Emphysematous vaginitis in a gravid woman.

A primigravida in her late 20s presented to the obstetrics and gynaecology department in labour. On per speculum examination, multiple cystic lesions, 1-5 mm in size were observed occupying the anterior, posterior and lateral vaginal walls. Vaginal wet mount was normal and vaginal cultures were negative. Biopsy findings were consistent with emphysematous vaginitis. Vaginitis emphysematosa is a rare, benign self-limiting condition that presents with multiple, air-filled cysts in the vaginal or ectocervical mucosa. This condition is seen in both gravid and non gravid women, usually associated with a Trichomonas or Gardnerella infection.

Vaginal bleeding in prepubertal females: a case of Shigella vaginitis and review of literature.

Shigella vulvovaginitis is an uncommon aetiology of prepubertal vaginal bleeding that should be considered in the differential diagnosis, especially in patients who have travelled to developing countries. A young girl presented with prepubertal vaginal bleeding, pelvic pain, occasional dysuria and no gastrointestinal symptoms. After a year-long extensive workup, including vaginoscopy and biopsy, genital culture and Gram stain revealed vulvovaginitis due to Shigella flexneri After review of bacterial sensitivity, the patient was given a 30-day course of sulfamethoxazole-trimethoprim. The patient returned to the clinic 1 month later with no signs of vaginal bleeding, discharge or pelvic pain. This case prompted review of the indicated evaluation and differential diagnosis of prepubertal vaginal bleeding, including infectious aetiologies such as Shigella vulvovaginitis with the authors' goal to expedite diagnosis and treatment in paediatric patients.

Association Between Common Vaginal Infections and Cervical Non-Human Papillomavirus (HPV) 16/18 Infection in HPV-Vaccinated Women.

BACKGROUND: How vaginal infections such as bacterial vaginosis, Candida spp, and Trichomonas vaginalis affect persistence of human papillomavirus (HPV) infection is not well established. Our study aimed to evaluate the association between common vaginal infections and cervical non-HPV16/18 infection, as risk factors associated with persistence of nonvaccine HPV types will become increasingly relevant in the setting of HPV vaccination. METHODS: We performed an analysis in 2039 AS04-HPV16/18-vaccinated women enrolled in a phase II/III trial in China, who were HPV DNA negative at month 0 and 6 and had at least 1 subsequent follow-up visit. Vaginal infections were detected in liquid-based cytology according to the diagnostic criteria of the Bethesda System. Associations between vaginal infections and incident and 6-month persistent non-HPV16/18 infections in the cervix were evaluated using generalized estimating equations, adjusting for the age at initial vaccination, as well as HPV types in the persistence analysis. RESULTS: Study visits with any vaginal infection had a statistically significant increased risk of incident non-HPV16/18 infection compared to those without vaginal infections (odds ratio [OR], 1.44 [95% confidence interval {CI}, 1.09-1.92]). However, vaginal infections were not associated with 6-month persistent non-HPV16/18 infection (OR, 1.02 [95% CI, .62-1.69]). CONCLUSIONS: Our study suggests that common vaginal infections are not associated with persistence of non-HPV16/18 infection among HPV16/18-vaccinated women.

Does Aerobic Vaginitis Have Adverse Pregnancy Outcomes? Prospective Observational Study.

Background: Aerobic vaginitis (AV) is an aberration within the balanced vaginal microbiota. Only few reports have documented the adverse pregnancy outcomes related to AV. Nonetheless, the exact role of AV in pregnancy and the potential benefit of its screening need further study. Our goal was to evaluate the association between aerobic vaginitis (AV) in late pregnancy and maternal and neonatal outcomes. Methods: In this prospective observational study, a total of 600 singleton pregnant women with intact fetal membranes at a gestational age of 34-36 weeks were recruited (one hundred women with AV and 500 pregnant women without AV). The study protocol excluded patients with other forms of vaginal infection. Pregnancy outcomes were traced and documented. The primary outcome was the association between AV and preterm labor. The current study compared the maternal and neonatal outcomes among pregnant women with and without AV in unadjusted and adjusted analyses with the odds ratio (OR) and 95% confidence interval (CI) reported. Results: There was an association between AV and with preterm birth (adjusted OR 3.06, 95% CI 1.58-5.95) and prelabor rupture of membranes (adjusted OR 6.17, 95% CI 3.24-11.7). For neonatal outcomes, AV was associated with a higher incidence of neonatal ICU admission (adjusted OR 2.19, 95% CI 1.1-4.34). Severe forms of AV significantly increased the incidence of PTB (p = 0.0014) and PROM (p = 0.0094) when compared to less severe forms of AV. Conclusion: AV is common in late pregnancy and is linked to a diversity of adversative pregnancy outcomes including preterm birth, PROM, and neonatal ICU admission. Moreover, the incidence of PTB and PROM might further increase with the severity of AV. Clinicians should pay more consideration to vaginal microbiota assessment during pregnancy.

Infections During Pregnancy.

Several infections have unique consequences or considerations in pregnancy. Some common infections such as urinary tract infections, influenza, sexually transmitted diseases, and vaginitis affect pregnant women differently than the general population, can cause pregnancy complications, and require treatments that are safe in pregnancy. Infections such as hepatitis B and C and human immunodeficiency virus can be transmitted vertically and therefore management focuses on decreasing perinatal transmission. Certain infections can be transmitted in utero and cause congenital infections. Classically, these were grouped together as the TORCH infections, although now several others, including varicella virus, parvovirus, and Zika virus, have also been recognized.

Cervicovaginal Inflammation Facilitates Acquisition of Less Infectious HIV Variants.

We evaluated whether genital inflammation affects the selection of the transmitted virus. Among South African women, we found that preinfection genital inflammation facilitates transmission of less infectious human immunodeficiency virus, but highly infectious viruses are able to establish infection regardless of inflammation status. This suggests that viral phenotype can influence transmission risk.

Couple-related factors of ART outcome.

PURPOSE OF INVESTIGATION: Although assisted reproductive technologies (ART) are the current mainstay of infertility treatment, several mechanisms leading to ART failure are still unclear. The aim of the present study was to determine possible health-related risk factors in both counterparts of the couple affecting the ART outcome. MATERIAL AND METHODS: The authors recruited 100 consecutive couples who were undergoing ART procedure. All subjects filled out a health questionnaire, and the presence of bacterial vaginosis in females and/or prostatitis in males was evaluated. RESULTS: Success of the ART procedure was 30.2%, failure being most significantly related to woman's age (OR = 0.24, 95% CI 0.09-0.66, p = 0.003) and excess body weight (OR = 0.08, 95% CI 0.01-0.63, p = 0.002). Male factors, previous conceptions, and presence of children increased the likelihood of ART success. Bacterial vaginosis and prostatitis did not significantly compromise the effectiveness of the ART procedure in this study. CONCLUSION: In 100 consecutive infertile couples scheduled for ART procedure, pregnancy was achieved in 30.2%, with female age and overweight and previous children from male side being the most significant factors affecting the ART outcome.

New Perspectives on the Normal Vagina and Noninfectious Causes of Discharge.

An understanding of how the vaginal flora is influenced by hormonal status is crucial in distinguishing normal from abnormal secretions. New studies exploring the vaginal microbiome with culture-independent techniques have led to the discovery of previously uncultivable bacteria on a species level, and have contributed to a better understanding of disease processes including bacterial vaginosis. It is important to note that not all vaginal discharge is abnormal or infectious in etiology, but a thorough evaluation will help reassure both the patient and the provider.

[In case of pelvic pain desquamative inflammatory vaginitis is an important differential diagnosis]. / Ved smerter i underlivet er deskvamativ inflammatoriskvaginitis en vigtig differentialdiagnose.

Desquamative inflammatory vaginitis (DIV) is an uncommon, severe form of chronic vaginitis of unknown aetiology. The syndrome is characterised by profuse vaginal discharge, vulvovaginal irritation, dyspareunia and vaginal erythema. As the symptoms and signs are nonspecific, other causes of purulent discharge have to be excluded first. Definition necessitates specific wet smear findings. The purpose of this case report is to consider DIV as a diagnosis in women presenting with persistent vaginitis. An effective treatment using clindamycin and/or glucocorticoids is available.

Basic vaginal pH, bacterial vaginosis and aerobic vaginitis: prevalence in early pregnancy and risk of spontaneous preterm delivery, a prospective study in a low socioeconomic and multiethnic South American population.

BACKGROUND: Bacterial vaginosis (BV) increases the risk of spontaneous preterm deliveries (PD) in developed countries. Its prevalence varies with ethnicity, socioeconomic conditions and gestational age. Aerobic vaginitis (AV) has also been implicated with spontaneous PD. The present study aimed to estimate the prevalence of asymptomatic BV, the accuracy of vaginal pH level to predict BV and to estimate the risk of spontaneous PD <34 and <37 weeks' gestation of BV and AV. METHODS: Women attending prenatal public services in Rio de Janeiro were screened to select asymptomatic pregnant women, < 20 weeks' gestation, with no indication for elective PD and without risk factors of spontaneous PD. Vaginal smears of women with vaginal pH > = 4.5 were collected to determine the Nugent score; a sample of those smears was also classified according to a modified Donders' score. Primary outcomes were spontaneous PD < 34 and <37 weeks' gestation and abortion. RESULTS: Prevalence of asymptomatic BV was estimated in 28.1% (n = 1699); 42.4% of the smears were collected before 14 weeks' gestation. After an 8-week follow up, nearly 40% of the initially BV positive women became BV negative. The prevalence of BV among white and black women was 28.1% (95% CI: 24.6%-32.0%) and 32.5% (95% CI: 28.2%-37.2%), respectively. The sensitivity of vaginal pH= > 4.5 and = > 5.0 to predict BV status was 100% and 82%, correspondingly; the 5.0 cutoff value doubled the specificity, from 41% to 84%. The incidence of < 37 weeks' spontaneous PDs among BV pregnant women with a pH= > 4.5 was 3.8%. The RR of spontaneous PD < 34 and <37 weeks among BV women with pH > =4.5, as compared with those with intermediate state, were 1.24 and 1.86, respectively (Fisher's exact test, p value = 1; 0.52, respectively, both ns). No spontaneous case of PD or abortion was associated with severe or moderate AV. CONCLUSIONS: A high prevalence of asymptomatic BV was observed without statistically significant difference between black and white women. The RRs of spontaneous PD < 34 and <37 weeks among women with BV, as compared with those with intermediate state were not statistically significant but were consistent with those found in the literature.

Signaling via tumor necrosis factor receptor 1 but not Toll-like receptor 2 contributes significantly to hydrosalpinx development following Chlamydia muridarum infection.

Chlamydial infection in the lower genital tract can lead to hydrosalpinx, which is accompanied by activation of both pattern recognition receptor TLR2- and inflammatory cytokine receptor TNFR1-mediated signaling pathways. In the current study, we compared the relative contributions of these two receptors to chlamydial induction of hydrosalpinx in mice. We found that mice with or without deficiencies in TLR2 or TNFR1 displayed similar time courses of live organism shedding from vaginal swabs, suggesting that these receptor-mediated signaling pathways are not required for controlling chlamydial lower genital infection. However, mice deficient in TNFR1 but not TLR2 developed significantly reduced hydrosalpinx. The decreased pathogenicity correlated with a significant reduction in interleukin-17 by in vitro-restimulated splenocytes of TNFR1-deficient mice. Although TLR2-deficient mice developed hydrosalpinx as severe as that of wild-type mice, peritoneal macrophages from mice deficient in TLR2 but not TNFR1 produced significantly reduced cytokines upon chlamydial stimulation, suggesting that reduced macrophage responses to chlamydial infection do not always lead to a reduction in hydrosalpinx. Thus, we have demonstrated that the signaling pathways triggered by the cytokine receptor TNFR1 play a more significant role in chlamydial induction of hydrosalpinx than those mediated by the pattern recognition receptor TLR2, which has laid a foundation for further revealing the chlamydial pathogenic mechanisms.

Histologic and cytologic effects of vaginal estrogen in women with pelvic organ prolapse: a randomized controlled trial.

OBJECTIVE: This study aimed to evaluate the histologic and cytologic effects of preoperative vaginal estrogen in women with atrophic vaginitis and pelvic organ prolapse. METHODS: Forty-two women with atrophic vaginitis and stage greater than or equal to 2 prolapse were enrolled in this assessor-blinded randomized controlled trial comparing daily vaginal estrogen cream use for 2 to 12 weeks preoperatively versus no intervention. Data were analyzed using t test and analysis of variance. RESULTS: Of these 42 women, 22 received treatment and 20 were controls. After a mean 7 (3) weeks of use, the vaginal maturity index increased 15.5% in the treatment group and declined 1.5% in the control group (P < 0.001). The vaginal epithelial thickness was 339 (96) µm in the treatment group compared to 302 (119) µm (P = 0.275) in the controls. CONCLUSIONS: Preoperative vaginal estrogen application for 2 to 12 weeks restores vaginal cytology to premenopausal levels, but does not increase vaginal epithelial thickness in women with prolapse.

Urinary tract infection in vaginitis: a condition often overlooked.

Despite the differences between the organisms that cause vaginitis and urinary tract infections (UTI), it is possible that women with vaginitis develop UTI. The main objective of the study was to find the association of the common types of infectious vaginitis with UTI. Cross sectional study was conducted for six months in a referral hospital at Lalitpur, Nepal. Three hundred and sixmid-stream urine samples and high vaginal swabs (HVS) collected from non pregnant women were investigated by standard microbiological techniques. Among the women with bacterial vaginosis (BV), 75% also had UTI. Similarly, 46% and 13% of those with vaginal candidiasis and trichomoniasis respectively had concurrent UTI. Considering this strong association of UTI and vaginitis, women with either of these conditions should be tested for the other.

Associations between genital tract infections, genital tract inflammation, and cervical cytobrush HIV-1 DNA in US versus Kenyan women.

Cervical shedding of HIV-1 DNA may influence HIV-1 sexual transmission. HIV-1 DNA was detected in 250 (80%) of 316 and 207 (79%) of 259 cervical cytobrush specimens from 56 US and 80 Kenyan women, respectively. Plasma HIV-1 RNA concentration was associated with increased HIV-1 DNA shedding among US and Kenyan women. Kenyan women had higher cervicovaginal concentrations of proinflammatory interleukins (IL)-1ß, IL-6, IL-8, and anti-inflammatory secretory leukocyte protease inhibitor compared with US women (all P < 0.01). HIV-1 DNA shedding was associated with increased concentrations of IL-1ß and IL-6 and lower secretory leukocyte protease inhibitor among US women but not Kenyan women.

Vaginal toxic shock reaction triggering desquamative inflammatory vaginitis.

OBJECTIVE: The study aimed to report 2 cases of desquamative inflammatory vaginitis associated with toxic shock syndrome toxin 1 (TSST-1)-producing Staphylococcus aureus strains. MATERIALS AND METHODS: Case report of 2 patients, 1 with an acute and 1 with a chronic presentation, diagnosed with desquamative inflammatory vaginitis on the basis of clinical findings and wet mount microscopy. Pretreatment and posttreatment vaginal bacterial and yeast cultures were obtained. RESULTS: Pretreatment vaginal bacterial cultures from both patients grew TSST-1-producing S. aureus. Subsequent vaginal bacterial culture results after oral antibiotic therapy were negative. CONCLUSIONS: Desquamative inflammatory vaginitis may be triggered through TSST-1-mediated vaginal toxic shock reaction.

Plasma cell mucositis of the vagina: a case report.

BACKGROUND: Plasma cell mucositis is a rare dermatologic condition known to affect the upper aerodigestive tract and external genitalia but has never yet been described to affect the vaginal epithelium. CASE: A 57-year-old woman presented to the urogynecology clinic with chief complaint of symptomatic pelvic organ prolapse and vaginal spotting. Examination of the pelvis revealed grade 2 pelvic organ prolapse and diffuse multifocal erythematous patches on the vaginal introitus, vagina, cervix, and periurethra. Histopathologic examination of biopsies revealed plasma cell mucositis. CONCLUSION: This is the first report of plasma cell mucositis affecting vaginal epithelium. It is possible that pelvic organ prolapse caused irritation and inflammation of vaginal epithelium and contributed to the development of plasma cell mucositis in these areas.

Incidence of genital infection among patients with type 2 diabetes in the UK General Practice Research Database.

The objective of this population-based study was to evaluate the incidence of vaginitis (females) and balanitis (males) among a cohort of type 2 diabetes patients and compare this risk to patients without diabetes. The study population included 125,237 female patients and 146,603 males identified from GPRD. All patients were followed for 1-year from their study index date for the first record of an infection or a censored event. Among patients with diabetes the incidence of vaginitis was 21.0/1000PY (95% CI 19.8-22.1) with the risk being 1.81 (95% CI 1.64-2.00) greater that patients without diabetes. The incidence of balanitis among diabetes patients was 8.4/1000PY (95% CI 7.8-9.1) with a relative risk of 2.85 (2.39-3.39) compared to patients without diabetes. Additional analyses were performed by HbA1c level. Results from this large population-based study indicate that patients with diabetes are at an increased risk of being diagnosed with infections of the genital tract and patients with poorly controlled diabetes have higher risks.

Genital tract inflammation during early HIV-1 infection predicts higher plasma viral load set point in women.

BACKGROUND: The biggest challenge in human immunodeficiency virus type 1 (HIV-1) prevention in Africa is the high HIV-1 burden in young women. In macaques, proinflammatory cytokine production in the genital tract is necessary for target cell recruitment and establishment of simian immunodeficiency virus (SIV) infection following vaginal inoculation. The purpose of this study was to assess if genital inflammation during early HIV-1 infection predisposes women to rapid disease progression. METHODS: Inflammatory cytokine concentrations were measured in cervicovaginal lavage (CVL) from 49 women 6, 17, 30, and 55 weeks after HIV-1 infection and from 22 of these women before infection. Associations between genital inflammation and viral load set point and blood CD4 cell counts 12 months after infection were investigated. RESULTS: Elevated genital cytokine concentrations 6 and 17 weeks after HIV-1 infection were associated with higher viral load set points and, to a lesser extent, with CD4 depletion. CVL cytokine concentrations during early infection did not differ relative to preinfection but were elevated in women who had vaginal discharge, detectable HIV-1 RNA in their genital tracts, and lower blood CD4 counts. CONCLUSION: Genital inflammation during early HIV-1 infection was associated with higher viral load set point and CD4 depletion, which are markers of rapid disease progression. Strategies aimed at reducing genital inflammation during early HIV-1 infection may slow disease progression.