A bit of terminology
Vulvovaginitis is an inflammatory disease of the female genital tract.
Vulvovaginitis is divided into vulvitis and vaginitis by localization.
With vaginitis (the second name is “ colpitis ”), the vaginal mucosa is inflamed. When the vulva inflames the mucous membrane of the labia minora and vaginal vestibule.
Vaginitis and vulvovaginitis are one of the most frequent reasons for patients to go to a gynecologist, and the most common complaints are abundant discharge (“whiter”), itching and redness in the genital area, pain in the vagina.
Also, the diagnosis of ” colpitis ” or “vaginitis” can be exposed to a woman during a physical examination, during examination on the result of a vaginal smear.
Normally, lactic acid bacteria ( lactobacterium and bifidobacteria) predominate in the smear . The cells of the vaginal epithelium under the action of sex hormones accumulate the substance glycogen, and lactobacteria break it down into lactic acid, therefore the environment in the vagina is normally acidic (pH = 3.8-4.5). This is an ideal habitat for beneficial bacteria, as well as their protection from other microorganisms – “competitors”. In normal vaginal discharge light, dairy to 2-3 ml per day. Dryness in the vagina in a woman of young childbearing age should not be. Symptom of dryness is in menopause and ovarian dysfunction and indicates a decrease in the level of sex hormones.
Bacterial vaginosis is inherently neglected dysbacteriosis without inflammation of the tissues in the vagina, replacing the useful normal microflora with bacteria, which are normally insignificant. They do not cause inflammation, because the body knows them, got used to them. But to maintain the normal state of the vagina, these microorganisms can not, can not cope, because the manifestation of dysbiosis – pathological discharge with smell.
Vaginitis means primarily inflammation of the mucous membrane in response to the introduction of an infectious agent (pathogenic flora).
- Vaginitis is inflammation
- Vaginosis – a violation of microflora.
Also, do not confuse bacterial vaginitis (inflammation caused by bacteria) and bacretiary vaginosis.
If the infectious agent is a bacterium, then vaginitis is called bacterial. Bacterial vaginitis can be divided into aerobic (caused by bacteria that consume oxygen in the process of life), and anaerobic (in this case, bacteria do not need oxygen). Yeast mushrooms can also cause vaginitis. Most often these are fungi of the genus Candida, hence the name Candida colpitis (vaginitis).
Specific vaginitis – the term means that a specific pathogen (for example, gonococcus, trichomonas, yeast mycelium filaments) is clearly identified by smear or seeding from the vagina. The treatment of such vaginitis will also be specific, taking into account the sensitivity of the microorganism to antibiotics.
Non-specific vaginitis does not clearly indicate a specific sexually transmitted infection. The cause of nonspecific vaginitis can be a group of staphylococci, streptococci, Escherichia coli, which are rarely present in the healthy vagina, but cause inflammation, replacing the lactobacilli.
Hence the answer to the following question that concerns many people:
Only specific vaginitis is transmitted sexually through contact with a partner (that is, it is easy to get gonorrhea or trichomonas vaginitis in the case of unprotected sex). With non-specific vaginitis, there is no risk of infection.
In a pregnant woman, the course of vaginitis and the presence of inflammation in a smear (both specific and non-specific) can lead to an unfavorable outcome of pregnancy, including:
- infected miscarriage
- intrauterine infection of the fetus,
- insufficiency of the function of the placenta due to its infection, which leads clinically to fetal growth retardation, to polyhydramnios or low water,
- preterm labor,
- premature rupture of amniotic fluid.
In addition, if vaginitis appeared during pregnancy, then in childbirth a woman sets foot with irritated, red, edematous mucous walls of the vagina. When vaginitis, the walls are more prone to cracking, abrasions and ruptures of the mucous membrane during childbirth occur easily. In the face of reduced immunity, anemia (often during pregnancy and childbirth), lack of sleep, vaginitis after delivery against the background of an injury to the vaginal mucosa can become recurrent in nature.
When vaginitis occurs
- When ingested specific microorganism , which causes inflammation, through sexual intercourse ( trichomoniasis, in candidal candidiasis, gonorrhea, mycoplasmosis, chlamydia );
- When activating its own non-pathogenic microflora in the vagina, which supplanted both bifidobacteria and started the process of inflammation.
Factors contributing to this:
- any decrease in immunity in a woman (during pregnancy, diabetes, infectious diseases, long-term administration of glucocorticoids, for example, in case of bronchial asthma or rheumatoid arthritis, during treatment for cancer with chemotherapy);
- non-compliance with personal hygiene;
- lack of hygiene of sexual life (frequent change of sexual partners, unprotected sexual contact);
- prolonged or irrational use of antibiotics, which leads to the destruction of beneficial lactobacilli and dysbacteriosis;
- malnutrition of the mucous membrane while reducing the level of sex hormones (premature menopause syndrome, senile atrophy, the creation of artificial menopause in the treatment with chemotherapy) and during radiation therapy of cancer;
- other disorders of the female endocrine system (for example, in diabetes mellitus and high blood sugar levels, the vaginal epithelium cells accumulate glycogen excessively, a favorable environment for the development of fungal flora is created, so diabetes mellitus is very characteristic of recurrences of thrush; in obesity in hot weather, irritation often occurs and diaper rash in the folds, groin, perineum);
- violation of the anatomy of the vagina due to the omission of its walls, prolapse of the uterus – there is a constant microtrauma of the mucous membrane;
- vaginitis after childbirth can have a recurring nature, if there is a gaping genital slit as a result of cicatricial changes after ruptures in childbirth or with poor episiotomy healing – the entrance to microorganisms is open;
- damage to the mucous membrane during manipulation in the vagina and in the uterus (for example, trauma to the mucous membrane with the introduction of mirrors and other tools, abrasions and micro-tears during labor);
- allergies (for example, condom gum, or the use of vaginal creams or pills for contraception, or synthetic underwear).
- vaginitis with menstrual irregularities. For example, the patient has menstruation for 7 days, and then another ten days for spotting, the next menstruation generally lasted 2 weeks – all this time, when menstrual blood leaks into the vagina, its normal acidic environment changes to a more alkaline direction. Lactobacilli in such an environment is not comfortable living. The number of normal microflora is reduced, thus, with menstrual disorders, prerequisites for the occurrence of vaginitis are created.
All of the above points contribute to the settlement in the vagina of an unusual microflora with the further development of inflammatory changes.
Cystitis is an acute inflammatory disease of the bladder, the symptoms of which are painful …
In the acute stage of vaginitis, the patient complains of contamination of the underwear with vaginal secretions – “belium”.
The discharge in acute vaginitis can be thick, viscous, whitish to brown, abundant (up to 20 ml per day at a rate of up to 2-3 ml). Abundant frothy yellow-green discharge is characteristic of Trichomonas colpitis . When thrush, or yeast fungal colpitis , discharge resembles cottage cheese, flaky, with the smell of yogurt. Admixture of pus to the mucous discharge in gonorrhea makes the discharge ” creamy “, yellowish.
Patients in the acute stage also often complain of itching and burning in the area of the vulva, the entrance to the vagina, sometimes because of this the patient’s sleep is disturbed. Sexual intercourse is painful – it is called in medicine the term ” dyspareunia .”
Often a burning sensation during urination and pain in the lower abdomen, lower back joins acute vaginitis. This most often happens when a specific microbe is infected with the mucous membrane of the urethra – cystitis joins.
There is usually no increase in temperature in vulvovaginitis, hyperthermia occurs with complicated forms of the disease (abscess of the vulva, ulceration of the vulva) and with the spread of infection (ascending path from the vagina through the cervix into the uterus, fallopian tubes, appendage area).
In the chronic stage of vaginitis in adult patients, complaints of discharge from the genital tract persist, less prone to itching and discomfort in the vaginal area. Chronic vaginitis implies a sluggish long-term course and a tendency to relapse more often 4 times a year.
Atrophic ( postmenopausal or senile) vaginitis
Atrophic vaginitis usually occurs 3-5 years after the end of menstruation, as a result of a decrease in the level of sex hormones (estrogens) with age. In conditions of lack of estrogen, the epithelium of the vagina does not accumulate glycogen, it becomes thinner and unfavorable for the life of lactic acid bacteria. Lactobacilli becomes less and less, and clinically in a woman in menopause, this is manifested by severe dryness in the vagina, burning sensation when urinating and washing with the use of soap, soreness during sexual intercourse, the appearance of bloody discharge after sexual intercourse. Most often in the atrophic smear in general any microflora is absent, but sometimes microbial nonspecific or specific vaginitis can occur. In this case, ulceration will easily appear on the thinned pale bleeding mucous membrane.
Sometimes little girls with symptoms of vulvitis and vulvovaginitis are brought to the gynecologist’s appointment . After all, a child may also experience a decrease in immunity, activation of its own non-pathogenic flora, it can also receive antibiotics, and diabetes.
Girls in such cases complain of itching on the eve of the vagina, the mother can see “whites” on the panties, sometimes the child just starts crying, holding a hand over the lower abdomen and perineum. It happens that small girls of 3-5 years old (at the age of increased attention of the child to their genitals) can introduce small toys on the eve of the vagina, for example, details from the designer or “kinder surprise”, which then cause inflammation inside.
If you notice something wrong in time, then everything is fixable. In the chronic form, young girls experience synechiae (adhesions) of the vaginal walls, white adhesions in the urethra and perineum. Such adhesions then need to be separated and treated for a long time.
The doctor draws attention to the nature of the patient’s complaints, asks her about a possible provocation of the disease – a woman can tell about a change of sexual partner, an episode of uncontrolled antibiotics, a recent abortion, taking oral contraceptives with a high content of estrogen, etc.
What will see the gynecologist during the inspection
- When viewed on a gynecological chair, the redness of the mucous membrane of the labia minora and the skin around the entrance to the vagina draws attention to itself, there may be a whitish bloom and cheesy flakes on the mucosa.
- The urethra may be swollen and swollen.
- The mucosa is also irritated, red, swollen, and may bleed upon contact with a gynecological mirror.
- On the walls of the vagina there may also be an inflammatory white patina, cheesy discharge, and foamy, creamy or abundant milky discharges on the mirrors, sometimes with a smell.
The main methods of diagnosis and confirmation of vulvovaginitis –
- bacterioscopic (examination of smears from the vagina, cervix, and urethra on the glass under a microscope)
- bacteriological (seeding of secretions on media with observation of the growth of microorganisms). In the process of sowing microbes, it can also immediately determine its sensitivity to various antibacterial drugs, which in some cases makes it easier to choose a treatment regimen.
Patients with fever and frequent recurrences of vaginitis are prescribed pelvic ultrasound to prevent the spread of infection above the vagina (uterus, fallopian tubes, and ovaries).
If during the examination revealed vaginitis and cervical erosion , signs of inflammation of the cervical canal of the cervix, condyloma – the patient should be examined for ureaplasmosis , chlamydia and human papillomavirus and herpes virus. Under conditions of infection and vaginitis, cervical erosion does not heal for a long time, bleeds, and requires first treatment of the inflammatory process.
Treatment of vulvovaginitis should be a two-step process – antibacterial therapy is first carried out to eliminate the pathological microflora, and then preparations are used to restore normal biocenosis.
In addition, as far as possible, predisposing moments of the disease should be eliminated, attention should be paid to the treatment of associated diseases and functional disorders. For example, in ovarian hypofunction, it is necessary to correct their activity, aimed at filling the body’s hormone deficiency, when omitting the vaginal walls, to perform a planned operation to restore the pelvic floor, and in case of diabetes, together with the endocrinologist, to adjust the blood sugar level close to the target.
At stage 1 of drug treatment of vaginitis, antibacterial and local sanitizing therapy is prescribed.
If the causative agent of inflammation is not identified, then broad-spectrum antibacterial drugs are prescribed (that is, effective against most known microbes).
The recommended (main) scheme for the treatment of acute vaginitis of non-pregnant women:
- candles with hlogeksidiny ( hexicon ) vaginally 1-2 times a day for up to 7-10 days;
- or clindamycin candles (1 candle daily for 6 days in a row);
- or metronidazole (in vaginal suppositories twice a day for 5 days in a row or in tablets of 0.5 mg for oral administration twice a day for a week).
In cases of chronic course and relapse, an alternative treatment regimen is recommended:
- clindamycin 300 mg tablets take 2 times a day during the week;
- or metronidazole orally once in a dose of 2 grams;
- or tinidazole in a dose of 2 grams taken orally once.
Therapy for Specific Vaginitis
If the cause of vaginitis is a specific microorganism (for example, trichomonads, gonococcus, fungi of the genus Candida , etc.), then antibacterial drugs at stage 1 are prescribed for sensitivity to these pathogens.
Trichomonas colpit is effectively treated using metronidazole: vaginal suppositories with metronidazole are used daily at night, one at a time and simultaneous intake of metronidazole in tablets (total for a course of 5-7.5 g of metronidazole, with obesity, the dose increases to 10-15 g per course).
In pregnant women, you can use this drug from the second trimester of pregnancy.
When gonorrhea is usually used ceftriaxone 250 mg / m once, or azithromycin 2 g orally once, it is also possible to use ciprofloxacin, ofloxacin . In persistent cases of vaginitis, vaginal baths are used: after preliminary douching with soda solution, 1–2 tablespoons are introduced through a round vaginal mirror. l 2-3% solution of silver nitrate, 3-10% solution of protargol. After 2-3 minutes, the liquid is removed. Baths are done in 2-3 days.
With relapses and chronic gonorrhea, treatment is necessarily carried out and prescribed by the dermatovenereologist.
In pregnancy, gonorrhea is subject to compulsory treatment. Usually use ceftriaxone, sometimes – macrolides.
In candidal vaginitis (for acute thrush or fungal vagitis ), treatment begins with the use of antifungal drugs:
- miconazole in vaginal suppository 100 mg at night, one per week;
- fluconazole 150 mg orally once;
- Introconazole tablets 200 mg twice a day, take 3 days;
- clotrimazole 100 mg each (for the night of 7 days, 1 candle is administered vaginally).
Pregnant women can, starting with the first trimester of pregnancy, use candles with pimafucine , starting with the second trimester of pregnancy – candles “ terzhinan ”, “ gino-pevaril ”, candles with clotrimazole .
Thrush ( candidal vaginitis) bothers women more often than other specific vaginitis and it is characterized by chronic course and constant relapses.
In chronic thrush, the combined use of vaginal suppositories (for example, with ketoconazole ) for 14 consecutive days and taking a systemic antifungal drug (for example, fluconazole in 150 mg capsules once for 3 consecutive days) is recommended.
After treatment of chronic thrush, it is also recommended to continue the prophylactic administration of antifungal drugs to prevent recurrence of thrush: you need to take 150 mg of fluconazole orally on the first day of menstruation once during 6 menstrual cycles (six months).
Treatment of atrophic ( postmenopausal ) vaginitis should include:
- replenishment of hormonal deficiency with the help of hormone replacement therapy or phytoestrogens (which can be applied in each case the doctor decides),
- candles in the vagina or cream with wound healing and softening effect (candles with sea buckthorn, calendula, string), tampons with aloe juice at home,
- antibacterial vaginal suppositories for vaginitis with the identification of pathogenic flora.
- The treatment of a male partner is necessary for specific vaginitis, since even in the absence of complaints of microorganisms (for example, Trichomonas), the man can be contained in the body of a man in the prostate and in the seminal vesicles, cause chronic inflammation and lead to prostatitis and infertility. In addition, there is no point in treating a woman if the sexual partner after treatment re-rewards her with germs. In the case of non-specific vaginitis in a partner, the man should be treated only if he has complaints (itchy genitals, discharge, painful urination, pain in the lower abdomen).
- During the treatment of vaginitis, it is recommended to exclude alcohol, limit sweet
- It is strongly recommended to exclude sex life.
- If the patient is more worried about itching of the vulva in the region of the labia minora, then you can use a cream with the same preparation instead of vaginal suppositories (for example, cream with clotrimazole , clindamycin ).
- Douching with vaginitis is auxiliary, for example, you can douche with chamomile solution, calendula, chlorhexidine solution, but antibacterial and antifungal drugs in vaginal suppositories, tablets, creams will have the main therapeutic effect. It will be useful to apply the spray ” epigen “, it is worth mentioning it separately, as it has an immunostimulating effect. It helps fight nonspecific vaginitis, candidal vaginitis, in cases of genital warts and herpes.
- For severe itching and painful sensations in the vagina, local anesthetic ointments ( emla , kamistad ) can be recommended for a short time.
- In the treatment of vaginitis, you can visit the pool and swim. To infect someone or to become infected with vaginitis yourself is possible only if you do not just swim, but have sex in the water.
Restoration of microflora
At the second stage of treatment, biopreparations with bacteria are used to restore normal microflora in the vagina. It is necessary to make a pause in 3-4 days between taking antibacterial agents and biologics.
Preparations of this series can be divided into:
- containing only lactobacilli (acylact, acipol , lactogen , lactobacterin ),
- containing only bifidumbacterium ( bifidumbacterin , probifor ),
- kombirirovannye ( lineks , bifiform et al.).
Biologics are best used in vaginal suppositories, and inside for systemic exposure.
After treatment of acute vaginitis, smear monitoring is carried out a week after the end of therapy, and again after the end of the next menstruation. With a normal microscopic smear and no recurrence, the prognosis for recovery is favorable.