Vaginitis emphysematosa
Emphysematous vaginitis is a vaginal condition whereby gas-filled cysts appear on vaginal, vulvar or cervical mucosal surfaces.
The cysts are 1-5mm in diameter, but up to 2cm have been found. Cysts may pop upon examination.
Vaginitis emphysematosa appears to be related to bacterial infections/dysbiosis, with an association has been found with low protective lactobacilli species in vaginal flora. The exact mechanism of action that causes the development of these cysts has not be identified.
Symptoms of emphysematous vaginitis
- Vaginal discharge, may be bloody
- Itching of the vagina or vulva, may worsen across the day
- Inflammation
- Irritation
- Bubbling sensation in the vagina caused by gas release from cysts
- Feeling of vaginal fullness
- Popping noises during manual manipulation, e.g. during sex, masturbation or upon speculum examination
- May have no symptoms, but cysts are found upon examination
What causes emphysematous vaginitis?
The cause is unclear, but this type of vaginitis is associated with pregnancy and conditions that impact the immune system. However, otherwise healthy-appearing women are not excluded and can still develop this condition.
The gas inside the cysts is high in nitrogen and oxygen, with some carbon dioxide, sulfur dioxide and argon.
The cysts are associated with pathogenic bacterial activity inside the mucosal tissue; however, some reports have not found any bacterial growth inside the cysts and another mechanism of action was suggested.
Understanding emphysematous vaginitis
Emphysematous vaginitis was first described by Zweifel in 1877 but has rarely been reported since, with only low hundreds of cases reported from 1960.
Treatment options
Standard medical treatment is likely to include antibiotics (metronidazole), particularly in the presence of Trichomonas vaginalis, Haemophilus vaginalis or Gardenerella vaginalis.
Emphysematous vaginitis may be self-limiting and resolve without treatment.
The case reports show that treating the underlying bacterial infection/dysbiosis resolves this condition without any adverse impacts.
Treating an underlying bacterial infection or dysbiosis may include non-antibiotic treatments that address inflammation and restoration of microbial populations. Addressing underlying compromised immunity appears to be an important treatment element since most case reports show underlying immune deficiency.
Treatment should start with a comprehensive microbiome report to identify problematic species and direct effective treatment. Rebuilding protective lactobacilli species is important, but may not be possible immediately if underlying conditions are not right for the colonisation of these bacteria. Strategies to modify vaginal flora can be found in Killing BV or under practitioner guidance.
Supporting immunity comes in many forms, from ensuring healthy sleep, nutrient stores and intake, managing stress, and supportive treatments such as medicinal mushrooms, which have a measurable impact on the immune system.
A set of blood tests, including a hormone panel, run through a functional medicine lense may be useful. Please ensure practitioner guidance by an experienced naturopath or functional medicine doctor to decipher test results by looking at optimal ranges rather than broad, standard lab ranges.
Other immune-supporting herbal formulations may be incorporated, such as echinacea, chamomile (topically and orally), goldenseal and Euphrasia officinalis (eyebright), to support mucous membrane integrity and the immune system, while offering strong antimicrobial and anti-inflammatory activity.
Diagnosis – notes for practitioners
The cysts tend to occupy the upper two-thirds of the vagina and may appear on the cervix and down to the vaginal introitus and vulva. Emphysematous vaginitis may look like cancerous cancer lesions, so it’s important to consider differential diagnosis.
The Leder​1​ et al paper offers a solid guide to work from.
Imaging will show the gas-filled lesions in the mucosa. A transvaginal ultrasound will show echogenic dots or lines spread uniformly throughout the vaginal wall in sagittal and transverse views.
A vaginal microbiome test can identify bacterial species that may be contributing to the cysts.
The squamous epithelium will appear normal with the cystic spaces in the lamina propria, with acute and chronic inflammatory cells and giant cells typical.
Use imaging, biopsy (if necessary) and clinical presentation to support a diagnosis.
References​1–4​
- 1.Leder R, Paulson E. Vaginitis emphysematosa: CT and review of the literature. AJR Am J Roentgenol. 2001;176(3):623-625. doi:10.2214/ajr.176.3.1760623
- 2.Lima-Silva J, Vieira-Baptista P, Cavaco-Gomes J, Maia T, Beires J. Emphysematous Vaginitis. Journal of Lower Genital Tract Disease. Published online April 2015:e43-e44. doi:10.1097/lgt.0000000000000092
- 3.Akang E, Matiluko A, Omigbodun A, Aghadiuno P. Cervicovaginitis emphysematosa mimicking carcinoma of the cervix: a case report. Afr J Med Med Sci. 1997;26(1-2):99-100. https://www.ncbi.nlm.nih.gov/pubmed/10895244
- 4.Leder RA, Paulson EK. Vaginitis Emphysematosa. American Journal of Roentgenology. Published online March 2001:623-625. doi:10.2214/ajr.176.3.1760623
