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Aerobic vaginitis

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Aerobic vaginitis was first described by Donders et al. in 2002[1]. It is characterized by a more or less severe disruption of the lactobacillary flora, along with inflammation, atrophy and the presence of a predominantly aerobic microflora, composed of enteric commensals or pathogens[2].

It can be considered the aerobic counterpart of bacterial vaginosis. The lack of acknowledgement of the the difference between the two conditions might have led to inaccurate conclusions in several studies in the past[3].
The entity that has been described as "desquamative inflammatory vaginitis" probably corresponds to the more severe forms of aerobic vaginitis[4].

1. Prevalence
The prevalence of aerobic vaginitis, according to several studies, ranges from 2-12%[5][6] [7] [8][9].


2. Clinical manifestations
Women with aerobic vaginitis usually present with a thinned reddish vaginal mucosa, sometimes with extensive erosions or ulcerations and abundant yellowish discharge (without the fishy amine odor, typical of bacterial vaginosis). The pH is usually high.
Symptoms can include burning, stinging and dyspareunia.
The symptoms can last for long periods of time - sometimes even years. Typically patients have been treated several times with antimycotic and antibiotic drugs, without any relieve[10]. Aerobic vaginitis can also be asymptomatic (microscopic evidence of it, but absence of symptoms); the proportion of asymptomatic women is unknown.


3. Diagnosis
The diagnosis is based on microscopic criteria. Ideally phase contrast microscopy should be used and magnification of 400x (high power field - hpf)[11]. For scoring purposes, lactobacillary grade must be evaluated (grade I, numerous pleiomorphic lactobacilli, no other bacteria; IIa, mixed flora, but predominantly lactobacilli; IIb, mixed flora, but proportion of lactobacilli severely decreased because of an increased number of other bacteria; III, lactobacilli severely depressed or absent because of overgrowth of other bacteria), relative number of leucocytes, percentage of toxic leucocytes, background flora and proportion of epitheliocytes.


The "AV score" is calculated according to what is described in the table.
  • AV score <3: no signs of AV
  • AV score 3 or 4: light AV
  • AV score 5 or 6: moderate AV
  • AV score ≥6: severe AV.

pH measurement alone is not enough for the diagnosis.

4. Complications
Aerobic vaginitis has been associated with several gynecological and obstetrical complications, including:
  • Premature rupture of membranes
  • Preterm labour
  • Ascending chorioamnionitis[12]
  • Increased risk to acquire sexually transmitted diseases (including human immunodeficiency virus)[13]
  • Abnormal Pap test results[14][15]

5.Treatment
Treatment is not always easy and aims at correcting the three key changes encountered in aerobic vaginitis: the presence of atrophy, inflammation and abnormal flora. The treatment can include topical steroids to diminish the inflammation, topical steroids to reduce the inflammation. The use and choice of antibiotics to diminish the load/proportion of aerobic bacteria is still a matter of debate. The use of local antibiotics, preferably local non-absorbed and broad spectrum, covering enteric gram-positive and gram-negative aerobes, like kanamycin can be an option. In some cases, systemic antibiotics can be helpful (amoxyclav or moxifloxacin[16]). Vaginal rinsing with povidone iodine can provide rapid relief of symptoms but does not provide long-term reduction of bacterial loads[17]. Dequalinium chloride can also be an option for treatment[18].

References

  1. ^ Donders GG. Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis. Br J Obstet Gynecol 2002;109:1–10
  2. ^ Donders G, Bellen G, Rezeberga D. Aerobic vaginitis in pregnancy. BJOG. 2011 Sep;118(10):1163-70
  3. ^ Han C, Wu W, Fan A et al (2015) Diagnostic and therapeutic advancements for aerobic vaginitis. Arch Gynecol Obstet 291(2): 251–257. doi:10.1007/s00404-014-3525-9
  4. ^ Newbern EC, Foxman B, Leaman D, Sobel JD (2002) Desquamative inflammatory vaginitis: an exploratory case–control study. Ann Epidemiol 12(5):346–352. http://www.ncbi.nlm.nih.gov/pubmed/12062923.
  5. ^ illaseca R, Ovalle A, Amaya F et al (2015) Vaginal infections in a family health clinic in the metropolitan region, Chile. Rev Chilena Infectol 32(1):30–36. doi:10.4067/S0716-10182015000200007
  6. ^ Tomusiak A, Heczko PB, Janeczko J, Adamski P, Pilarczyk-Zurek M, Strus M (2013) Bacterial infections of the lower genital tract in fertile and infertile women from the southeastern Poland. Ginekol Pol 84(5):352–358. http://www.ncbi.nlm.nih.gov/pubmed/ 23819400.
  7. ^ Bologno R, Díaz YM, Giraudo MC et al (2011) Importance of studying the balance of vaginal content (BAVACO) in the preventive control of sex workers. Rev Argent Microbiol 43(4):246–250. doi:10.1590/S0325-75412011000400002
  8. ^ Tansarli GS, Kostaras EK, Athanasiou S, Falagas ME (2013) Prevalence and treatment of aerobic vaginitis among non-pregnant women: evaluation of the evidence for an underestimated clinical entity. Eur J Clin Microbiol Infect Dis 32(8):977–984. doi: 10.1007/s10096-013-1846-4
  9. ^ Vieira-Baptista P, Lima-Silva J, Pinto C, Saldanha C, Beires J, Martinez-de-Oliveira J, Donders G. Bacterial vaginosis, aerobic vaginitis, vaginal inflammation and major Pap smear abnormalities. Eur J Clin Microbiol Infect Dis. 2016 Apr;35(4):657-64. doi: 10.1007/s10096-016-2584-1
  10. ^ Donders G, Bellen G, Rezeberga D. Aerobic vaginitis in pregnancy. BJOG. 2011 Sep;118(10):1163-70
  11. ^ Donders GGG, Larsson PG, Platz-Christensen JJ, Hallén A, van der Meijden W, Wölner-Hanssen P (2009) Variability in diagnosis of clue cells, lactobacillary grading and white blood cells in vaginal wet smears with conventional bright light and phase contrast microscopy. Eur J Obstet Gynecol Reprod Biol 145(1):109–112. doi: 10.1016/j.ejogrb.2009.04.012
  12. ^ Donders GG, Moerman P, De Wet GH, Hooft P, Goubau P (1991) The association between Chlamydia cervicitis, chorioamnionitis and neonatal complications. Arch Gynecol Obstet 249(2):79–85. http://www.ncbi.nlm.nih.gov/pubmed/1953055
  13. ^ Donders G, De Wet HG, Hooft P, Desmyter J (1993) Lactobacilli in Papanicolaou smears, genital infections, and pregnancy. Am J Perinatol 10(5):358–361. doi:10.1055/s-2007-994761
  14. ^ Jahic M, Mulavdic M, Hadzimehmedovic A, Jahic E (2013) Association between aerobic vaginitis, bacterial vaginosis and squamous intraepithelial lesion of low grade. Med Arch 67(2): 94–96. http://www.ncbi.nlm.nih.gov/pubmed/24341052
  15. ^ Vieira-Baptista P, Lima-Silva J, Pinto C, Saldanha C, Beires J, Martinez-de-Oliveira J, Donders G. Bacterial vaginosis, aerobic vaginitis, vaginal inflammation and major Pap smear abnormalities. Eur J Clin Microbiol Infect Dis. 2016 Apr;35(4):657-64. doi: 10.1007/s10096-016-2584-1
  16. ^ Wang C, Han C, Geng N, Fan A, Wang Y, Yue Y, Zhang H, Xue F. Efficacy of oral moxifloxacin for aerobic vaginitis. Eur J Clin Microbiol Infect Dis. 2016 Jan;35(1):95-101. doi: 10.1007/s10096-015-2513-8
  17. ^ Donders GG, Ruban K, Bellen G. Selecting anti-microbial treatment of aerobic vaginitis.Curr Infect Dis Rep. 2015 May;17(5):477. doi: 10.1007/s11908-015-0477-6
  18. ^ Mendling W, Weissenbacher ER, Gerber S, Prasauskas V, Grob P.Use of locally delivered dequalinium chloride in the treatment of vaginal infections: a review. Arch Gynecol Obstet. 2016 Mar;293(3):469-84. doi: 10.1007/s00404-015-3914-8
AV score Lactobacillary grades Number of leukocytes Proportion of toxic leucocytes Background flora Proportion of parabasal epitheliocytes
0 I and IIa <10/hpf None or sporadic Unremarkable or cytolysis None or <1%
1 IIb >10/hpf and; <10/epithelial cell <50% of leukocytes Small coliform bacilli ≤10%
2 III >10/epithelial cell >50% of leukocytes Cocci or chains >10%
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