Cytologic Manifestations of Vaginitis

Introduction: As the lower genital tract is directly exposed to t he external environment, it is subjected to inflamm ation as well as infection, which may remain localized or may progress to other areas such as the endometriu , fallopian tubes, peritoneal cavity and, less likely, the ovaries. Va ginitis is a common health problem. The main aim of the present study is to recognize the cytological manifestations in vagi nitis and to identify the possible causative agent. Materials and Methods: Cytologic evaluations of vaginal smear were made i n 167 patients. Clinical details were obtained by examining the patients and relevant investigations were noted. With the consent of the patient posteri or vaginal fornix was swabbed with cotton tipped applicator. PH was d etermined. Whiff’s amine test was done for presence of fishy amine odor. Wet mount preparation was immediately made an d examined under microscope. Three smears were made , one each for Gram’s, Giemsa and papanicolaou. Result: Out of 167 cases, most common cytological diagnose s ff red were Bacterial vaginosis (50.8%), Koilocytotic atypia (1 3.7%), Trichomonas vaginalis infestations (12.5%), and vaginal candidiasis (4.8%). Majority were in age group 21-3 0 years (49.59%). Conclusion: There were diverse cytologic manifestations in vaginitis and was useful in ident ifying the possible etiological factors. Hence the results obtained are useful in screening large population.


Introduction
As the lower genital tract is directly exposed to the external environment, it is subjected to inflammation as well as infection, which may remain localized or may progress to other areas such as the endometrium, fallopian tubes, peritoneal cavity and less likely, the ovaries [1]. Vaginitis and vaginosis refer to vaginal infection, skin diseases involving the vagina, or a disruption of the normal vaginal flora. Common and nonspecific symptoms include vaginal discharge, odor, introital itching, or irritation. Vaginosis refers to vaginal disease unassociated with inflammation as characterized by redness and a wet mount showing an increase in white blood cells. Vaginitis is associated with clinical and wet-mount changes of inflammation [2]. Vaginitis is a clinical syndrome characterized by vaginal discharge, vulvar irritation, or malodorous discharge [3]. These patients complain of an excessive vaginal discharge, which may be white (leucorrhea), discolored or blood stained. This may not be always due to infection, since hormonal changes and allergies may be associated with similar manifestations [4]. Vaginitis is a common health problem [5]. The normal flora of the vagina varies from person to person but lactobacilli are usually the preponderant organism. Bacterial flora also contains other aerobic and anaerobic microorganisms. Some of these are considered to be pathogenic. Many of these organisms can be identified in cytologic preparation [6].
It is recognized that, bacterial vaginosis may be associated with pelvic inflammatory disease, preterm premature rupture of the membranes (PROM), post operative gynecologic infections and abnormal Papanicolaou smear [7].
Vaginal infections lead to inflammatory changes in the epithelial cells which may be cytoplasmic abnormalities of diagnostic importance. Symptoms of vaginitis are non-specific and neither self diagnostic nor diagnosis by a physician is reliable without laboratory confirmation [8].

Materials and Methods
Study of 'Cytologic Manifestations of Vaginitis' was conducted in the pathology department, KBNIMS, Gulbarga, over a period of two years from 1 st July 2013 to 30 th June 2015. This study consists of 167 patients referred for cytological evaluation to the pathology department.
Inclusion criteria: All the patients, clinically having the symptoms of vaginitis, were included in the study.
Exclusion criteria: Patients in menstrual period and patients who had taken antibiotics or received any treatment for vaginitis with in the previous month were excluded from this study.
With the prior consent, patient was subjected to detail clinical examination. Posterior fornix was swabbed with a cotton tipped applicator. pH was determined by using pH strips. Whiff's amine test was done as follows, the swab was mixed with two drops of 10 percent potassium hydroxide on a glass slide. This solution was immediately examined for the presence of fishy amine odour. Wet mount preparation was immediately made and examined under microscope. A second sample was obtained with another swab and three smears were made, one each for Gram's Stain, Giemsa Stain and Papanicolaou Stain. All the smears were carefully examined for the various cytologic manifestations and the causative agent. Data obtained has been analyzed.

Results
A prospective study on cytologic manifestations of vaginitis on 167 patients in the department of Pathology KBNIMS, Gulbarga, Salient features observed in this study were as follows.
Age: Age of the patients ranged from 19 years to 70 years and the majority of the Patients were in the age group of 21 -30 years (49.59%)   ), pain abdomen (42 cases); menstrual disturbances (20 cases); dysparunia (10 cases), as mentioned in Table 2.
Cytological diagnoses: Cytological diagnoses observed in this study were bacterial infections (bacterial vaginosis, Gonorrheoa, Donovanosis, Actinomycoses and leptothrix vaginalis); viral infections (koilocytotic atypia); Fungal infections (candidiasis); Parasitic infestations (Trichomonas vaginalis infestation); Radiation induced vaginitis and senile vaginitis as. In the present study maximum patients were in the age group of 21-30 years. The most common diagnosis was bacterial vaginoses (50.8%). Many of these patients had thin homogenous grey white discharge, pH of discharge was more than 4.5, positive Whiff's amine test and presence of Clue cells on microscopy. Koilocytes, Dyskeratotic cells, Binucleation and multinucleation were observed in pap smear of HPV infected woman.. Wet mount for motile trichomonas organism was positive in all cases. Epithelial cells changes showed marked cytoplasmic eosinophilia with perinuclear halo, Cytoplasmic vacuolation and enlarged, hyperchromatic nucleus. Trichomonas vaginalis organisms, pear shaped with pale grey green cytoplasm and eccentrically located round vesicular nucleus was identified along with Profound inflammatory exudates consisting predominantly of neutrophil, agglomeration of neutrophil around the parasite resulting in "BB shot effect was also evident. Gram"s stained smear form gonococcal vaginitis showed characteristic Gram-negative intracellular diplococcic. Smear from Donovanosis showed macrophages with multiple vacuole containing straight or curved dumbbell shaped rods resembling "closed safety pins". Actinomyces was identified exclusively in patients wearing an intrauterine device.

Discussion
Vaginitis, although frequently due to infection, may also have non infectious causes. Moreover, mixed infections are not uncommon. The management of vaginitis remains largely empirical [8]. Cytologic manifestations are of diagnostic importance.
Vaginitis is one of the frequent clinical situations where cytological examination is requested. Kent also observed that vaginitis was the most common reason for a patient to visit her obstetrician-gynaecologist and vaginal discharge was the commonest symptom [9]. Majority belonged to the age group 21-30 years (49.59%). Similar peak age incidence is noted in other studies [10]. Clue cells are quite specific in papanicolaou-stained smears, as well as in Gram stained smears, for detecting shift in flora from lactobacillus predominant to the anaerobic, Gardnerella Vaginalis population likely to be associated with bacterial vaginosis [11]. Koilocytes are pathognomic of a permissive HPV infection. Koilocytes are seen predominantly in LGSIL with features of HPV infection. Herrero et al (2000), have also found different age pattern of HPV prevalence, according to them this intriguing could be partly explained by cohort effect associated with changes in the sexual behavior [12].

Research Article
Tropical Journal of Pathology & Microbiology Available online at: www.pathologyreview.in 23 | P a g e The diagnostic sensitivity of the vaginal smear for candida depends on the thoroughness of the individual who examines the slide, the variability of the fungal staining reaction and the quality of fixation. Sonnex and Collegue (1999) detected candida organisms in 78% of culture positive sample. Wet mount preparation, although quick and unexpensive, the test has limited sensitivity, ranging from 60-70% [13]. Diagnosis of trichomoniasis was made by observing the organism in a stained smear. Demirezen and colleague (2000) observed in 16 out of 20 patients with T.vaginalis infestation that group of trichomonads surrounding the vaginal epithelial cells [14]. Gupta et al(1976) first reported the identification of actinomycosis in Papanicolaou smears from 13 women who had worn IUD for varying length. Accuracy of identification using light microscopy and pap stained material ranged from 48.5% to 82 69%. Development of PID in actinomycetes has been observed in many studies [15].
The microscopic diagnosis of gonococci is based on the cell morphology and arrangement, location, and colour of the bacteria. Gonococci are mainly identified as Gram-negative coffee bean-shaped diplococci, with concave sides opposing each other. Microscopy is a rapid point of care test that can be performed at bedside and facilitates the treatment of N.gonorrhoeae infection in patients at the first clinical visit [16]. Cannefax (1948) gave a full description of the organism. Donovan bodies are identified as mature or immature organisms that are present inside the cytoplasm of mononuclear cells [17]. Richens (1991), the finding of Donovan bodies provides a simple, highly specific way of confirming the diagnosis [18].

Conclusion
This study emphasizes the urgent need to study both normal vaginal flora and its physiologic variation together with the need to obtain the data on the role of vaginal flora in various forms of infections and noninfectious vaginitis as pathogenesis may remain obscure.
Funding: Nil, Conflict of interest: None initiated, Permission from IRB: Yes