A Clinicopathological Diagnostic and Therapeutic Approach to Cytolytic Vaginosis

Abstract

Objectives: Cytolytic vaginosis is a very rare entity that may be clinically misdiagnosed as vulvovaginal candidiasis. The aim of this study was to determine the incidence of cytolytic vaginosis in patients displaying symptoms similar to vulvovaginal candidiasis and to develop a clinicopathological diagnostic and therapeutic approach. Materials and Methods: In total, 3000 cervical smear samples were evaluated at our center between 2015 and 2018. Patients whose PAP smears demonstrated significant epithelial cytolysis, naked nuclei, excessive increase in lactobacilli population, absent or minimal neutrophils and no microorganisms were subjected to a symptom assessment questionnaire and had their vaginal pHs measured. They were classified into two groups according to their complaints, symptoms and vaginal pHs: Cytolytic vaginosis and Asymptomatic intravaginal lactobacillus overgrowth. A standardized NaHCO3 Sitz bath therapy was applied to the cytolytic vaginosis group. Results: Fifty-three of the patients (1.7%) were diagnosed as cytolytic vaginosis. After Sitz bath therapy, there was a statistically significant decrease in the cytolysis and lactobacillus scores of the patients. Vaginal discharge of 43 (81%) patients ceased completely while that of the remaining 10 (19%) patients decreased after the therapy. The improvement was statistically significant ( P < 0.001). There was a complete resolution in 28 (96%) patients with severe; and in 21 (94%) patients with intermediate vaginal discomfort, after the therapy. Dyspareunia was resolved in 35 (97%) patients ( P < 0.001). Conclusion: Cytolytic vaginosis is a rare entity that can be diagnosed with the help of cytopathology and has a therapy based on the modulation microbiota by decreasing the vaginal pH.

Recent Advances in Presentation, Diagnosis and Treatment for Mixed Vaginitis

“…CV: The diagnosis of CV should be based on a combination of clinical features and microscopic findings. The signs and symptoms of CV are as follows (Hacısalihoglu and Acet, 2021): vulvar and vaginal itching and burning, entry dyspareunia and a (Cibley and Cibley, 1991).…”

“…CV : The diagnosis of CV should be based on a combination of clinical features and microscopic findings. The signs and symptoms of CV are as follows ( Hacısalihoğlu and Acet, 2021 ): vulvar and vaginal itching and burning, entry dyspareunia and a scant amount of white, frothy or cheesy vaginal discharge. The laboratory diagnosis follows a Cibley’s criteria: absence of Trichomonas , Gardnerella or Candida ; an increased number of lactobacilli (often adherent to the intermediate epithelial cell); a paucity of white cells; evidence of cytolysis with bare or naked intermediate nuclei; and a pH between 3.5 to 4.5 ( Cibley and Cibley, 1991 ).…”

Scoping review of cytolytic vaginosis literature

“…Two studies (9%) provided scores/observations for diagnosing CV. Specifically, Hu et al [ 39 ] was based on quantity of lactobacilli and cytolysis; Hacisalihoglu et al [ 36 ] evaluated lactobacilli, neutrophils, cytolysis, Candida ssp. hyphae, and Trichomonas vaginalis on a scale of 0–3, based on number of colonies per oil immersion field.…”

“…Four of the 32 non-review studies (13%) provided results of treatment: Cerikcioglu et al reported baking soda irrigation was effective in two women who used it [ 23 ]; Shopova et al stated that 32 out of 47 women improved after baking soda irrigation [ 59 ]; Hacisalihoglu et al reported that >95% of dyspareunia, discharge, and severe discomfort symptoms improved after a 10-day course of baking soda sitz baths [ 36 ]; and Lapina et al treated women post cystocele surgery with sertaconazol vaginal suppository and an alkaline (pH 8–9) vaginal moisturizer and found that women with CV had 100% resolution of their symptoms [ 43 ]. Only Lapina et al did further testing after symptomatic resolution, using pH, and found that pH normalized in women after the treatment [ 43 ].…”

“…There is some movement in this direction; for instance, Hu et al found distinct differences in quantity of Lactobacillus spp., percentage of fragmented epithelial cells, and percentage of whole epithelial cells between women presenting with CV and other vaginosis conditions [ 39 ], whereas Hacisalihoglu et al scored cytolysis, lactobacilli quantity, neutrophils, finding of bacterial vaginosis, Candida spp. hyphae/spores, and Trichomonas vaginalis based on quantity under oil immersion (0–3 scale) [ 36 ]. However, they reported only individual scores rather than also providing a composite score.…”