Desquamative inflammatory vaginitis is an inflammation of the vagina of unknown etiology, characterized by deep damage to the epithelium with the formation of ulcers and subsequent scarring. This form of the inflammatory process is manifested by itching and burning of the vagina and vulva, dyspareunia, contact bleeding, abundant pus-like secretions. Diagnosis of desquamative vaginitis includes gynecological examination, vaginal pH-metry, bacterioscopy, bacteriological examination. Conservative treatment – local use of corticosteroids and antibiotics, restoration of normal vaginal microbiocenosis.
ICD 10
N76.0 N76.1 N76.5 N76.
General information
Desquamative inflammatory vaginitis (ulcerative colpitis, Gardner syndrome – named after the American researcher Herman Gardner) is an inflammation of the vagina accompanied by pronounced destructive changes (cellular decay, rejection of the affected epithelium, exposure of the basement membrane) and massive diffuse exudate. The disease is considered a type of nonspecific (aerobic) vaginitis and is their most severe form. This form is rare, its prevalence is less than 1%. Desquamative colpitis is most often registered in girls of the pre-puberty period and in adult postmenopausal women. Among women of reproductive age, the incidence of pregnant women is 1.2-1.3 times higher.
Causes
The disease develops against the background of colonization of the vagina by aerobic microorganisms that get there most often from the lower intestine, with a predominance of streptococcal flora in the microcenosis. Contamination of the vagina by opportunistic streptococci can occur as a result of recto- and orogenital sexual contacts, obstetric and gynecological manipulations and operations. However, contamination does not always entail dysbiosis and, moreover, an inflammatory process. The etiology of the disease has not yet been studied, it is unknown what factors lead to the dominance of streptococci in the microbiota and the development of desquamative vaginitis, but it is noted that women with estrogen deficiency are susceptible to this form of inflammation.
Usually, the imbalance of microorganisms is caused by an increase in pH and develops as a result of hypoestrogenism – both physiological (in childhood and old age) and caused by ovariectomy, progestin therapy, congenital ovarian insufficiency, suppression of gonad function as a result of pathological conditions and diseases (anorexia, genital tuberculosis, severe oophoritis, pituitary disorders), as well as due to toxic effects of cytostatic drugs, radiation therapy. Other reasons for pH changes include regular hygienic douching of the vagina, the use of chemical methods of contraception, frequent change of sexual partners, massive use of antibiotics.
A significant predisposing condition for the development of inflammation against the background of dysbiosis is a decrease in immune activity. Physiological immunodeficiency is associated with gestation and is aggravated by the complicated course of pregnancy and labor (gestosis, prolonged labor, large blood loss). Among the causes of pathological weakening of the immune response are diabetes mellitus, obesity, prolonged use of corticosteroids, severe infections and general somatic diseases, acute and chronic poisoning (including alcohol and nicotine), prolonged stress conditions.
Pathogenesis
Normally, the vagina of healthy women is populated mainly (by 93-97%) with lactobacilli. A necessary condition for the existence and reproduction of these microorganisms is a sufficient concentration of glycogen in the cells of the superficial epithelium of the vagina, which directly depends on the level of estrogen in the female body. With the participation of lactobacilli, glycogen is metabolized to lactic acid with the formation of hydrogen peroxide, which creates a medium acidic (pH 3.8-4.5) environment in the vagina that prevents the growth of colonies of other microorganisms. In addition, lactobacilli are able to synthesize natural antibiotics against facultative and obligate flora. With disorders leading to a decrease in the population of lactobacilli, dysbiosis develops – conditionally pathogenic bacteria begin to dominate in the vaginal biocenosis.
By itself, dysbiosis, as a rule, does not lead to vaginitis, but the presence of a microbial film significantly increases the likelihood of developing an inflammatory process. Microbial biofilm is an organized community of associations of microorganisms consisting of bacterial colonies adhered to the epithelium and connected by an intercellular matrix. Microorganisms combined in the film are characterized by a significant increase in pathogenicity and resistance to external influences. Even with a low pathogenicity of facultative microbes forming a biofilm, the presence of the latter can lead to an inflammatory process due to stimulation of the production of antibodies by the immune system, which as a result damage tissues, but are not able to destroy the antigen (this explains the high probability of relapses).
In desquamative inflammatory vaginitis, the basis of the microbial biofilm is streptococci of group B. The role of streptococci in the development of this form of inflammation has not yet been precisely studied: at least half of women with such a film do not develop the disease. The mechanisms of action (whether the inflammatory process is the result of the manifestation of the pathogenic ability of a microorganism or an immune hypersensitivity reaction) are also unknown today. However, the involvement of streptococci in the disease is indirectly evidenced by a fairly high (94%) effectiveness of treatment with specific antibiotics.
Classification
Like most inflammatory processes, desquamative vaginitis has three forms of clinical course, there is no generally accepted classification for any other sign. The disease occurs in acute, subacute or chronic forms, which can replace each other for a long time (for months or years):
- Acute form. It is most characteristic of the primary episode and is characterized by the most vivid symptoms – pronounced edema, pain syndrome, abundant pathological secretions.
- Subacute form. Symptoms subside, acquire a moderate manifestation. This course is usually inherent in relapses after treatment.
- Chronic form. It has minimal external signs, but is characterized by an increased risk of complications.
Symptoms
The first manifestations of the acute form of the disease are pronounced itching and burning in the vulva and vagina, pain and (or) discomfort accompanying sexual contact. Soon pain, a feeling of heaviness and pressure in the lower abdomen and abundant discharge – thick, pus-like, sometimes with a hemorrhagic component, often with a putrid smell. Ulcers appear on the vulva mucosa. During vaginal manipulation, bleeding is often noted. Sexual intercourse or vaginal examination may be difficult, and sometimes impossible due to significant swelling. Urination in such cases may also become difficult and more frequent.
In the subacute phase, the swelling subsides, the pain becomes less pronounced, the volume of discharge decreases. The chronic form is characterized by minor discharge, itching, dyspareunia, some patients have ulceration in the area of the vestibule of the vagina. The period of remission proceeds without subjective symptoms. Relapses and exacerbations most often occur after menstruation or an episode that reduces the body’s resistance – hypothermia, stress.
Complications
The outcome of the inflammatory process is often rough scars, leading to stenosis and shortening of the vagina – a condition that makes it difficult to have sex, conception and vaginal delivery. In girls, as a result of desquamative vaginitis, complete vaginal obstruction may occur – atresia with the further development of hematocolpos, hematometra and hematosalpinx – conditions that lead to infertility and significantly worsen the quality of life due to debilitating pain syndrome. Since exo- and endocervix is almost always involved in the inflammatory process affecting the vagina, chronization and frequent relapses of desquamative vaginitis can cause dysplasia – precancerous changes in the epithelium of the cervix. Desquamative vaginitis during pregnancy can be a source of septic condition of the mother and intrauterine infection of the fetus.
Diagnostics
To choose a rational treatment, desquamative vaginitis should be differentiated with specific infectious colpitis – gonorrhea, trichomonas, chlamydia, candidiasis, urea- and mycoplasma, herpes and papillomavirus, tuberculosis, as well as those developed against the background of childhood infections (measles, scarlet fever, chickenpox, diphtheria). The diagnosis is carried out by an obstetrician-gynecologist, the diagnosis is established according to gynecological examination and laboratory tests.
- Gynecological examination. Examination on a chair with desquamative colpitis objectively reveals hyperemia and edema, gray sticky films on the walls of the vagina, petechial rash, increased vulnerability of the mucous membrane with the formation of erosions and ulcers with minor exposure. pH-metry is performed to indirectly confirm the diagnosis. With colpitis, the pH level is > 6 (higher than with specific infections).
- Smear microscopy. During microscopic examination of the smear , desquamative vaginitis is established according to five criteria: the lactobacillar degree is the third (absence of lactobacilli); the number of leukocytes in the field of vision is more than 10; the proportion of toxic leukocytes is more than half; background flora is an abundance of cocci; the proportion of parabasal epithelial cells is more than 10%.
- Identification of the pathogen. It is carried out for the purpose of choosing medications and differential diagnosis. Culture analysis reveals the dominant bacterial flora (in the case of desquamative inflammatory vaginitis, it is streptococcus B), the concentration of associates capable of causing infectious inflammation (for example, candida fungus) and their sensitivity to drugs. Real-time PCR study most accurately identifies the causative agents of infection and is valuable for differential diagnosis and monitoring the effectiveness of treatment.
Treatment
Ulcerative colpitis is treated with conservative methods, surgical intervention is indicated only to correct its consequences – in cases of gross scarring, leading to pronounced deformation of the vagina. Therapeutic measures are aimed at relieving the acute inflammatory process and preventing relapse.
- Therapy of acute inflammation. To suppress the coccoid flora, local treatment with antibiotics (mainly lincosamide group) and antiseptics is prescribed. Antibiotic therapy is carried out for 1-6 weeks. In cases of ineffectiveness of local therapy, severe course, attachment of secondary infection, systemic drugs are used – fluoroquinolones of the IV generation, inhibitor-protected penicillins. In order to stop the hypersensitivity reaction, corticosteroids are prescribed for a short time (in the form of creams or suppositories). If candidiasis develops in connection with antibacterial therapy, treatment is supplemented with antimycotic agents.
- Anti-relapse therapy. It is carried out to restore the normal microflora of the vagina after antibacterial treatment. The main method of normalization of vaginal biocenosis in modern gynecology is the creation of a medium acidic environment using ascorbic, lactic or boric acid. In the case of hypoestrogenism in adults, local estrogen therapy is prescribed. Intravaginal use of traditional intestinal types of lactobacilli is ineffective, since vaginal and intestinal strains are antagonists, therefore eubiotics (preparations of lacto- and bifidobacteria) are prescribed orally in order to normalize the intestinal microflora and reduce the risk of streptococcal autoinfection of the vagina.
Prognosis and prevention
The prognosis for the treatment of acute inflammation is usually favorable, but relapses are likely in the future, the frequency of which is 30%. Preventive measures include the regulation of sexual contacts and compliance with the rules of sexual hygiene, avoidance of vaginal douching (except recommended by a gynecologist), exclusion of self-treatment (both local and systemic) with antibiotics and hormonal drugs, early detection and treatment of endocrine-metabolic and immune pathologies. In order to prevent and timely diagnose primary and recurrent desquamative vaginitis, regular (at least once or twice a year) visits to a gynecologist are necessary.
