Aerobic vaginitis

Author: Dr Carolina González, Dermatology Registrar, Santiago, Chile. DermNet NZ Editor in chief: Dr Amanda Oakley; Dermatologist, Hamilton, New Zealand. January 2018.  


What is vaginitis?

Vaginitis means an inflamed vagina. The term is loosely used to refer to any vaginal condition that results in a vaginal discharge. it can be due to infectious and non-infectious causes.

What is aerobic vaginitis?

Aerobic vaginitis is characterised by:

  • Vaginal inflammation
  • Atrophy of vaginal epithelium
  • Abnormal vaginal microflora
    • Increased levels of aerobic bacteria
    • Decreased levels of lactobacilli.

Aerobic vaginitis was first characterised by Donders et al in 2002 [1]. 

Desquamative inflammatory vaginitis is a severe form of aerobic vaginitis [2].

Who gets aerobic vaginitis?

Aerobic vaginitis may affect adult women of any age, pre- and post-menopause. The prevalence has been estimated in different populations as 5–13% of asymptomatic women and affects a greater proportion of women with vaginal symptoms. It may be less prevalent among pregnant women.

Risk factors for infection are under evaluation.

What is the cause of aerobic vaginitis?

The cause of aerobic vaginitis is unknown. It is a dysbiosis (disturbed microbiome) in which aerobic micro-organisms reside in the vaginal microflora. These include:

It is unclear whether the primary cause of aerobic vaginitis is pathogenic organisms, lack of lactobacilli, immune dysregulation and pro-inflammatory cytokines, or insufficient oestrogen in the vaginal mucosa (atrophic vulvovaginitis) [2].

What are the clinical features of aerobic vaginitis?

Symptoms can fluctuate over a long period of time. They include [2]:

  • Vaginal stinging and burning sensations
  • Dyspareunia
  • A sticky yellow or green discharge with a rotten odour.

Examination findings may include:

  • Vaginal inflammation (introital and vaginal redness, oedema, and sometimes, petechiae and ecchymoses)
  • Vaginal epithelial disruption (erosions, ulcers)
  • Increased vaginal pH.

What are the complications of aerobic vaginitis?

Aerobic vaginitis has been associated with [2]:

  • Other forms of vaginitis
  • Infection-related miscarriage, premature rupture of membranes, ascending chorioamniotis, and preterm birth
  • Activation of human papillomavirus (HPV) infection and cervical cancer, possibly due to increased pH and lack of lactobacilli
  • Increased risk of acquiring sexually transmitted infections, due to erosions in vaginal mucosa
  • Pelvic inflammatory disease and infertility [4].

How is aerobic vaginitis diagnosed?

Diagnosis is confirmed by wet mount microscopy of fresh vaginal fluid, ideally using phase contrast. The aerobic vaginitis (AV) score is graded as 0–3 (absent), 3–4 (mild), 5–6 (moderate). 6–10 (severe). AV score is calculated from [1]:

  • Lactobacillary grade (LBG) 1, IIa, IIb, III 
  • Number of leucocytes compared to epithelial cells
  • Proportion of toxic leucocytes (these are recognised by their cytoplasmic granules)
  • Characteristics of the microflora (cocci, coliforms)
  • Presence of immature/parabasal epithelial cells.

Vaginal cultures are useful only for clinical research and to detect group A streptococci, trichomoniasis, and Candida albicans infection.  

Various advanced diagnostic methods are being established for aerobic vaginitis.

Phase contrast microscopy of aerobic vaginitis*

*By PedroVieiraBaptista (Own work) [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons

What is the differential diagnosis for aerobic vaginitis?

Aerobic vaginitis is distinct from other forms of infectious vaginitis — particularly bacterial vaginosis, with which it is often confused. Characteristics of bacterial vaginosis are:

  • Lack of symptoms
  • Greyish-white, watery vaginal discharge with fishy odour
  • Lack of inflammation on vaginal examination
  • Microscopy findings of decreased lactobacilli and granular flora.

What is the treatment for aerobic vaginitis?

Treatment of aerobic vaginitis depends on the microscopic findings and patient needs [2].

  • Topical corticosteroids, eg, hydrocortisone cream or foam, are used to treat a prominent inflammatory component, (> 20 leucocytes per epithelial cell on microscopy).
  • Antimicrobials (topical, oral or by suppository) are used to eradicate pathogenic bacteria.
    • Antiseptic, eg, dequalinium chloride
    • Topical antibiotic, eg, topical kanamycin or clindamycin (note, clindamycin can promote bacterial resistance)
    • Oral antibiotic, eg, amoxiclav or moxifloxacin
  • Topical oestrogen is used to treat vaginal atrophy (when parabasal cells are >10% of epithelial cells on microscopy).
  • Vaginal probiotics are used to restore vaginal lactobacilli.

Metronidazole, which is used for bacterial vaginosis, and antifungal agents, used for Candida albicans infection, are not effective in aerobic vaginitis.

Expert advice should be sought from a medical microbiologist in pregnant women with aerobic vaginitis.

 

Related Information

References

  1. Donders GG, Vereecken A, Bosmans E, Dekeersmaecker A, Salembier G, Spitz B. Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis. BJOG. 2002 Jan;109(1):34-43. PubMed PMID: 11845812. Journal.
  2. Donders GGG, Bellen G, Grinceviciene S, Ruban K, Vieira-Baptista P. Aerobic Vaginitis: No longer a stranger. Res Microbol 2017; In press [available online 11 May 2017] (accessed 2 October 2017). PubMed.
  3. Donders GG, Ruban K, Bellen G. Selecting anti-microbial treatment of aerobic vaginitis. Curr Infect Dis Rep 2015;17(5):477. PubMed.
  4. Han C, Wu W, Fan A, et al. Diagnostic and therapeutic advancements for aerobic vaginitis. Arch Gynecol Obstet 2015;291(2):251-7. PubMed.
  5. Mason MJ, Winter AJ How to diagnose and treat aerobic and desquamative inflammatory vaginitis. Sex Transm Infect 2017;93:8-10. Journal.

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