If the uterus is compared to a palace or castle in a woman’s body, various infectious diseases that occur in the cervix, vagina and vulva are fires that occur at the entrance of the castle. Under unfavorable wind conditions, these fires can affect the uterus and further infect the fallopian tubes, ovaries and pelvic peritoneum, triggering pelvic inflammatory diseases that can affect fertility and health.
Vaginitis is the most common disease in gynecological clinics
In normal healthy women, the vagina has a natural defense against pathogens due to anatomical and biochemical characteristics. When the natural defenses are disrupted, pathogens can easily invade and lead to vaginal inflammation. Young girls and postmenopausal women are more susceptible to vaginal infection than adolescent and fertile women because of the lack of estrogen, thin vaginal epithelium, and reduced intracellular glycogen content.
Vaginitis is characterized by a change in the nature of the leukorrhea and itching and burning pain in the vulva, and painful intercourse is also common. If the infection involves the urethra, symptoms such as painful urination and urgency may be present. Common vaginitis include trichomonas vaginalis, mycobacterial (pseudomycotic) vaginitis, bacterial vaginosis, senile vaginitis, and vaginitis in young women. Statistics show that bacterial vaginosis accounts for 40% of all vaginitis, while trichomoniasis and mycotic vaginitis each account for about 25%.
I. Trichomoniasis
The pathogen is Trichomonas vaginalis, which is suitable for growth in a humid environment with pH 5.2-6.4 at 25°C to 40°C. It is difficult to grow in an acidic environment below pH 5 or in an alkaline environment above pH 7.5. After menstruation, the pH of the vagina is close to neutral, and trichomonads hidden in the vaginal glands and folds often multiply around menstruation, causing inflammation. Trichomonas can enter not only the vagina but also the urethra or paraurethral glands, and even the bladder and renal pelvis, as well as the folds of the foreskin, urethra and prostate in men. Trichomonas consumes oxygen and glycogen, making the vagina an anaerobic environment and causing anaerobic bacteria to multiply, so that 60% of patients with trichomoniasis have a combination of bacterial vaginosis (described later).
Sexual transmission is the main mode of transmission. There is a recurrent infection called “ping pong”, which is not an infection caused by playing ping pong, but rather by a man passing trichomonas to a woman, who may in turn pass it to a man, who may pass it to a woman, and so on. If there is sexual promiscuity, the mode of transmission is similar to the passing of flowers on a drum. It is annoying that men who are infected with trichomonas are often asymptomatic and become a hidden source of infection. There are also a few cases of transmission through public baths, tubs, towels, toilets, clothing, etc.
The main symptoms of trichomoniasis are increased vaginal discharge and itching of the vulva, with some patients experiencing burning, pain and painful intercourse. The typical discharge is thin, purulent, yellow-green, foamy and smelly. The itching is mainly at the vaginal opening and vulva. If combined with urinary tract infection, there may be frequent, painful urination or even hematuria. Trichomonas vaginalis can engulf sperm and affect sperm survival in the vagina, causing infertility.
The disease is easily diagnosed based on typical symptoms and can be confirmed if trichomonas is found in vaginal secretions. Every woman who visits the Obstetrics and Gynecology Department of Peking Union Medical College Hospital for gynecological inflammation will see the doctor looking at the microscope like a scientist. A drop of 0.9% sodium chloride solution is placed on a slide and a small amount of vaginal discharge is mixed with this drop for immediate microscopic examination, called “saline wet film method”. If trichomoniasis is highly suspected, but no trichomonas is found on repeated examinations, a culture of the discharge should be taken.
Treatment of trichomoniasis is simple, inexpensive and immediate. The main medication is metronidazole or tinidazole and the partner should be treated at the same time. In addition, underwear and washcloths should be boiled for 5 to 10 minutes to avoid repeated infections.
Mycosis fungoides
The official name is “Vulvovaginal Vaginosis (VVC)”, which used to be called “Vulvovaginal Candidiasis”, but the name “Mycosis Vaginalis” has been preferred by patients and doctors. The name “mycosis vaginalis” has always been preferred by patients and doctors, just like the English word Internet, which was forced to be translated as “Internet”, but internet users won out and called it “Internet”.
VVC is caused by Pseudomonas aeruginosa. Foreign data show that 3/4 of women have had close contact with VVC at least once in their lives, and half of them have experienced 2 or more episodes, so the saying may be changed to: laughing at the poor and not at the inflammation.
Ninety percent of the pathogens are mostly Pseudomonas albicans. It is found in 10% to 20% of non-pregnant women and 30% of pregnant women, but in small amounts and in a yeast phase that does not cause symptoms. Symptoms appear only when the systemic and vaginal immunity decreases and the organism multiplies and transforms into the mycelial phase. Causes include broad-spectrum antibiotics, pregnancy, diabetes mellitus, and immunosuppressive agents.
VVC is mainly endogenous, as Pseudomonas aeruginosa is parasitic outside the vagina, but also in the oral cavity and intestinal tract, and the germs from the three sites can be transmitted to each other. A small number of patients can be directly transmitted through sexual intercourse, and those who get sick through contact with infected clothing are rare.
The main symptoms are vulvar itching, burning pain, painful intercourse and painful urination. The typical vaginal discharge is white, thick, curd-like or tofu-like. In some patients, itching is unbearable and the vulva is red, swollen, eroded and superficially ulcerated after scratching.
The diagnosis is confirmed by finding pseudofilaments under the microscope. The method is similar to trichomonas examination, but the solvent is 10% potassium hydroxide to dissolve the other cellular components of the leukorrhea, leaving the pseudofilamentous yeast behind. If highly suspected but microscopic examination is negative, a culture of mycobacteria is required.
Treatment of VVC includes elimination of the causative agent and medication. It is mainly topical vaginal medication, but can also be combined with systemic medication. Topical vaginal medications are over-the-counter and available in pharmacies, commonly used are clotrimazole and miconazole. Since most transmission of VVC is endogenous, treatment is not routinely given unless the sexual partner is symptomatic.
For a typical case of VVC, an experienced doctor can basically diagnose it with one look.
To tell a story, more than a decade ago, a doctor in the department suffered from allergic asthma, and the allergen was found to be mycobacteria. During that time, one of the limited number of microscopes in the clinic broke down, so someone suggested that a man go to the clinic and let him smell a suspicious patient he encountered, and if he sneezed or had a runny nose, he would immediately diagnose. The “smell a woman” story is just a joke, but there is a specific type of vaginitis where the leukorrhea does have a foul odor, and that is bacterial vaginosis.
Bacterial vaginosis
Bacterial vaginosis is a mixed infection caused by dysbiosis of the normal vaginal flora, but lacks the typical inflammatory features on clinical and pathological examination. Normal vagina is dominated by hydrogen peroxide-producing Lactobacillus, whereas with bacterial vaginosis, the number of hydrogen peroxide-producing Lactobacillus in the vagina decreases and other microorganisms proliferate, especially anaerobic bacteria. It is speculated that the cause of the change in vaginal flora may be related to frequent sexual intercourse, multiple sexual partners or alkalinization of the vagina by vaginal douching.
If there are symptoms, they are mainly increased vaginal discharge with a fishy odor, aggravated by sexual intercourse, and mild vulvar itching or burning sensation. The discharge can also be examined for “clue cells”, which are granules that adhere to the edges of the epithelial cells that are shed from the vagina, which is a buildup of various anaerobic bacteria.
Although the symptoms of bacterial vaginosis are not serious, it can cause endometritis and pelvic inflammatory disease by upstream infection. And in women who are pregnant, it also leads to chorioamnionitis, premature rupture of membranes, and preterm delivery. Therefore, the diagnosis of bacterial vaginosis needs to be treated with the same treatment plan as trichomoniasis.
IV. Atrophic vaginitis
Atrophic vaginitis, also known as “senile vaginitis”, is common in postmenopausal women. When estrogen levels are low for various reasons, the vaginal wall atrophies and the mucous membrane thins, making it easy for bacteria to invade, while the decrease in glycogen in the vaginal epithelium increases the pH of the vagina, making lactobacilli less dominant and reducing the local resistance to overgrowth of other pathogenic bacteria.
The main symptoms are vulvar burning discomfort, itching and increased vaginal discharge. The vaginal discharge is thin and pale yellow in color. The doctor’s examination will reveal atrophic changes in the vaginal mucosa, which is congested and thin, with scattered bleeding spots. Sometimes there are superficial ulcers, or in severe cases, vaginal adhesions and atresia.
The diagnosis of atrophic vaginitis is based on the patient’s age and symptoms, and the examination does not reveal trichomonas or pseudofilamentous yeast. The main treatment options are estrogen supplementation to increase vaginal resistance and topical antibiotics to inhibit bacterial growth.
V. Vaginitis in infants and children
It is common in young girls under 5 years of age. The anatomical and physiological characteristics of the vulva and vagina of infants make them less resistant to bacterial invasion, which can easily lead to infection if they have poor hygiene habits. In addition, infants can put foreign objects such as erasers, pencil tips and buttons into the vagina and cause infection.
The main symptom is a pus-like vaginal discharge. Irritation from the discharge causes painful itching of the vulva, and the child cries and is irritable, often scratching the vulva. Examination shows that the mucous membrane of vulva is congested and edematous, with purulent discharge coming out from the vaginal opening. In severe cases, ulcers can be seen on the vulva and the labia minora are adherent. Babies and young children have poor language skills, so they mainly rely on the mother’s careful observation. In addition, it is necessary to be alert to the possibility of sexual abuse of young girls or teenage girls.
VI. Foreign body in the vagina
One of the causes of vaginitis in infants and children is a vaginal foreign body, but vaginal foreign bodies are not exclusive to young girls; adults can also be seen for vaginal foreign bodies. In curious infants, all kinds of small objects within reach can become vaginal foreign bodies, such as hairpins, matchsticks, peanuts, corn kernels, soybeans, wheat kernels, bicycle balls, cigarette filters, small stones, plastic pen caps, hemp straw, pins, snaps, short plastic cords, glass ampoules, and metal perfume bottle caps. In adults, vaginal foreign bodies such as contraceptives, cucumbers, oranges, onions, perfume bottles, and phallic models have been reported, and I treated a case of vaginal foreign body more than 20 years ago.
I had just graduated from the emergency room that year. One day at noon, a call came in from the emergency room about a college girl who suspected a ping pong ball had gotten into her vagina. I rushed to the emergency room and found some nurses who were supposed to be off duty, but the curiosity of the doctors and nurses was no different from that of normal people. The girl was pretty and quiet. Seeing that many people were present, I did not ask too much about the medical history and asked her to go to the examination bed for examination first. I thought it would be easy to do an anal examination and squeeze the ping pong ball out through the rectum. I didn’t realize that the deeper the ball was hooked, so I had to talk to her about using a vaginal speculum to open it up, but the wide upper and narrow lower structure of the vagina made it a lot of work and I had to think of some ways to remove the ping pong ball completely.
After the crowd dispersed I asked for medical history. The girl said she likes to play ping pong, and yesterday after class she went to change her sweatpants before playing ping pong and sat on her buttocks on the bed and felt a pinch on her vagina, which hurt a little, but didn’t care. Later, she found that the ping pong ball could not be found, and only then she suspected that it had gotten inside her vagina. Finally she said, “You won’t believe this, doctor.” The medical history did break down a lot, but as I am a doctor and not a detective, I did not bother to delve into it and just wrote in the medical record, “20 hours ago, ping pong ball accidentally entered ……”
The main purpose of telling this case without the woman’s consent is to show that there are various types of foreign bodies in the vagina, for a variety of reasons, but the main consequence is inflammation. If the foreign body is too large and hard, it can be left in the body for a long period of time, compressing the rectum and bladder and causing a rectovaginal or vesicovaginal fistula. At the time of the visit, the college girl’s vaginal wall was significantly edematous, and if she had been seen for a while, she would have been at risk for ischemic necrosis and rectovaginal fistula, which would have been a real tragedy.