Skip to main content

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

European Journal of Clinical Microbiology & Infectious Diseases volume 37, pages 1679–1685 (2018)Cite this article

Abstract

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.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1

Abbreviations

AV:

aerobic vaginitis

AVF:

abnormal vaginal flora

BV:

bacterial vaginosis

CV:

Candida vaginitis

LBG:

lactobacillary grade

ISSVD:

International Society for the Study of Vulvovaginal Disease

LPV:

localized provoked vulvodynia

References

  1. Moyal-Barracco M, Lynch PJ (2004) 2003 ISSVD terminology and classification of vulvodynia: a historical perspective. J Reprod Med 49(10):772–777

    PubMed  Google Scholar 

  2. Bornstein J, Goldstein AT, Stockdale CK, Bergeron S, Pukall C, Zolnoun D et al (2016) 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia. Obstet Gynecol 127(4):745–751

    Article  PubMed  Google Scholar 

  3. Bergeron S, Binik YM, Khalife S, Pagidas K, Glazer HI (2001) Vulvar vestibulitis syndrome: reliability of diagnosis and evaluation of current diagnostic criteria. Obstet Gynecol 98(1):45–51

    PubMed  CAS  Google Scholar 

  4. Arnold LD, Bachmann GA, Rosen R, Rhoads GG (2007) Assessment of vulvodynia symptoms in a sample of US women: a prevalence survey with a nested case control study. Am J Obstet Gynecol 196(2):128–126

    Article  PubMed  PubMed Central  Google Scholar 

  5. Reed BD, Crawford S, Couper M, Cave C, Haefner HK (2004) Pain at the vulvar vestibule: a web-based survey. J Low Genit Tract Dis 8(1):48–57

    Article  PubMed  Google Scholar 

  6. Reed BD, Harlow SD, Sen A, Legocki LJ, Edwards RM, Arato N et al (2012) Prevalence and demographic characteristics of vulvodynia in a population-based sample. Am J Obstet Gynecol 206(2):170–179

    Article  PubMed  Google Scholar 

  7. Burrows LJ, Klingman D, Pukall CF, Goldstein AT (2008) Umbilical hypersensitivity in women with primary vestibulodynia. J Reprod Med 53(6):413–416

    PubMed  Google Scholar 

  8. Bornstein J, Cohen Y, Zarfati D, Sela S, Ophir E (2008) Involvement of heparanase in the pathogenesis of localized vulvodynia. Int J Gynecol Pathol 27(1):136–141

    Article  PubMed  Google Scholar 

  9. Foster DC, Piekarz KH, Murant TI, LaPoint R, Haidaris CG, Phipps RP (2007) Enhanced synthesis of proinflammatory cytokines by vulvar vestibular fibroblasts: implications for vulvar vestibulitis. Am J Obstet Gynecol 196(4):346–348

    Article  PubMed  CAS  Google Scholar 

  10. Goldstein A, Burrows L, Goldstein I (2010) Can oral contraceptives cause vestibulodynia? J Sex Med 7(4 Pt 1):1585–1587

    Article  PubMed  Google Scholar 

  11. Johannesson U, Sahlin L, Masironi B, Hilliges M, Blomgren B, Rylander E et al (2008) Steroid receptor expression and morphology in provoked vestibulodynia. Am J Obstet Gynecol 198(3):311–316

    Article  PubMed  CAS  Google Scholar 

  12. Johannesson U, Sahlin L, Masironi B, Rylander E, Bohm-Starke N (2007) Steroid receptor expression in the vulvar vestibular mucosa—effects of oral contraceptives and menstrual cycle. Contraception 76(4):319–325

    Article  PubMed  CAS  Google Scholar 

  13. Johannesson U, Blomgren B, Hilliges M, Rylander E, Bohm-Starke N (2007) The vulval vestibular mucosa-morphological effects of oral contraceptives and menstrual cycle. Br J Dermatol 157(3):487–493

    Article  PubMed  CAS  Google Scholar 

  14. Papoutsis D, Haefner HK, Crum CP, Opipari AW Jr, Reed BD (2016) Vestibular mast cell density in vulvodynia: a case-controlled study. J Low Genit Tract Dis 20(3):275–279

    Article  PubMed  PubMed Central  Google Scholar 

  15. Friedrich EG Jr (1987) Vulvar vestibulitis syndrome. J Reprod Med 32(2):110–114

    PubMed  Google Scholar 

  16. Donders G, Bellen G, Van Peperstraete B, Folens S (2012) Simple posterior vestibuloplasty for central introital dyspareunia. Gynecol Surgery 9(3):292–302

    Article  Google Scholar 

  17. Donders GG, Folens S, Peperstraete B, Bellen G (2011) Age of sexual debut and central introital dyspareunia. Eur J Obstet Gynecol Reprod Biol 158(1):90–92

  18. Donders G, Bellen G (2011) Characteristics of the pain observed in the focal vulvodynia syndrome (VVS). Med Hypotheses 78(1):11–14

  19. Donders GG, Marconi C, Bellen G, Donders F, Michiels T (2014) Effect of short training on vaginal fluid microscopy (wet mount) learning. J Low Genit Tract Dis 19(2):165–169

  20. Donders GG (2007) Definition and classification of abnormal vaginal flora. Best Pract Res Clin Obstet Gynaecol 21(3):355–373

    Article  PubMed  Google Scholar 

  21. Donders GG, Bellen G (2014) Assessing severity of pain in women with focal provoked vulvodynia: are von Frey filaments suitable devices? J Reprod Med 59(3–4):134–138

    PubMed  Google Scholar 

  22. Arnold LD, Bachmann GA, Rosen R, Kelly S, Rhoads GG (2006) Vulvodynia: characteristics and associations with comorbidities and quality of life. Obstet Gynecol 107(3):617–624

    Article  PubMed  PubMed Central  Google Scholar 

  23. Donders GG, Vereecken A, Bosmans E, Dekeersmaecker A, Salembier G, Spitz B (2002) Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis. BJOG 109(1):34–43

    Article  PubMed  Google Scholar 

  24. Donders GG, Bellen G (2012) Cream with cutaneous fibroblast lysate for the treatment of provoked vestibulodynia: a double-blind randomized placebo-controlled crossover study. J Low Genit Tract Dis 16(4):427–436

    Article  PubMed  Google Scholar 

  25. Donders GG, Ruban K, Bellen G (2015) Selecting anti-microbial treatment of aerobic vaginitis. Curr Infect Dis Rep 17(5):477

    Article  PubMed  Google Scholar 

  26. Burrows LJ, Goldstein AT (2013) The treatment of vestibulodynia with topical estradiol and testosterone. Sex Med 1:30–33

    Article  PubMed  PubMed Central  CAS  Google Scholar 

Download references

Funding

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

Author information

Authors and Affiliations

  1. Femicare vzw, Clinical Research for Women, Gasthuismolenstraat 31, 3300, Tienen, Belgium

    Gilbert G. G. Donders, Gert Bellen & Kateryna S. Ruban

  2. Department of OB/Gyn, Antwerp University, Antwerp, Belgium

    Gilbert G. G. Donders

  3. OB/Gyn General Hospital H Hart, Tienen, Belgium

    Gilbert G. G. Donders

Authors
  1. Gilbert G. G. Donders
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gert Bellen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kateryna S. Ruban
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Gilbert G. G. Donders.

Ethics declarations

Conflict of interests

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.

Additional information

Précis

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.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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). https://doi.org/10.1007/s10096-018-3299-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10096-018-3299-2

Keywords

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