Vulvitis: Predisposing Factors, Clinical Manifestations, Diagnosis, and Treatment
Vulvitis refers to vulvar inflammation affecting the labia, clitoris, mons pubis, and vestibule of the vagina. Clinical manifestations, diagnosis, and treatment.
Syphilitic Vaginitis: Symptoms, Diagnosis, Treatment
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Syphilis is a systemic disease in humans caused by Treponema pallidum. Syphilitic vaginitis is a manifestation of early primary genital syphilis.
Incubation period: 10-90 days between infection and chancre appearance.
Clinical presentation
Upon a pelvic speculum examination, a single superficial chancre is revealed, typically painless; its base is clear, and the discharges are transparent. A chancre may be associated with regional lymphadenopathy. Atypical chancres may appear multiple, painful, deep, and indistinguishable from a herpetic ulcer. Any anogenital ulcer is to be considered syphilitic until proven otherwise.
Diagnosis of syphilitic vaginitis
To confirm syphilitic vaginitis, direct and indirect (serological) diagnostic methods are used.
1. Direct methods (detection of the pathogen)
These methods aim to detect Treponema pallidum in lesion samples:
- Dark field microscopy refers to a visualization of motile treponemes in chancre or erosion exudate.
- Molecular tests (PCR) are used to detect T. pallidum DNA in tissues or discharges.
- Immunohistochemistry (less commonly used) is provided to detect treponemes in mucosal biopsy specimens using antibodies.
Direct methods are most effective in the early stages (primary syphilis) when serological tests may still be negative.
2. Serological diagnosis (main method)
To confirm syphilis, it is mandatory to use two types of tests:
| Test type | Method examples | Description |
|---|---|---|
| Non-treponemal (screening) | Venereal Disease Research Laboratory (VDRL), Rapid Plasma Reagin (RPR), Toluidine Red Unheated Serum Test (TRUST), Unheated Serum Reagins (USR) | They help to detect anti-lipid antibodies, appearing 1–4 weeks after chancre formation. Results can be false positive (with autoimmune diseases, pregnancy, etc.) |
| Treponemal (confirmatory) | Enzyme-Linked Immunosorbent Assay (ELISA), Treponema Pallidum Hemagglutination Assay (TPHA), Direct Immunofluorescence (DIF), Immunoblot, Chemiluminescent Immunoassay (CLIA), and Treponema Pallidum Immobilization (TPI) test | Help to detect specific antibodies to T. pallidum. Results remain positive even after treatment |
Note:
- Only the combination of two tests (non-treponemal + treponemal) allows an accurate diagnosis.
- Using only one type of test may lead to:
- False negative results (in the early stage).
- False positive results (due to cross-reactions or a history of syphilis).
Treatmentof syphilitic vaginitis
Penicillin G
Parenteral penicillin G is the preferred agent for treating patients at all syphilis stages. The initial dose for adults and adolescents with early syphilis, according to the WHO Guidelines for the management of sexually transmitted infection (STIs), is benzathine benzylpenicillin 2.4 million units administered intramuscularly once.
The medication, its dosage, and the duration of therapy may vary according to the stage of disease and clinical presentation. To achieve a therapeutic effect, it is necessary to ensure a treponemicidal level of antimicrobials in the serum.
Characteristics of treponemicidal concentration:
| Parameter | Value |
|---|---|
| Minimal treponemicidal level | > 0.018 mg/L |
| Effective concentration in vitro | 0.36 mg/L |
| Recommended therapy duration | At least 7-10 days |
Longer treatment is necessary for chronic infection, especially in late stages of syphilis. This is due to the slower division of treponemes, which reduces the efficacy of short courses and increases the risk of relapses.
Alternatives for patients with penicillin allergy
- Desensitization to penicillin followed by first-line therapy.
- Alternative medications:
- Ceftriaxone;
- Doxycycline (oral).
Treatment monitoring
To observe disease progression and assess treatment effect, VDRL or RPR quantitative serological tests are used. The quantitative titer must be documented on the first day of treatment as a baseline level.
Recommended follow-up schedule:
- 1 month after the start of therapy;
- 3 months later;
- Then every 6 months.
It is important to use the same test in the same laboratory for result comparability. Follow-up continues until the test result becomes negative or a stable low titer is achieved (1:1–1:4 over 1 year in the absence of re-infection risk).
Patients with persistently high titers should be monitored long-term.
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Treatment of syphilitic vaginitis in pregnancy
In pregnant women with untreated early syphilis, the risk of intrauterine fetal infection is 70–100%. Up to one-third of cases may result in stillbirth.
Fetal infection most often occurs late in pregnancy (after 28 weeks). Treatment before this term usually prevents complications in the fetus.
Parenteral penicillin G is the only medication proven effective in treating syphilis during pregnancy.
FAQ
1. How does syphilitic vaginitis differ from other STIs?
Syphilitic vaginitis is caused by Treponema pallidum and presents with a painless ulcer (chancre) with a clean base. Unlike herpes, the ulcer in syphilis is usually single, without evident inflammation, and is associated with regional lymphadenopathy.
2. Can a syphilitic chancre cause pain?
Yes, in some cases, the chancre may be atypical: multiple, painful, and deep. Such forms are difficult to differentiate from herpetic lesions, requiring laboratory diagnosis.
3. Why is the combination of two serological tests important in diagnosis?
Non-treponemal tests can be false negatives at the early stage or false positives in other conditions (pregnancy or autoimmune diseases). Treponemal tests confirm the presence of specific antibodies but do not differentiate a past infection from the present one. Using both tests increases diagnostic accuracy.
4. Can syphilis be treated during pregnancy?
Yes, and it is necessary. Penicillin G is the only medication with proven effectiveness in the treatment of syphilis during pregnancy. Timely treatment reduces the risk of intrauterine infection and stillbirth.
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