[NP-Clinical] UTI/lactobacillis

[Priscilla Merrill]

Thanks!   Will post to the site.  Priscilla

 

   _____  

From: Jill Rollet [mailto:JRollet at Merion.com] 
Sent: Monday, May 07, 2007 8:23 AM
To: Priscilla Merrill
Subject: RE: [NP-Clinical] UTI/lactobacillis

 

Hi, Priscilla,

 

I think this is the article you’re referring to:
http://nurse-practitioners.advanceweb.com/common/EditorialSearch/AViewer.asp
x?AN=NP_07feb1_npp45.html&AD=02-01-2007

 

Vol. 15 •Issue 2 • Page 45 
Cytolytic Vaginosis And Lactobacillosis 

Consider These Conditions With All Vaginosis Symptoms 

By Robin L. Hills, NP 

A 35-year-old woman presents with complaints of vulvovaginal itching and
thick, white discharge that started 9 months earlier. She reports that the
itching and discharge increase in severity during the 2 weeks prior to her
menstrual period. She says she is in a monogamous relationship and that she
sometimes experiences introital pain with intercourse. Her medication
history includes an initial attempt to self-treat with an over-the-counter
vaginal antimycotic treatment. It provided only temporary relief. The
patient then sought diagnosis and treatment from multiple health care
providers. She received prescriptions for fluconazole (Diflucan) and
metronidazole (Flagyl), but these provided little relief. One provider
suggested that she seek psychiatric counseling. 

Vulvovaginal complaints are the most frequent gynecologic reason that U.S.
women visit their health care providers.1 Bacterial vaginosis,
trichomoniasis and vulvovaginal candidiasis account for approximately 90% of
vulvovaginal diagnoses.2 Although knowledge of these common diagnoses, as
well as normal findings, is fundamental, it is also imperative that nurse
practitioners consider the differential diagnoses for the remaining 10%.
Recent research suggests that two conditions characterized by lactobacilli
overgrowth, cytolytic vaginosis and lactobacillosis, may account for as much
as 5% of vulvovaginal complaints.3 Although the body of evidence about these
conditions is immature, nurse practitioners and their patients will benefit
from an increased awareness of their existence and recommended treatment
regimens. 

Etiology and Background 

More than 80 species of lactobacilli, the predominant bacteria in the
healthy vagina, have been identified. Select anaerobic species of
lactobacilli have a protective effect against the overgrowth of potentially
pathogenic indigenous flora and common infectious vaginal microorganisms by
maintaining an acidic vaginal pH between 4.0 and 4.5.4 Lactobacilli
contribute to this acidic environment by producing lactic acid and hydrogen
peroxide as byproducts of glucose and glycogen synthesis.5,6 In cytolytic
vaginosis and lactobacillosis, however, a disruption in this vaginal
equilibrium occurs. Although these conditions are characterized by an
overgrowth of lactobacilli, a direct causal relationship has not been
identified.7,8 Therefore, the etiology of these conditions remains unknown. 

What is known is that the lactobacilli overgrowth in cytolytic vaginosis
appears to trigger the cytolysis of intermediate vaginal epithelial cells,
first described in the early 1890s as Dderlein's cytolysis.7,9 In 1991, two
researchers determined that this was a misnomer because it excluded the
various species of lactobacilli that cause the cytolysis, leading to the
more appropriate label of cytolytic vaginosis.7 

Like cytolytic vaginosis, the etiology of lactobacillosis is unknown. Unlike
cytolytic vaginosis, however, no cytolysis of vaginal epithelial cells
occurs with lactobacillosis. An association with recent antimycotic
treatment may exist, but no evidence has proved a direct causal link.8,10 

Incidence 

Cytolysis is a somewhat common finding on Pap smear specimens in patients
with symptoms typically attributed to vulvovaginal candidiasis.5,7,11 A
study of the rate of cytolysis on 2,947 Pap smears determined that 54
(1.83%) had microscopic findings consistent with cytolytic vaginosis.5 In a
study of 101 women with cyclic vaginal discharge, 5% had cytolytic vaginosis
based on microscopic findings.3 Based on these limited studies, 1% to 5% of
patients who present with vaginal complaints may have cytolytic vaginosis. 

The incidence of lactobacillosis has not been quantified. It seems
reasonable to hypothesize that, due to the inaccuracy of patient
self-diagnosis and the increased over-the-counter availability of mycolytic
therapy during the last decade, the incidence of lactobacillosis may have
increased.12 

Assessment 

The typical patient complaints associated with cytolytic vaginosis and
lactobacillosis include pasty, odorless, white vaginal discharge, pruritus
and vulvar dysuria (HYPERLINK
"http://www.AdvanceForNP.com/PrintArchives/2-1-2007/images/NP020107_p45Table
1.pdf"Table 1).8,10 A low-grade vulvar burning or discomfort may occur and
increase with sexual activity, especially with cytolytic vaginosis.13,14
These symptoms are often cyclical in nature, being more pronounced during
the luteal phase and reaching a peak shortly before menses.10,13 In
addition, the patient frequently presents with a lengthy history of these
symptoms.8 It is clear why these conditions, based on presentation alone,
are frequently misdiagnosed as vulvovaginal candidiasis. 

As a result of self-diagnosis and then blind diagnosis by providers,
patients with these conditions typically present with numerous partially
used medications that have neither cured nor alleviated the symptoms.7 The
most frequently administered medications are mycolytic because the patient
or provider assumes that yeast is the causative organism.8 Recommendations
for psychiatric counseling to address the chronic vaginal complaints have
also been reported by these patients.7 

On physical examination, the cervix, uterus, adnexa, vulva and vaginal
tissues typically appear normal.8 Vulvar and vaginal tissues may, however,
be diffusely erythematous and slightly edematous. The introitus may be
mildly tender with speculum insertion. The discharge may be thick, opaque,
paste-like or flocculent, and it is typically odorless.9 

Laboratory Workup 

Microscopic examination and pH analysis are key for accurate diagnosis.
Microscopic findings for cytolytic vaginosis by saline wet preparation
include a large number of intermediate epithelial cells — present in greater
numbers during the luteal phase of the menstrual cycle — as well as copious
amounts of lactobacilli of varying lengths. These lactobacilli sometimes
adhere to the epithelial cells, which then may be mislabeled as false clue
cells. Cytoplasmic debris, including bare or naked nuclei from cytolyzed
epithelial cells, is also visible. In addition, a low pH (3.5 to 4.5) is
typical. Pseudohyphae, spores, trichomonads and clue cells are absent, and
leukocytes are scarce or absent.10,13 Although leukocytes are generally
absent, a mislabeling of the bare or naked nuclei as white blood cells may
also occur, which would lead to misdiagnosis. 

In lactobacillosis, intermediate epithelial cells are also visible on
microscopy, with few leukocytes.8,10 A similar pH range of 3.6 to 4.7 is
typical.14 However, cytoplasmic debris is not present because of the absence
of cytolysis. Lactobacillosis also differs from cytolytic vaginosis in that
the lactobacilli appear as long, segmented chains (also known as leptothrix)
and are less abundant.8,11 

The length of these lactobacilli chains is six times greater than the
lactobacilli found in a normal vaginal sample. Whereas normal rods of
lactobacilli are between 5 and 15 microns in length, many long serpiginous,
nonbranching chains of lactobacilli ranging from 40 to 60 microns in length
are present in lactobacillosis.8,14 To make an accurate diagnosis, the
provider must be able to accurately identify the clue cells, pseudohyphae,
leukocytes, bare nuclei and lactobacilli overgrowth. 

If the patient has risk factors for sexually transmitted infections, obtain
cervical cultures in addition to vaginal microscopy. Consider obtaining a
vaginal yeast culture to rule out candidal infection.9,14 Because the Pap
smear is diagnostic for detecting cytolytic vaginosis, advise the patient
with a cytolysis result to return to the clinic to confirm the diagnosis and
be treated appropriately.5 

Diagnostic Criteria 

Diagnosing cytolytic vaginosis and lactobacillosis is inexpensive and
uncomplicated based on the subjective and objective assessments previously
discussed. Diagnostic criteria for cytolytic vaginosis and lactobacillosis
(HYPERLINK
"http://www.AdvanceForNP.com/PrintArchives/2-1-2007/images/NP020107_p45Table
2.pdf"Table 2) include the presence of pasty, odorless, white vaginal
discharge. The vulvar and vaginal tissues are normal or slightly
erythematous and may also be edematous. On saline wet preparation,
trichomonads, clue cells and hyphae are absent, and few leukocytes are
present. The pH is 3.5 to 4.5. Diagnostic criteria specific to cytolytic
vaginosis include evidence of cytolysis with bare or naked intermediate
nuclei and copious amounts of lactobacillus rods of varying lengths,
possibly adhered to the intermediate epithelial cells. 

In lactobacillosis, the lactobacillus rods are more sparse and markedly
longer than those found in cytolytic vaginosis. Trichomoniasis, bacterial
vaginosis, vulvovaginal candidiasis and cervicitis may all be excluded with
these findings and appropriate vaginal and cervical cultures. 

Management 

Symptom relief, achieved by restoring vaginal equilibrium, is the goal of
treatment. Decreasing the amount of lactobacilli in cytolytic vaginosis and
lactobacillosis will lead to a reduction in vaginal acidity and an increase
in the pH, producing symptom relief.13 The scientific evidence is sparse at
best regarding treatment regimens for these conditions. However, significant
empirical evidence has been published in the literature. 

Discontinuing tampon use may be the only necessary measure to decrease
vaginal acidity in cytolytic vaginosis, since menstrual flow may
sufficiently raise the pH.9 If this measure does not provide relief, suggest
the use of sodium bicarbonate (baking soda) in a sitz bath or douche to
achieve this pH elevation (HYPERLINK
"http://www.AdvanceForNP.com/PrintArchives/2-1-2007/images/NP020107_p45Table
3.pdf"Table 3).9,13 Both regimens have proven to be effective, but the sitz
bath should be recommended as first-line treatment.9 Recommending a douche
treatment regimen to the patient who has previously been encouraged to
discontinue douching will require specific patient education about the
disease process. Encourage the patient who experiences recurrence to begin
the sitz baths or douching 24 to 48 hours prior to the typical onset of
symptoms.7,13 

Lactobacillosis does not disappear spontaneously. One study found that the
sitz bath and douche were not consistently efficacious in the treatment of
lactobacillosis, but beta lactamase antibiotic therapy (Augmentin) was found
to be effective.8 When beta lactamase antibiotic therapy is contraindicated
due to penicillin sensitivity or is ineffective as initial treatment,
doxycycline (Doryx) is recommended. 

In rare cases, cytolytic vaginosis may occur concurrently with vulvovaginal
candidiasis. In such cases, recommend a 7-day regimen consisting of an
antimycotic agent inserted intravaginally at bedtime and douching with the
sodium bicarbonate mixture every morning.9 

When an accurate diagnosis is made and appropriate treatment is recommended,
relief of symptoms is generally achieved, and follow-up and referral are
unnecessary. In recalcitrant cases, referral to a collaborating physician or
a gynecologist may be warranted. 

Patient Education 

Patient education should begin with an explanation of the diagnosis. Advise
the patient that symptom resolution may require two to three treatment
cycles.9 Instruct her to discontinue any pharmacologic treatments or
homeopathic remedies, including yogurt and acidophilus supplements. As
previously discussed, menstrual flow through the vagina may aid in raising
vaginal pH; therefore, the patient should discontinue the use of tampons
except during physical activity or swimming. This use should be limited to 1
or 2 hours. Instead of tampons, she should use nondeodorant sanitary pads. A
return to tampon use may be considered only after the patient is symptom
free for at least 6 months.9 

Basic vulvovaginal care instructions are also important for patients with
cytolytic vaginosis or lactobacillosis. Advise the patient to wear white,
all-cotton underwear laundered in mild soap and hot water and to avoid using
soap to cleanse the genital area.9 Recommend abstinence from sexual activity
when symptoms are present and during initial therapy. Finally, educate the
patient about the importance of douching only when symptomatic, to avoid
creating a more alkaline vaginal environment conducive to bacterial
vaginosis. 

Putting It Into Practice 

Although vulvovaginal complaints are the most frequent gynecologic reason
women visit health care providers, clinical studies addressing the etiology
of vaginal microflora imbalance have been outnumbered by an emphasis on
other areas of women's health. As a result, the body of evidence on
cytolytic vaginosis and lactobacillosis is immature. Nurse practitioners
should include these conditions in the list of differential diagnoses for
vulvovaginal complaints, thus optimizing clinical outcomes and enhancing
quality of life for patients. As awareness of these conditions increases,
quantitative research studies should focus on the etiology, incidence and
effective treatment options for these conditions. 

References 

1. Stewart EG. Developments in vulvovaginal care. Curr Opin Obstet Gynecol.
2002;14(5):483-488. 

2. Reis AJ. Treatment of vaginal infections: candidiasis, bacterial
vaginosis, and trichomoniasis. J Am Pharm Assoc. 1997;NS37:563-569. 

3. Wathne B, et al. Vaginal discharge: comparison of clinical, laboratory
and microbiological findings. Acta Obstet Gynecol Scand.
1994;73(10):802-808. 

4. Redondo-Lopez V, Cook RL. Emerging role of lactobacilli in the control
and maintenance of the vaginal bacterial microflora. Rev Infect Dis.
1990;12(5):856-872. 

5. Demirezen S. Cytolytic vaginosis: examination of 2947 vaginal smears.
Cent Eur J Publ Health. 2003;11(1):23-24. 

6. Overman BA. The vagina as an ecologic system: current understanding and
clinical applications. J Nurse Midwifery. 1993;38(3):146-151. 

7. Cibley LJ, Cibley LJ. Cytolytic vaginosis. Am J Obstet Gynecol.
1991;165(4Pt2):1245-1249. 

8. Horowitz BJ, et al. Vaginal lactobacillosis. Am J Obstet Gynecol.
1994;170(3):857-61. 

9. Secor RM. Cytolytic vaginosis: a common cause of cyclic vulvovaginitis.
Nurse Pract Forum. 1992;3(3):145-148. 

10. Paavonen J. Vulvodynia: a complex syndrome of vulvar pain. Acta Obstet
Gynecol Scand. 1995;74(4):243-247. 

11. Bibbo M, Harris MJ. Leptothrix. Acta Cytol. 1972;16(1):2-4. 

12. Ferris DG, et al. Over-the-counter antifungal drug misuse associated
with patient-diagnosed vulvovaginal candidiasis. Obstet Gynecol.
2002;99(3):419-425. 

13. Hutti MH, Hoffman C. Cytolytic vaginosis: an overlooked cause of cyclic
vaginal itching and burning. J Am Acad Nurse Pract. 2000;12(2):55-57. 

14. Korenek P, et al. Differentiation of the vaginoses — bacterial
vaginosis, lactobacillosis, and cytolytic vaginosis. Internet J Adv Nurs
Pract. 2003;6(1). Available at: HYPERLINK
"http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijanp/vol6n1/vagi
nosis.xml"
\nhttp://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijanp/vol6n1/vag
inosis.xml. Accessed Oct. 26, 2006. 

Robin Hills is a women's health nurse practitioner and certified menopause
clinician who is a clinical instructor at Virginia Commonwealth University
School of Nursing in Richmond. 

 

 

 

Jill Rollet 

Senior Associate Editor 

ADVANCE for Nurse Practitioners 

Phone: (800) 355-5627 x1628 

Fax: (610) 275-8562 

HYPERLINK "mailto:jrollet at merion.com"jrollet at merion.com 

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From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net]
On Behalf Of Priscilla Merrill
Sent: Saturday, May 05, 2007 6:52 AM
To: 'NP Clinical'
Subject: [NP-Clinical] UTI/lactobacillis

 

There was a very interesting article the past month or 2 on lactobacillus
overgrowth and UTI sx's.  I wish I'd saved it!  Now I can't find it or
recall which journal.  I can search when I get some time but wondered if
anyone else had seen it?  I wonder if it's related to TOO MANY of the
probiotics now being touted and put into food?  I don't recall this from the
article, however.

I see this all the time, the culture returns with >100,000 lb's but no
sensitivities and these women have frequent UTI sx's without bacteria, yet
not suspicious for interstitial cystitis.

I wish I could recall the treatment modalities from the article. It may have
been the boric acid caps.  I just skimmed it, got busy and so now I've
forgotten.  Anyone have suggestions?

Thanks, 

Priscilla Merrill FNP 

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