Hi cprfaguy-ga, and thanks for your question. As usual, this is not a
substitute for medical advice or direct evaluation and treatment by a
physician.
As you state, the overwhelming amount of web information and published
medical literature deals with too little lactobacillus in the
reproductive tract, usually in the context of overgrowth of other
pathogens.
There is a lesser known disease entity called cytolytic vaginosis,
first described in 1982 (originally called Doderlein's cytolysis),
that results in vulvar and vaginal itching and burning, vulvar burning
with urination, and entry dyspareunia (pain with intercourse). The
symptoms can be cyclic, being more pronounced during the luteal phase
of the menstrual cycle. On physical exam, the vulva can appear
slightly edematous, with erythema (redness). If severe enough, I
believe that there could be associated spotting. cytolytic vaginosis
is associated with an overgrowth of lactobacilli (i.e., cytolytic
vaginosis is an advanced phase of lactobacillosis). Distinguishing
between lactobacillosis and cytolytic vaginosis would be difficult
without direct physical examination, a good history, and examination
of the vaginal pathology samples.
You can find a good comparison of symptoms and diagnostic criteria
from this article (Table 1):
http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijanp/vol6n1/vaginosis.xml
__________
A very good article that describes a specific case, as well as the
history, symptoms, diagnosis, and treatment of cytolytic vaginosis is
the following:
Hutti MH, Hoffman C. Cytolytic vaginosis: an overlooked cause of
cyclic vaginal itching and burning.
J Am Acad Nurse Pract. 2000 Feb;12(2):55-7.
Unfortunately, there isn't even an abstract available online, so I
will provide some relevant abstracts. You can also e-mail Marianne
Hutti at the University of Louisville School of Nursing to request a
free reprint:
mhhutt01@wise.louisville.edu
You can also purchase the article from this site:
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1745-7599.2000.tb00284.x
Diagnosis:
"Completion of a web prep of the vaginal discharge as well as a
vaginal pH evaluation is necessary for the diagnosis of cytologic
vaginosis (Goldman, 1995). The pH will be low, measuring 3.5 to 4.5.
Few white blood cells will be noted on the saline side of the wet
prep, and there will be evidence of cytolysis of epithelial cells
resulting in poorly defined cell borders and pale or bare nuclei.
There may be an increased number of rod shaped lactobacilli present
and a marked absence of the pathogens associated with bacterial
vaginosis, trichomoniasis or vulvovaginal candidiasis (Cibley, &
Cibley, 1991; Paavonen, 1995)."
"Vaginal cultures will demonstrate either normal vaginal flora or
heavy growth of lactobacilli, and they will not grow candida. The
examiner should be careful to sample only the vagina for the cultures.
Contaminating vaginal cultures with cervical secretions may obscure
the diagnosis (Cibley, & Cibley, 1991; Secor, 1992; Paavonen, 1995)."
Treatment
"The treatment goal is to reduce the vagina's acidity by reducing the
amount of lactobacilli present ot provide symptomatic relief. The
easiest way to reduce vaingal acidity is through the use of a vaginal
douche or [S]itz bath (see Table 1) containing sodium bicarbonate
(baking soda), which brings rapid symptomatic relief (Goldman, 1995).
Woman who experience recurrent symptoms should be encouraged to take
baking soda douches or Sitz baths 24 to 48 hours before the
anticipated onset of symptoms. A [S]itz bath is preferred since
douching may introduce pathogens into the upper reproductive tract and
increase the risk of pelvic inflammatory disease and ectopic pregnancy
(Hatch et al., 1994). Women should discontinue tampon use until they
are symptom-free for six months (Cibley, & Cibley, 1991; Secor, 1992;
Paavonen, 1995)."
You can see Table 1 from this article, which contains basic
instructions for making a Sitz bath, at this link:
http://img408.imageshack.us/img408/8051/snapshot200512311046151ml.jpg
You can find a similar description from the second article I cited:
"The treatment goal is to increase the vaginal pH with sodium
bicarbonate douching or Sitz baths (11,37,49). Cytolytic vaginosis is
an easily diagnosed and treated condition. Kaufman and Faro as well as
Goldman recommended 1 teaspoon of sodium bicarbonate in 1 pint warm
water, 1-2 times weekly as needed (8, 50 ). Paavonen recommended women
discontinue tampon use until they are symptom-free for at least 6
months ( 52 ). Hatcher and associates recommended Sitz baths since
douching may introduce pathogens and increase the risk of Pelvic
Inflammatory Disease (PID) ( 53 ). The woman is instructed to sit for
15 minutes in a Sitz bath of approximately 2-4 tablespoons of sodium
bicarbonate added to 2 inches of warm bath water 2-3 times in the
first week, then 1-2 times weekly as needed to prevent recurrences.
The woman who experiences recurrent symptoms is encouraged to start
bicarbonate douching or Sitz baths 24 to 48 hours before the
anticipated onset of symptoms (11,37,49)."
In terms of treating general lactobacillosis (LB), the second article
cited above compares the current treatment regimens:
"The most effective treatment of LB consists of Augmentin 500 mg
orally three times a day for one week. Horowitz et al. found that
86.3% of patients reported absence of symptoms after treatment with
Augmentin. Six of the patients who were penicillin sensitive were
selected for Doxycycline of 100 mg twice daily for 10 days. All six
obtained relief from symptoms. Seven patients were initially treated
with bicarbonate douches, and three-reported relief from symptoms. The
other four were treated with either Augmentin (n = 3) or Doxycycline
(n = 1) and successfully had resolution of symptoms. Eighteen months
later, patients were symptom free and reexamination of wet mount
slides revealed an absence of long serpiginous rods (24)."
Table 2 in this article has a nice summary of the various currently
accepted (but not the only) treatment regiments, about 3/4 of the way
down the page.
I believe in your question you mean "Clindamax" and "clindamycin." If
her doctor prescribed this medication, he/she is likely trying to
treat bacterial vaginosis. The vaginal culture results don't seem to
support this idea, but it's difficult to say without the direct lab
results, physical exam, etc. Some physicians do a step-wise approach
to these types of problems, i.e., treat for bacterial vaginosis; if
that doesn't work, look for other possibilities. Bacterial vaginosis
and lactobacillosis are not the same thing.
Given that Sitz baths are noninvasive and could potentially give quick
relief, I wouldn't hesitate to try this.
===================
Here are some other resources for more information:
Published articles on PubMed for cytolytic vaginosis:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=1951582&tool=ExternalSearch
_______
Another article discussing cytolytic vaginosis:
Cerikcioglu N, Beksac MS. Cytolytic vaginosis: misdiagnosed as candidal vaginitis.
Infect Dis Obstet Gynecol. 2004;12(1):13-6.
Free full text can be found here:
http://www.hindawi.net/access/get.aspx?journal=idog&volume=12&pii=S1064744904000031
_______
You can find a sample diagnostic algorithm in this paper. Your
girlfriend would currently be in the "empiric treatment" block in the
lower right.
Egan M, Lipsky MS. Vaginitis: case reports and brief review. AIDS
Patient Care STDS. 2002 Aug;16(8):367-73. Review.
Free full text is here:
http://www.liebertonline.com/doi/pdf/10.1089/10872910260196396
===========================
I hope this information is helpful. Please feel free to request
clarification prior to rating.
Best,
-welte-ga |
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