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Emphysematous vaginitis is a vaginal condition where gas-filled cysts appear on the vaginal, vulvar or cervical mucosal surfaces.
The cysts are 1-5mm in diameter, but ones up to 2cm have been found. They may pop when you or a clinician press on them.1
Vaginitis emphysematosa seems to be tied to bacterial imbalance in the vagina – dysbiosis – such as bacterial vaginosis (BV), with an association found between the cysts and low levels of the protective lactobacilli that should dominate your vaginal flora.
Nobody has pinned down the exact mechanism that makes these cysts form. It is genuinely rare, and many gynaecologists will never see a case.4
Is it your vaginal microbiome?
This is a vulvovaginal condition, so your vaginal microbiome sits right at the centre of it. The cysts keep turning up alongside a disrupted vaginal environment – low protective lactobacilli, and an overgrowth of the bacteria and parasites linked to BV and trichomoniasis.4
When lactobacilli dominate, they keep the vaginal pH low and acidic and hold opportunists in check. When they drop away, the door opens for the organisms most often named alongside emphysematous vaginitis: Trichomonas vaginalis, Gardnerella vaginalis (older papers call it Haemophilus vaginalis) and the mixed community of BV.1
So while the cysts themselves are the headline, the story underneath is usually about vaginal flora that has tipped out of balance. Sorting out that balance is where treatment tends to focus.
Symptoms of emphysematous vaginitis
- Vaginal discharge that may be bloody
- Itching of the vagina or vulva that may worsen across the day
- Inflammation
- Irritation
- A bubbling sensation in the vagina, caused by gas releasing from the cysts
- A feeling of vaginal fullness
- Popping noises during manual movement, e.g. during sex, masturbation or a speculum exam
- Sometimes no symptoms at all – the cysts are simply found during an examination
The discharge, itching and pressure are the usual complaints, and the course is generally mild and benign.2
What causes emphysematous vaginitis?
The cause is unclear, but this type of vaginitis is associated with pregnancy and with conditions that affect the immune system. That said, otherwise healthy-looking people are not off the hook and can still develop it.
The gas inside the cysts is high in nitrogen and oxygen, with some carbon dioxide, sulphur dioxide and argon.1
The cysts are linked with pathogenic bacterial activity inside the mucosal tissue. However, some reports have found no bacterial growth inside the cysts at all, and a different mechanism was suggested – so the picture is not settled.
A quick history
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 where Trichomonas vaginalis, Haemophilus vaginalis or Gardnerella vaginalis are present.
Emphysematous vaginitis may be self-limiting and settle on its own without any treatment.2
The case reports show that treating the underlying bacterial infection or dysbiosis clears the condition without adverse effects.
Treating an underlying infection or dysbiosis can include non-antibiotic approaches that address inflammation and rebuild your microbial populations. Sorting out any compromised immunity matters too, since most case reports show an underlying immune deficiency.
Treatment is best started with a comprehensive microbiome report to identify the problem species and direct effective treatment. Rebuilding protective lactobacilli is important, but it may not be possible straight away if the underlying conditions are not right for these bacteria to settle in.
Strategies to shift your vaginal flora can be worked through in the Killing BV treatment guide or under practitioner guidance.
Supporting immunity comes in many forms – healthy sleep, decent nutrient stores and intake, managing stress, and supportive treatments such as medicinal mushrooms, which have a measurable effect on the immune system.
A set of blood tests, including a hormone panel, read through a functional medicine lens may be useful. Do get practitioner guidance from an experienced naturopath or functional medicine doctor to interpret results against optimal ranges rather than broad, standard lab ranges.
Other immune-supporting herbs may be worked in, such as echinacea, chamomile (topically and orally), goldenseal and Euphrasia officinalis (eyebright), to support mucous membrane integrity and the immune system while offering 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 can look like cancerous lesions, so it is worth working through a differential diagnosis and an appropriate workup.3
The Leder1 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 through the vaginal wall in sagittal and transverse views.
A vaginal microbiome test can identify the bacterial species that may be contributing to the cysts.
The squamous epithelium will appear normal, with the cystic spaces sitting in the lamina propria, and acute and chronic inflammatory cells plus giant cells are typical.
Use imaging, biopsy (if necessary) and clinical presentation to support a diagnosis.
Frequently asked questions
Is emphysematous vaginitis dangerous?
No – it is benign and does not signal a life-threatening infection or tissue death, despite the alarming-sounding gas.1 It often clears on its own, and where treatment is needed it is aimed at the underlying vaginal imbalance rather than the cysts themselves. The main reason to get it checked is that it can mimic more serious lesions on examination, so a proper look and workup matter.3
Why does my vagina make popping or bubbling sounds?
Popping and bubbling can have plenty of ordinary explanations, including air moving in and out during sex or exercise. With emphysematous vaginitis, the noise comes from gas escaping the little cysts when they are pressed – during sex, masturbation or a speculum exam. If popping comes with itching, unusual or bloody discharge, or a feeling of fullness, that is worth having looked at, since it points towards a disrupted vaginal microbiome that would benefit from testing and treatment.
Will it come back after treatment?
Because the cysts travel with vaginal dysbiosis, keeping your flora in good shape is the best insurance against a repeat. That means clearing any BV or trichomonas, rebuilding protective lactobacilli, and supporting your immune system – especially if pregnancy or a run-down immune system was part of the picture the first time round.
This article is for general information and is not a substitute for individual medical advice. Emphysematous vaginitis is rare and can look like more serious conditions, so please see a doctor or experienced practitioner for diagnosis and treatment tailored to you.
References
- Leder RA, Paulson EK. Vaginitis emphysematosa: CT and review of the literature. AJR Am J Roentgenol. 2001;176(3):623-625.
- Lima-Silva J, Vieira-Baptista P, Cavaco-Gomes J, Maia T, Beires J. Emphysematous vaginitis. J Low Genit Tract Dis. 2015;19(2):e43-e44.
- Akang EE, Matiluko AA, Omigbodun AO, Aghadiuno PU. Cervicovaginitis emphysematosa mimicking carcinoma of the cervix: a case report. Afr J Med Med Sci. 1997;26(1-2):99-100.
- Al Aboud K, Al Hawsawi K, Ramesh V. Vaginitis emphysematosa. Sex Transm Infect. 2002;78(2):155.
