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Abnormal vaginal microbioma is associated with severity of localized provoked vulvodynia. Role of aerobic vaginitis and Candida in the pathogenesis of vulvodynia


Localized provoked vulvodynia (LPV) causes introital dyspareunia in up to 14% of premenopausal women. Vaginal infections like candidosis may play a initiating role. The aim of this study was to test a possible association of vaginal microbiota alternations such as Candida vaginitis (CV), aerobic vaginitis (AV) and bacterial vaginosis (BV) with severity of vulvodynia and painful intercourse. In an observational study, Q-tip touch test (score 1 (no pain) to 10 (worst possible pain)) was performed on seven vestibular locations in 231 LPV patients presenting in the Vulvovaginal Disease Clinics in Tienen, Leuven and Antwerp, Belgium. Severity of pain upon attempting sexual intercourse was recorded in a similar scale. Both scales were compared to results from fresh wet mount phase contrast microscopy on vaginal fluid smears tested for abnormal vaginal flora (AVF), BV, AV and CV according the standardized microscopy method (Femicare). Fisher’s exact test was used. Average age was 31.3 ± 11.6 years, and 58.8% (n = 132) had secondary vestibulodynia. There was an inverse relation between the presence of Candida in the vaginal smears and pain score (p = 0.03). There was no relation of pain score, nor Q-tip score with BV. LPV patients with Q-tip score above 7 at 5 and/or 7 o’clock or at 1 and/or 11 o’clock had more often AV than women with lower pain scores (30 vs 14.5%, p = 0.01, and 39 vs 14.7%, p < 0.005, respectively). Detailed study of the vaginal microflora in patients demonstrates that the most severe patients suffer more from AV and less from Candida. These abnormalities need to be actively looked for and corrected before considering surgery or other therapies.

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Fig. 1



aerobic vaginitis


abnormal vaginal flora


bacterial vaginosis


Candida vaginitis


lactobacillary grade


International Society for the Study of Vulvovaginal Disease


localized provoked vulvodynia


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Femicare supported the microscopy examinations. G Bellen and K Ruban are employees at Femicare.

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Correspondence to Gilbert G. G. Donders.

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The authors declare that they have no conflict of interest.

Review board status

The study protocol (Eudractnr: 2008-006756-22) was approved by the ethical committees of Leuven university and the general hospital of the H Hart Tienen.

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As abnormal vaginal microbiota like aerobic vaginitis contribute to the severity of vulvodynia, wet mount microscopy is strongly recommended in order to adjust treatment accordingly.

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Donders, G.G.G., Bellen, G. & Ruban, K.S. Abnormal vaginal microbioma is associated with severity of localized provoked vulvodynia. Role of aerobic vaginitis and Candida in the pathogenesis of vulvodynia. Eur J Clin Microbiol Infect Dis 37, 1679–1685 (2018).

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  • Aerobic vaginitis
  • Bacterial vaginosis
  • Vaginal microbioma
  • Vaginal infection
  • Candida vaginitis
  • Recurrent vulvovaginal candidiasis
  • Vulvar pain
  • Vulvo-vestibular syndrome
  • Painful sexual intercourse
  • Dyspareunia