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Symptoms and diagnostics
Vaginal inflammations are the most common gynaecological problem.
Depending on causative factor of a disease, infections of the vagina and vulva are divided into three groups: trichomoniasis caused by Trichomonas vaginalis, mycotic vaginitis caused by Candida spp. and bacterial vaginosis (BV). In the table below, differential diagnostics of the vaginal infections is presented compared to normal conditions.
| PHYSIOLOGY | TRICHOMONIASIS | MYCOSIS | BACTERIALVAGINOSIS | |
|---|---|---|---|---|
| DISCHARGE | moderate, white or transparent, flocculent, viscid | Abundant, grey, yellow-green, uniform, foamy or cream | Scanty to moderate, whitish of various shades, papular, cheesy | Moderate to abundant, grey, milky, uniform, watery |
| PH | 3.6 – 4.5 | above 4.5 | 3,6 – 4,5 | above 4.5 |
| SMELL | Absent | Unpleasant smell | Absent | Fish smell |
| LOCAL SYMPTOMS | Normal condition | discharge, itching, dysuria | discharge, itching, vaginal congestion | discharge without itching and burning |
| SEXUAL TRANSMISSION | not pertaining | Yes | Yes | No |
| TYPICAL CELLSI | Lactic acid bacteria | ciliary protozoa | hyphae of yeasts cells | clue cells |
It is estimated that at least 3 out of 4 women will suffer from vaginitis or vulvitis at least once in a lifetime. Yearly, milliard women in the whole world suffer from infections of urogenital tract which are not sexually-transmitted, including bacterial vaginosis, Candidiasis and infections of the urinary tract.
Bacterial vaginosis (BV)
Bacterial vaginosis (BV) constitutes around 60% of all vaginal and vulvar infections. During BV, disturbance of balance of vaginal microflora occurs. In women with diagnosis of bacterial vaginosis, quantitative changes are observed in the vagina (atrophy or decrease in number of Lactobacillus spp. with secondary proliferation of mixed flora relatively and absolutely anaerobic), as well as qualitative changes (related to lack of synthesis of hydrogen peroxide by Lactobacillus spp. strains and to an increase of enzyme activity, an increase of amount of bacterial endo- exotoxins, interleukins and tumour necrosis factor). During this pathologic process, the number of anaerobic bacteria in genital tract increases 10 – 100-fold. In about 60% of women, BV is not symptomatic. It often occurs and subsides spontaneously.
Predisposing factors for occurrence of BV include first of all frequent irrigations of the vagina, poor hygiene, many sexual partners, frequent travelling, using jacuzzi and swimming pools, injuries of the vagina and decreased number of lactic acid bacteria.
Among symptoms, attention should be paid to stinking discharge, sometimes itching of vulva and irritation of mucosa of this region may occur.
Clinical criteria used for diagnosis of BV require confirmation of at least three out of four symptoms, namely:
- presence of homogenous white, white and grey or grey non-inflammatory discharge, smoothly covering the wall of the vagina,
- presence of clue cells (epithelial cells covered with bacteria) in smear,
- pH of the discharge above 4.5,
- fishy odour of vaginal discharge before or after application of 10% potassium hydroxide (KOH) in smell test.
In the figure below, the picture of direct preparation of bacterial vaginosis is shown – clue cells forms are visible (clue cells, i.e., epithelium covered with small Gram – negative rods (i.e., Gardenella vaginalis).
Mycotic vaginitis
Mycotic vaginitis is caused most often by Candida genus. Infections may occur among others due to the use of the same towels, sexual contacts. Infection is asymptomatic in men, whereas in women, mycotic infection manifests by persistent itching, irritation, redness and burning in the region of vagina and vulva, painful sexual intercourses and dysuria, as well as presence of cheesy discharge. It should be noted that none of these symptoms is a characteristic symptom of mycotic vaginitis.
For the confirmation of diagnosis, microscopic examination of smear of vaginal discharge should be carried out or Gram stained confirming presence of yeasts, mycelium or quasi fimbriae or positive result of culture or other test confirming presence of yeasts. In the course of vaginal mycosis, changes of pH values are not observed (pH below 4.5). Positive result of culture toward Candida and lack of clinical symptoms are not an indication for start of treatment because Candida albicans is present in the vagina in every fifth woman in procreative age.
In the figure below a direct smear from vagina was shown – numerous Gram – negative rods as well as fungal cells are visible.
Trichomoniasis of urogenital tract
Trichomoniasis of urogenital tract is caused by Trichomonas vaginalis which occurs in vagina, urethra and peri-urethral glands, and is almost exclusively sexually-transmitted. In about 10 – 50% of patients, tichomoniasis is asymptomatic. In others, pathologic process starts with vaginal discharge, and as inflammation proceeds, burning in vagina, itching, dyspareunia, contact staining, dysuria and hypogastric pain are observed. In the clinical trial, in about 70% of women, grey and white discharge is seen of varying consistency. Only in small percentage of these patients, discharge in most advanced stage becomes greenish. Depending on the phase of disease, oedema, reddening of vulva, vagina and cervix occurs.
The diagnosis in most cases is made based on a direct specimen of vaginal discharge in normal saline. Mobile trichomonas are found in it. Lack of Trichomonas vaginalis in direct specimen upon clinical suspicion of infection is an indication for culture. In the case when trichomoniasis is found during examination of a cytological smear, it is recommended to carry out a direct specimen of vaginal discharge in order to confirm the diagnosis.
