A Clinicopathological Diagnostic and Therapeutic Approach to Cytolytic Vaginosis: An Extremely Rare Entity that may Mimic Vulvovaginal Candidiasis

Abstract

Objectives: Cytolytic vaginosis is a very rare entity that may be clinically misdiagnosed as vulvovaginal candidiasis. The aim of this study was to determine the incidence of cytolytic vaginosis in patients displaying symptoms similar to vulvovaginal candidiasis and to develop a clinicopathological diagnostic and therapeutic approach.

Materials and methods: In total, 3000 cervical smear samples were evaluated at our center between 2015 and 2018. Patients whose PAP smears demonstrated significant epithelial cytolysis, naked nuclei, excessive increase in lactobacilli population, absent or minimal neutrophils and no microorganisms were subjected to a symptom assessment questionnaire and had their vaginal pHs measured. They were classified into two groups according to their complaints, symptoms and vaginal pHs: Cytolytic vaginosis and Asymptomatic intravaginal lactobacillus overgrowth. A standardized NaHCO3 Sitz bath therapy was applied to the cytolytic vaginosis group.

Results: Fifty-three of the patients (1.7%) were diagnosed as cytolytic vaginosis. After Sitz bath therapy, there was a statistically significant decrease in the cytolysis and lactobacillus scores of the patients. Vaginal discharge of 43 (81%) patients ceased completely while that of the remaining 10 (19%) patients decreased after the therapy. The improvement was statistically significant (P < 0.001). There was a complete resolution in 28 (96%) patients with severe; and in 21 (94%) patients with intermediate vaginal discomfort, after the therapy. Dyspareunia was resolved in 35 (97%) patients (P < 0.001).

Conclusion: Cytolytic vaginosis is a rare entity that can be diagnosed with the help of cytopathology and has a therapy based on the modulation microbiota by decreasing the vaginal pH.

Keywords: Bacterial; PAP smear; candidiasis; cytolytic vaginosis; lactobacillus; vulvovaginal.

Figure 1

The cytopathological features of bacterial vaginosis: a) Sparse neutrophil leucocytes in the background (arrows), (PAP, 400X). b) Bacterial accumulation (circles), (PAP, 1000X). c) Cytolytic vaginosis: marked cytolysis (red arrows) and bare nuclei (black arrows), (PAP, 400X). d) Abundant small lactobacilli measuring between 2 and 10 µm. (circles), (PAP, 1000X). e) Candida vulvovaginitis: Candidal hyphae (arrows), neutrophils (stars) and spores (circle). (PAP, 1000X). f) Lactobacillosis: Abundant lactobacilli with size longer than normal (circles). (PAP, 1000X)