World Journal Of Pediatrics-articles

Author Affiliations: Obstetrics, Gynecology, Perinatology and Pediatric & Adolescent Gynecology, Donetsk Medical University, Ukraine, Peninsula Medical School, Plymouth, UK (Matytsina LA); Pediatrics & Human Development, Michigan State University College of Human Medicine, Michigan State University/Kalamazoo Center for Medical Studies, 1000 Oakland Drive, Kalamazoo, Michigan, USA (Greydanus DE); Pediatric Gynecology, St-Peterburgh Pediatric Academy, St-Peterburgh, Russia (Gurkin YA)

Corresponding Author: Lyubov A Matytsina, Obstetrics, Gynecology, Perinatology and Pediatric & Adolescent Gynaecology, Donetsk Medical University, Ukraine, Peninsula Medical School, Plymouth, UK (Tel: 44 1872 274501; Fax: 44 1872 274501; Email: lubore@mail.ru; lyubov.matytsina@yahoo.com)

Background: Clinicians and investigators often do not appreciate the importance of vaginal microbiocoenosis and vaginal cytology in the health of prepubertal and adolescent girls.

Data sources: Based on recent publications in human medicine and our own experience with vaginal cytology and microbiology in children and adolescent girls, we review the principles of vaginal microbiocoenosis and cytology and their roles in disease prevention in prepubertal and adolescent girls.

Results: The main role of vaginal microbiocoenosis and cytology in diagnosing as well as developing vulvovaginitis is demonstrated. Clinicians can identify states of vaginal health and disease by important well-known diagnostic tools, including vaginal cytology. Lactobacilli are infrequently observed in the prepubertal girls, but become more abundant in adolescent girls. Three basic types of vaginal smears are presented in addition to a classification of inflammatory urogenital diseases. Management of common types of vulvovaginitis is also considered.

Conclusions: This essential shift in vaginal bioco-enosis is important to prevent the growth of potentially pathogenic flora in the vagina. The detection of vaginal microbiocoenosis problems and recognition of changing cytology in vaginal development can provide helpful clues to identifying and preventing vaginal diseases in this pediatric population.

Key words: cytology; lactobacilli; vaginal microbiocoenosis; vulvovaginitis

Vaginal inflammatory and infectious diseases are the most common gynecological diseases found in prepubertal and adolescent girls. Microbiocoenosis (biocoenosis) refers to a group of interacting organisms that live in a specific habitat such as the vagina and form an ecological community. Cytological evaluation of vaginal cells is an important diagnostic method used in identifying vaginal disorders (Fig.).^[1-3] Such an analysis reveals vaginal epithelial status, presence or absence of inflammatory changes, and etiological factor(s) causing vaginal symptomatology.^[4-9] An examination of cervical cytology has proven useful in cervical cancer screening for adolescent and adult females.^[10,11]

This article focuses on vaginal microbiocoenosis and cytology. The vaginal microbiological picture can be divided into two groups: 1) normal or non-pathogenic agents (normal flora or microbiocoenosis);^[7] and 2) potentially dangerous or conditionally pathogenic microorganisms. A decrease of immunological health of an individual can lead to some organisms becoming pathogenic.^[1,12-15]

Vaginal microorganisms are divided into aerobes, facultative anaerobes and obligate (strict) anaerobes. The vaginal lactobacilli flora consists of 11 strains of lactobacilli (gram-positive bacilli); the dominant strain in quantity (42.9%) is Döderlein's bacillus (Lactobacillus acidophilus). The role of this lactobacilli flora is to prevent the presence of potentially pathogenic flora by producing an acidic environment that has a pernicious effect on these other flora.

In the prepubertal girls, the vaginal environment is alkaline or neutral in which the vaginal vestibule and mucosa are pink, tender, and devoid of overt vaginal secretion or fluid. Vaginal cytology reveals few epithelial cells and leukocytes; cytology or culture reveals cocci along with nitrobacteria and corynebacteria. Lactobacilli are absent or in low numbers due to low ovary endocrine function. As sex hormone secretion begins in the peripubertal period and increases as puberty progresses, the vagina becomes inhabited by increasing amounts of lactobacilli. The vaginal milieu becomes acidic and physiologic leukorrhea occurs.^[1,4]

A variety of flora can be found in the vagina at different ages and in different stages of health, growth, or disease.^[7,15,16] An important group is the cocci bacteria. The biological feature of cocci lies in the fact that young cocci are intensively colored by Gram staining, and when the cocci become older they turn to be gram-negative. Some of the cocci cultures belong to normal microbiological growth in skin, and mucus membranes of the respiratory tract, the gastrointestinal tract, and the genitals. However, some of the cocci flora in the vagina can become pathogenic flora. The staphylococci in the vagina include Staphylococci aureus, epidermidis, and micrococcus (saprophytic). The streptococci include Hemolytic (green) streptococci, Enterococci (Fecal streptococci), and Streptococcus pneumoniae. Environmental niches of Peptostreptococci (anaerobic cocci) are the oral cavity, intestine, and genitals.

Bacillus flora is also conditionally pathogenic and can grow in the vagina. Diphtheroids are gram-positive bacilli that belong to the Corynebacteria group. Some Diphtheroids represent normal flora in the respiratory tract and mucus membranes of the skin and genitals. Enterobacteria are gram-positive bacilli that include Intestinal bacilli, Proteus, Enterobacteria (blue pus bacilli), and Klebsiella. They make up a considerable part of normal flora of the intestine and take part in providing its normal gastrointestinal functioning; however, they can become pathogenic flora when found in the vagina.

Gardnerella vaginalis and other Gardnerella species are small gram-positive bacilli (sometimes found in the form of coccobacilli) that are facultative anaerobes.^[7,15,17] Gardnerellas are seen in healthy women (their frequency fluctuates from 47% to 68%) and girls aged from 2 months to 15 years without any clinical manifestations. Thus, Gardnerella vaginalis are considered as co-inhabitants of the vagina, though some experts feel that Gardnerella species can be pathogenic in some cases.^[7,15-17]

Leptothrix are gram-variable bacilli that can have the form of coccobacilli; they are facultative anaerobes growing in the vagina and do not grow on ordinary culture media. These bacteria are found in nature in streams of slowing running water polluted by various industries such as paper or milk factories. Acinetobacter are aerobic, thick, short, gram-positive bacilli that have the form of diplococci; in gram stains, they appear similar to gonococcal and meningococcal bacteria. Acinetobacter can be seen in the skin, mucus membranes, respiratory tract, and the urogenital tract in humans. Patients with immunodeficiency can develop sepsis in association with other microbes.^[1]

There are three basic vaginal smear types in pre-pubertal and adolescent girls: first type (normal state of vaginal biocoenosis), second type (reflection of non-specific vulvovaginitis), and third type (reflection of specific vulvovaginitis) (Table 1).^[18] This classification is recommended for clinicians caring for prepubertal and adolescent girls, providing a helpful picture of the clinical-laboratory status of the vagina and its disorders in this pediatric population.

In the first type classification of the vaginal smear (normocoenosis), there is a normal state of vaginal health. The quantity of leukocytes is rather negligible, and presented mainly by granulocytes; phagocytosis is not marked. Also, the flora is lean, containing mainly of a small quantity of gram-positive cocci (diplococci).

The smear called the second type represents an intermediate picture in which there is a transition state from normocenosis to a non-specific vaginitis picture. There is a low content of leukocytes (mainly granulocytes) and epithelial cells, and Döderlein's bacillus occur with girls of adolescent age. This type has considerable quantity of pathogenic and potentially pathogenic microbiologic flora with absence or minimal clinical characteristics of vaginal genital inflammation. The quantity of degeneratively changed cells is small.

The third type of vaginal smear reflects marked, specific vulvovaginitis. The quantity of leukocytes is more than 15, mainly neutrophils and macrophages; phagocytosis and mucous reaction are marked. The quantity of degenerative and reactively changed cells is considerable. The quantity of shed epithelium up to age of 9 years is often 9-12, and 10 to 20 for older adolescents. Döderlein's bacillus as a rule are absent. The flora is mixed and represented in considerable quantity. Further evaluation reveals a specific etiology such as Trichomonas vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis, Candida albicans, anaerobic bacteria reflective of bacterial vaginosis, or others (Table 1).^[5,19-22]

Diagnostic methods used to identify vaginal pathology in prepubertal and adolescent girls are clinical evaluation and specific laboratory tests, including saline as well as potassium hydroxide preparations and microbiology; a major tool in the diagnosis is vaginal cytology (Fig.).^[6,7] Vaginal inflammation is noted by exudative, degenerative, reparative, and defensive changes of cell composition (Table 2).

A classification of inflammatory urogenital disorders noted in prepubertal and adolescent girls is shown in Table 3. The specific diagnosis is based on a detailed history, genital examination, recto-abdominal examination, vaginoscopy, and laboratory evaluation of vaginal contents, including microscopic and microbiological testing looking for bacterial, viral, parasitic, and helminthic causes. In the medical history, the clinicians should pay attention to the begining of the disorder, its course, and any possible connection to other disorders the patient may also have.^[12] The most common disorder in children is non-specific vulvovaginitis. The bacteria that can lead to vulvovaginitis include Staphylococci, Streptococci, Enterococci, Proteus, Klebsiella, and others.^[5,7,12]

Management of vulvovaginitis is dependent on the specific etiology and underlying factors.^{[8,9,12,23-29]} Not all infections are caused by only one microbe (despite Koch's postulate: "one microbe—one disease"), and there can be some blurring of clinical features from one cause to another. Foreign bodies as a cause of vulvovaginitis are usually discovered because of foul smell and/or dark bloody discharge from the vagina. Some foreign bodies such as wads of toilet tissues are quite difficult to discover because they cannot be detected by rectal examination or ultrasound.

Methods of transmission of specific urogenital infections do change as puberty occurs. In the sexually active adolescent girl, sexually transmitted infections may occur.^[6,13] This is not the case in a prepubertal child, unless sexual abuse has occurred. Improper hygiene becomes more of a causative factor in children. Table 4 outlines treatment of vulvovaginitis of various causes.^{[8,9,13,14,30-48]}

This article reviews the principles of vaginal microbiocoenosis in prepubertal and adolescent girls. Clinicians can identify states of vaginal health and disease by using important diagnostic tools including vaginal cytology. Lactobacilli are infrequent in the prepubertal girls, but become more abundant in the adolescent girls. This important shift in vaginal biocoenosis is important to prevent the growth of potentially pathogenic flora. Three basic types of vaginal smears are presented in addition to a classification of inflammatory urogenital diseases. Management of common types of vulvovaginitis is also considered.

Competing interest: No benefits in any form have been received or will be received from any commercial party related directly or indirectly to the subject of this article.

Contributors: All authors contributed to the intellectual content and approved the final version.

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