Introduction

Vaginal symptoms suggestive of vaginitis such as vaginal itching, discharge, and dyspareunia are common reasons for women to visit gynecological clinics . In spite of the high prevalence of such complaints, one of three patients will be undiagnosed . Desquamative inflammatory vaginitis (DIV) is an uncommon severe form of chronic purulent vaginitis causing discharge, vestibulo-vaginal irritation, and dyspareunia . It occurs mainly in Caucasians and although diagnosed in a wide age range, its occurrence peaks in perimenopausal women . Diagnosis is based on a detailed medical history, physical examination, and wet mount (office-based microscopy). The symptoms and signs are nonspecific and may require the use of vaginal culture, polymerase chain reaction (PCR), rare use of blood tests (hormone levels), and infrequent histology only to exclude other causes of vaginal inflammation. Unfortunately, such thorough evaluation does not often occur in primary gynecological clinics, and the ability to estimate the true prevalence of DIV in the general population is limited. By contrast, specialized studies in vulvovaginal clinics estimate the incidence of DIV as 0.8–4.3% of referred cases. This incidence likely reflects a referral or accrual bias . The etiology is unknown. There are only 29 published articles in the English literature (as of August 2013) of which seven (24%) are case reports and series and eight (28%) are reviews. The majority of the original studies (10 all together) are mainly retrospective descriptive studies. ( Table 1 ).

History

The term “desquamative inflammatory vaginitis (DIV)” was first introduced in 1965 when Gray and Barnes described six women from a group of 478 consecutive patients with vaginal complaints who had a “reddened” vagina and “numerous pus cells … with oval and round parabasal cells.” Cultures were sent for all six patients and two were positive for Trichomonas vaginalis. The authors concluded that the other four had an “interesting form of vaginitis … seems to represent a clinical entity … and the true nature is not clear.” The definition was refined only 3 years later when Gardner published his milestone case series of eight patients titled “Desquamative inflammatory vaginitis: a newly defined entity.” All eight patients presented with purulent discharge and demonstrated ecchymotic vaginal spotting and desquamation of vaginal walls. A microscopy evaluation of vaginal discharge showed increased inflammatory cells with excess of parabasal cells and lack of lactobacilli. Vaginal pH was universally elevated. Notably, there was poor response to antimicrobial treatment and local estrogens were ineffective. Gardner concluded that this was a rare condition given that only eight of the 3000 vaginitis patients he evaluated in 15 years matched the description . Once DIV was characterized by Gardner, in retrospect it was possible to recognize case reports describing DIV – although calling the condition by a variety of descriptive terms, as was the case published by Scheffey in 1956 (12 years before Gardner). Scheffey described a 50-year-old women with 14 months of copious vaginal discharge with severe inflammation of vagina and increase of inflammatory and parabasal cells. Scheffey called the condition “exudative vaginitis” – this is probably the first case report describing a patient with DIV . Others attribute the earliest description of DIV to Franken’s report in 1956 of a 12-year-old girl with exudative vaginitis who responded well to estrogen, yet as we consider today such a response to treatment excludes the diagnosis of DIV . During the 30 years following Gardner’s publication, there was one letter to the editor addressing Gardner’s publication and one review of DIV describing the case reports presented above including cases of erosive lichen planus and vulvo-vaginal–gingival syndrome . After a gap of four decades from the first case report, a retrospective study of 51 patients diagnosed with DIV based on Gardner’s characteristics was published . The study described the short-term follow-up of 51 women with DIV with successful treatment utilizing topical 2% clindamycin. This suggested a bacterial etiology. This assumption changed 17 years later by the same author . In the last decade, approximately eight new original publications regarding DIV were published, however with only minor contributions to etiology and prognosis .

History

The term “desquamative inflammatory vaginitis (DIV)” was first introduced in 1965 when Gray and Barnes described six women from a group of 478 consecutive patients with vaginal complaints who had a “reddened” vagina and “numerous pus cells … with oval and round parabasal cells.” Cultures were sent for all six patients and two were positive for Trichomonas vaginalis. The authors concluded that the other four had an “interesting form of vaginitis … seems to represent a clinical entity … and the true nature is not clear.” The definition was refined only 3 years later when Gardner published his milestone case series of eight patients titled “Desquamative inflammatory vaginitis: a newly defined entity.” All eight patients presented with purulent discharge and demonstrated ecchymotic vaginal spotting and desquamation of vaginal walls. A microscopy evaluation of vaginal discharge showed increased inflammatory cells with excess of parabasal cells and lack of lactobacilli. Vaginal pH was universally elevated. Notably, there was poor response to antimicrobial treatment and local estrogens were ineffective. Gardner concluded that this was a rare condition given that only eight of the 3000 vaginitis patients he evaluated in 15 years matched the description . Once DIV was characterized by Gardner, in retrospect it was possible to recognize case reports describing DIV – although calling the condition by a variety of descriptive terms, as was the case published by Scheffey in 1956 (12 years before Gardner). Scheffey described a 50-year-old women with 14 months of copious vaginal discharge with severe inflammation of vagina and increase of inflammatory and parabasal cells. Scheffey called the condition “exudative vaginitis” – this is probably the first case report describing a patient with DIV . Others attribute the earliest description of DIV to Franken’s report in 1956 of a 12-year-old girl with exudative vaginitis who responded well to estrogen, yet as we consider today such a response to treatment excludes the diagnosis of DIV . During the 30 years following Gardner’s publication, there was one letter to the editor addressing Gardner’s publication and one review of DIV describing the case reports presented above including cases of erosive lichen planus and vulvo-vaginal–gingival syndrome . After a gap of four decades from the first case report, a retrospective study of 51 patients diagnosed with DIV based on Gardner’s characteristics was published . The study described the short-term follow-up of 51 women with DIV with successful treatment utilizing topical 2% clindamycin. This suggested a bacterial etiology. This assumption changed 17 years later by the same author . In the last decade, approximately eight new original publications regarding DIV were published, however with only minor contributions to etiology and prognosis .

Case definition

Definition

DIV is a clinical syndrome of severe chronic purulent vaginitis. Unfortunately, the case definition is based on symptoms, signs, and laboratory findings that are nonspecific ( Table 2 ). Exclusion of other etiologies causing purulent vaginitis is essential for confirming diagnosis ( Fig. 1 ).

Table 2

Case definition for diagnosing desquamative inflammatory vaginitis.

Symptoms	Discharge, dyspareunia, itching, vaginal discomfort
Signs	purulent vaginitis, vaginal petechiae, colpitis macularis
Wet mount (microscopy)	increase in inflammatory and parabasal cells, abnormal flora
pH	elevated (>4.5)

Case definition of Desquamative inflammatory vaginitis.