) or metronidazole can effectively lower the concentration of Lactobacillus while suppressing the growth of obligate anaerobic bacteria. Clindamycin will also have an inhibitory effect on Gram-positive bacteria, except the enterococci. Additionally, clindamycin would not have a suppressive effect on the Gram-negative facultative bacteria. Therefore, the administration of oral or intravaginal antibiotics should not be for a prolonged period of time in order to avoid selection of resistant bacteria, which could become the dominant bacteria of the vaginal ecosystem.

Selections from the book: “Vaginitis: Differential Diagnosis and Management” (2003).

Tagged with:  
Share →