Vaginitis, Colpitis: Causes

Pathogenesis (development of disease)

In keeping with the widely varying causes of colpitis, there is no single pathophysiology. However, even for the most common causes of colpitis, infections, the pathophysiologic basis is largely unknown. As shown in the chapter “Anatomy – Physiology”, there are smooth transitions from eubiosis (balanced intestinal flora) to dysbiosis (imbalance of the intestinal flora; bacterial overgrowth), vaginosis (atypical colonization of the vagina (vagina) mainly with anaerobes) and colpitis. The biological balance varies greatly between individuals. What can still be described as normal for a woman who is asymptomatic, with microbiologically confirmed massive bacterial colonization of the vagina, can be accompanied by massive complaints for another woman. Infections and discomfort depend, on the one hand, on the quality and quantity of the infectious agents, but also on the immunity situation, the ability of the different lactobacillus strains to form H2O2 and the bactericidal (“bacteria killing”) and virucidal (“virus killing”) nitric oxide formation, the so-called NO system, which depends on an acidic pH. Fungi, on the other hand, multiply best in an acidic environment. It is unclear which pathophysiological basis is responsible for the fact that colonization develops into infection, occasionally with a chronic recurrent course.

Infections (common)

Bacterial vaginosis (amine colpitis)

Although the clinical picture has long been known, the etiology and pathophysiology remain unknown. It is the most common environmental disorder of the vagina in childbearing age (40-50%). It is a microbial infection of multiple (numerous) germs, of which the main disease-inducing bacteria (as far as known so far) are Gardnerella vaginalis and Atopobium vaginae (more recently). Genetic and immunological factors, a gene polymorphism, psychosocial stress, also a disturbed oral flora in periodontitis (inflammation of the periodontium) and a deficiency of vitamin B3 are discussed as causes. The pathophysiological basis can obviously be different. Typical is a decrease of H2O2 producing lactobacilli with a simultaneous increase of pH, combined with an increase of various microorganisms. Invariably, the bladder is also co-infected. The typical fishy smell is caused by metabolic products (amines) of anaerobes. On the other hand, they inhibit the growth of yeast fungi. Since it is not an inflammation, the name colpitis or amine colpitis is not correct. What is special is that a so-called biofilm is formed, which does not occur in colpitides. It consists of a basic substance (matrix substance), in which the pathogens typical for amine colpitis are stored and become symptomatic. Since bacterial biofilms are typical for chronic and/or for foreign body associated infections, we know that they cannot be reliably eliminated by today’s established therapy, although there is an impression of healing (elimination of symptoms, normal pH, normal native preparation). Although it is not one of the typical STDs, it is mainly transmitted through sexual intercourse. Germs or the biofilm can be detected in urine and in the partner’s sperm. Risks

Bacterial vaginosis increases in:

Nonpregnant women the risk for:

Pregnant women’s risk of:

  • Amniotic infection syndrome (English : amniotic infection syndrome, abbreviated: AIS) – infection of the egg cavity, placenta, membranes and possibly the fetus (unborn child) during pregnancy or birth with risk of sepsis (blood poisoning) for the child.
  • Premature birth
  • Premature rupture of membranes
  • Premature labor
  • post partum (after birth)
    • Endometritis (inflammation of the uterus)
    • Wound healing disorders

The prevalence (disease incidence) is 5% of women who come for screening and over 30% of women who are seen in a sexually transmitted disease clinic.In pregnant women, the prevalence is 10-20%.

Fungal infections with Candida

Candida is one of the saprophytic inhabitants (organisms that do not undergo chemo- or photosynthesis and feed exclusively heterotrophically, i.e., feed on dead organic matter) of the vaginal flora, which can be detected in about 30% of healthy women at sexual maturity. Increased colonization is dependent on estrogen levels. Only under certain conditions, which have not yet been finally clarified pathophysiologically, does a pseudomycelium develop from the blastospores (sprouting cells) (formation of a network by pregrowth of the blastospores or buds that remain connected to the mother cell), which then leads to infection and symptomatology. Candida albicans is the most frequent cause and is usually responsible for pronounced clinical symptoms, accounting for about 80%. Candida glabrata (10-15%) and Candida krusei (1-5%) are rare but important because they are often responsible for recurrences and may be resistant to common therapeutics. Colpitis is almost always combined with vulvitis (inflammation in the vulva/external genital area), which is ultimately mainly responsible for the symptoms. The following forms exist:

Classification according to clinic

  • Colonization: no complaints, blastospores detectable in the native preparation.
  • Latent (“being hidden”) vaginal candidiasis: no complaints, blastospores detectable in the native preparation (unfixed preparation for microscopic examination), condition after fungal disease.
  • Mild vaginal candidiasis: premenstrual pruritus (itching), possibly burning, fluorine (discharge), blastospores, indicated colpitis.
  • Moderate vaginal candidiasis: pruritus, burning, fluor, vulvitis, colpitis, pseudomycelia, leukocytes (white blood cells).
  • Severe vaginal candidiasis: pruritus, burning pain, necrotizing colpitis, pseudomycelia, leukocytes.

Classification according to the duration of symptoms

  • Persistence (persistence) of vaginal candidiasis: despite therapy, the sprouting cells and clinical symptoms persist. Cause: disease or resistance.
  • Recurrence (resurgence) of vaginal candidiasis: after therapy and freedom from symptoms recurrence within 4-12 weeks.
  • Chronic recurrent vaginal candidiasis: after therapy at least 4 recurrences within one year.

Predisposing factors

  • Sexual maturity
  • Pregnancy
  • Premenopause (10 to 15 years before menopause).
  • Clothing (too tight clothes, synthetic underwear).
  • Consumption of stimulants
    • Tobacco (smoking)
  • Drug use
    • Cannabis (hashish and marijuana)
  • Psychosocial stress
  • Sexual activity
  • Special sexual practices (anal intercourse/anal sex, orogenital intercourse).
  • Excessive personal hygiene in the genital area (too frequent washing with soap or syndets).
  • Intimate shaving (= microtrauma) – increases the risk of mycoses (fungal infections) or infections with wart pathogens, such as condylomata acuminata caused by HP viruses 8 and 11.
  • Vaginal douches
  • Diseases:
    • Atopic eczema (neurodermatitis)
    • Diabetes mellitus (poorly controlled)
    • HIV infections
    • Type I allergies
  • Medications
    • Antibiotics
    • Glucocorticoids
    • Immunosuppressants
    • Ovulation inhibitors? (due toSprout fungi contain estrogen receptors).
    • Cytostatic drugs

Vaginal Candida species are found in about 30-50% of premenopausal women

Trichomonads

Infection with the anaerobic protozoan (single-celled organism) Trichomonas vaginalis is one of the most common STDs, about 15-20% worldwide. In Germany, this infection is very rare with an estimated prevalence (disease incidence) of about 1 %. The highest incidence (frequency of new cases) occurs between the ages of 19 and 35. Trichomonas vaginalis develops preferentially in an acidic environment (pH 3.8 – 5.2) under the influence of estrogen. Therefore, girls may acquire Trichomonas colpitis and urethritis (inflammation of the urethra) through peripartum (“around birth”) infection by the mother. As estrogen levels decrease towards menopause, the risk of trichomonad infection decreases.Although transmission is thought to occur almost exclusively through person-to-person sexual contact, there is occasional discussion – although rather unlikely – of possible infection through towels, toilet seats, bath and swimming pool water. In men, the prostate and seminal vesicles are infected in addition to the bladder. The elevated pH, amine odor, and key cells, in combination with marked fluorine, make confusion with bacterial vaginosis possible. Diagnosis is made by the typical movement patterns of the trichomonads under the microscope. A strongly reddened mucosa is typical, as well as large, red spots of irregular contour (also on the portio and cervical), occasionally vesicles, combined with a strong discharge that only diminishes after months without therapy. The initially elevated granulocyte count (belonging to the leukocytes/white blood cells) decreases in the longer course and the inflammatory reaction also recedes. Spontaneous healing does not occur. The infectiousness (contagiousness) of the disease remains untreated. Risks

  • Concomitant infections with other STDs are common. Therefore, other infections must be sought such as:
    • Bacterial vaginosis
    • Chlamydia
    • Gonococcus
    • Hepatitis B and C
    • HIV
    • Fungi
    • Syphilis
  • Portio erosion
  • Colpitis granularis
  • Pseudodyskaryosis
  • Pregnancy:
    • Amniotic infection syndrome
    • Premature birth
    • Premature rupture of membranes
    • Premature labor

Infections (rare)

Colpitis plasmacellularis (purulent colpitis, follicular colpitis, purulent vaginitis)

This is a very rare (0.1% of all colpitides?) chronic and very marked colpitis, with yellowish discharge, and diffuse or patchy redness of the vagina. In terms of symptoms, it resembles trichomonad colpitis. It is observed between the ages of 20 and 60. To date, no causative agent is known. Persistence after metronidazole therapy is typical, as is an inconclusive search for other pathogens. Also typical is an odyssey from one physician to another, often lasting months. The only known therapy is local administration of clindamycin.

Staphylococcus aureus colpitis

Colonization of the vagina with Staphylococcus aureus is usually clinically unproblematic but can lead to massive wound healing problems in the event of surgery or other injury.

  • The “toxic shock syndrome (TSS)” should still be mentioned here as a special form.

It is an infection with Staphylococcus aureus, which leads within a short time to sepsis (blood poisoning) and through toxins (poisons) to circulatory collapse and potentially death. Around 1980, this syndrome was first described in young girls who used tampons during their periods. The cause was a strong absorption capacity of the pathogens in the tampon and a strong multiplication under favorable infection conditions (large wound area in the uterus during the period). Today it is known that this disease can also be caused by other entry routes of Staphylococcus aureus, e.g. through wounds. Since the absorption capacity of tampons was regulated in the 1990s, this clinical picture no longer plays a role. A similar clinical picture can also result from streptococci (see below).

Streptococcal colpitis

Pathogens from the streptococcus group, like many other microorganisms of the skin, mucous membranes of the throat, and gastrointestinal tract, can occur in low bacterial numbers in the vagina. Under special circumstances, severe infections may result. Clinically, these infections are occasionally difficult to distinguish from trichomonad colpitis or colpitis plasmacellularis. A-streptococcal colpitis (beta-hemolytic streptococci serogroup A, Streptococcus pyogenes).

This is a very rare but highly dangerous infection (estimated < 0.1%). These germs are frequently found asymptomatically in the nasopharynx. They are transmitted by smear infection from oral to genital, but also during oral-genital sexual practices. Ascension (ascending infection) can lead to high-fever pelvic inflammation and sepsis. For this reason, antibiotic therapy must always be given if it is detected.Marked redness of the vagina with yellowish fluorine and burning, and vulvitis are among the clinical signs.

  • Puerperal fever/infant bed fever caused by beta-hemolytic streptococci of serogroup A is very rare today but has a lethality (mortality relative to the total number of people with the disease) of 20-30%. It is caused by sponging of the pathogens post partum (“after delivery”) into the bloodstream via the large wound area “uterus” (uterus).
  • Toxic shock syndrome (TSS; streptococcal TTS) caused by A streptococci is particularly dangerous, with a lethality rate (mortality relative to the total number of people suffering from the disease) of about 30%. After the pathogens have been washed into the bloodstream as a result of injuries (e.g. operations), the release of toxins (so-called superantigens) triggers shock symptoms with subsequent multi-organ failure. Life-saving is therefore an early diagnosis, in order to be able to carry out an effective intensive medical treatment. (see also TSS by Staphylococcus aureus).

B streptococci (beta-hemolytic streptococci serogroup B, GBS (group B streptococci), Streptococcus agalaktiae). They can colonize the vagina to varying degrees, but do not cause colpitis. During delivery, there is a risk of transmission to the infant and development of the dreaded neonatal sepsis.

Viral colpitis

Herpes simplex viruses

A prerequisite for primary infection of the vagina is a wound as the site of entry. Because the constellation of infection and injury to the vagina is rare, such infection does not play a role in praxi. However, in a primary infection of the vulva, the vagina and the portio are frequently involved. Symptoms include: Burning pain, fluoride, and leukocytosis (usually mild). In recurrent infection, the vagina and portio are affected even less frequently. Symptomatology is usually very mild. Condylomata acuminata (papillomavirus infection types 6 and 11).

A solitary (sole) infestation of the vagina is certainly extremely rare, since a wound in the vagina as a port of entry is a prerequisite for such a case. However, when there is a pronounced infestation of the vulva, the vagina and cervix are often also affected.

Noninfectious colpitis

Atrophic colpitis, (estrogen deficiency colpitis).

Estrogen deficiency leads to breakdown of the vaginal epithelium. The mucosal layers are partially (“partly”) broken down. As a result, there is greater vulnerability. Due to the lack of glycogen and the consecutive (“immediately following”) failure of lactic acid formation, there is an alkaline pH (5.0-7.0), which makes it easier for bacteria to colonize. Affected individuals often complain of a dry vagina, itching, a burning and sore pain inside the vagina, fluorine (discharge), occasional spotting (spotting), and dyspareunia (discomfort during intercourse). The mucosa is thin, reddened, shows petechiae (flea-like hemorrhages), and is barely folded.Often, infectious colpitis presents as colpitis granularis. It may develop into ulcerative colpitis. On the other hand, most women with atrophic colpitis are asymptomatic. There are two forms.

Skin diseases

The cause of colpitides can also be autoimmune diseases, which can manifest on the skin and mucous membranes, and various dermatitides. They are much more common in the vulvar area. A few may also become symptomatic in the vagina, such as Behçet’s disease (erosive, ulcerative, edematous): the cause is unknown. They are characterized by burning, painful, recurrent ulcers in multiple sites in the oral mucosa, introitus (“vaginal entrance“), and very rarely in the vagina. They heal spontaneously after 4-6 weeks. Often the lesions (“lesions”, “lesions”) are mistaken for those of recurrent (reoccurring) herpes. Lichen ruber planus (synonym: lichen planus) (erosive, papular) (nodular lichen) is characterized by intensely itchy skin nodules with whitish discoloration. Erosive components also occur in the oral mucosa and external genital area, which may be particularly burning genitally and cause pain on touch. The vagina is very rarely affected. Solitary (sole) involvement of the vagina is even rarer.In addition to discharge and burning, bleeding occurs when touched, e.g. during sexual intercourse or tampon use. If only the vagina is affected, diagnosis can be very difficult. Psoriasis: in contrast to the typical scales on the skin, flaming red, often intensely itchy areas appear in the genital area, usually sharply demarcated from the surrounding area. The solitary occurrence in the vagina belongs to the rarities.

Varia

Allergenic, chemical, medicinal, toxic substances such as drugs, douches, condoms, among others, injuries, operations, pessaries, various sexual practices may also be possible triggers of colpitis. Because of the variety, this will not be discussed in detail.

Etiology (causes)

Biographic causes

  • Sexually mature women

Behavioral causes

  • Nutrition
    • Micronutrient deficiency (vital substances) – see Prevention with micronutrients.
  • Sexual intercourse (eg, change from vaginal to anal or oral coitus; orogenital contacts).
  • Excessive intimate hygiene
  • Intimate shaving (= microtrauma) – increases the risk of mycoses (fungal infections) or infections with wart pathogens, such as condylomata acuminata caused by HP viruses 8 and 11.
  • Contraception with the intrauterine device (IUD).
  • Promiscuity (sexual contact with relatively frequently changing different partners).

Disease-related causes

Endocrine, nutritional, and metabolic diseases (E00-E90).

Skin and subcutaneous (L00-L99).

  • Lichen ruber/planus (nodular lichen).
  • Pemphigus vulgaris (blistering skin disease).
  • Psoriasis (psoriasis)
  • Dermatitis (inflammatory reaction of the skin)

Infectious and parasitic diseases (A00-B99).

  • Chlamydia
  • Gonorrhea (gonorrhea)
  • Genital herpes
  • Herpes zoster
  • Mites
  • Mycoses
  • Molluscum cotagiosum
  • Pemphigus vulgaris
  • Phthiriasis (crabs)
  • Scabies (scabies)
  • Staphylococcus aureus
  • Streptococcus group A, B
  • Syphilis
  • Trichomonads
  • Varicella (chickenpox)
  • Vulvitis plasmacellularis

Musculoskeletal system and connective tissue (M00-M99)

  • Behçet’s disease (synonym: Adamantiades-Behçet’s disease; Behçet’s disease; Behçet’s aphthae) – multisystem disease of the rheumatic type associated with recurrent, chronic vasculitis (vascular inflammation) of the small and large arteries and mucosal inflammation; The triad (the occurrence of three symptoms) of aphthae (painful, erosive mucosal lesions) in the mouth and aphthous genital ulcers (ulcers in the genital region), as well as uveitis (inflammation of the middle eye skin, which consists of the choroid (choroid), the ray body (corpus ciliare) and the iris) is stated as typical for the disease; a defect in cellular immunity is suspected

Neoplasms – tumor diseases (C00-D48).

  • Cervical carcinoma (cervical cancer).
  • Corpus carcinoma (cancer of the body of the uterus)
  • Tubal carcinoma (fallopian tube cancer)
  • Vaginal carcinoma (cancer of the vagina)
  • Vulvar carcinoma (vulvar cancer; cancer of the external genital organs of women).

Psyche – Nervous System (F00-F99; G00-G99).

  • Depression
  • Partner conflict
  • Psychosomatic disorders – especially in sexual conflicts (sexual disorder).

Genitourinary system (kidneys, urinary tract – sex organs) (N00-N99).

  • Adnexitis – inflammation of the so-called adnexa (Eng. : appendage formation); combination of inflammation of tubes (Latin tuba uterina, Greek salpinx, inflammation: salpingitis) and ovaries (Latin ovary, Greek oopheron, inflammation: oophoritis).
  • Cervicitis (inflammation of the cervix).
  • Cervical ectopy – displacement of glandular mucosa of the cervical canal to the portio (vaginal portion of the cervix).
  • Cervical polyp – benign mucosal tumor originating from the cervix.
  • Cervical tear – tear on the cervix.
  • Endometritis (inflammation of the uterus)
  • Corpus polyp – growths of the endometrium.
  • Pyometra – purulent inflammation of the uterus.
  • Infections caused by:
    • Bacteria
    • Parasites
    • Fungi
    • Protozoa
    • Viruses

Injuries, poisonings and other consequences of external causes (S00-T98).

  • Foreign body colpitis
  • Sexual abuse
  • Special sexual practices
  • Allergic, toxic effects of soaps, detergents, etc

    • .

Operations

  • Episiotomy (episiotomy)
  • Hysterectomy (removal of the uterus)
  • Laparotomy (opening of the abdominal cavity).

Medication

  • Antibiotics
  • Glucocorticoids
  • Immunosuppressants
  • Ovulation inhibitors
  • Cytostatics

Other causes

  • Pregnancies / births