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Original Report |
1 Both authors: Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.
Received July 31, 2000;
accepted after revision September 6, 2000.
Address correspondence to E. K. Paulson.
Abstract
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CONCLUSION. Vaginitis emphysematosa is characterized by gas-filled cysts in the vaginal wall, in a pattern similar to pneumatosis of the intestines or bladder. This bacterial vaginitis is benign and self-limited and does not signify the presence of tissue necrosis or life-threatening infection.
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Patient 1 was a 29-year-old woman with newly diagnosed acute myelogenous leukemia and vaginal bleeding. A CT scan was performed to examine a pelvic and right lower quadrant mass noted on physical examination. Patient 2 was a 62-year-old woman with postmenopausal bleeding who had an extensive medical history that included diabetes mellitus and endstage renal disease requiring hemodialysis. CT was performed to examine possible abscess. Patient 3 was a 25-year-old woman with a medical history of systemic lupus erythematosis, pelvic inflammatory disease, and chronic vaginitis. Her CT was performed after a motor vehicle collision in which she sustained a liver laceration and femoral neck fracture. Patient 4, a 42-year-old woman with a history of end-stage renal disease treated with peritoneal dialysis, chronic obstructive pulmonary disease treated with steroids, and hypertension, underwent CT to examine abdominal pain and diarrhea.
All patients were seen by a gynecologist after the CT findings of vaginitis emphysematosa were reported. All patients had symptoms of vaginitis, including vaginal pruritis, irritation, and discharge. In one patient, pelvic examination revealed multiple crepitant bullae, 0.5-1.0 cm in size, along the vaginal wall. In three patients, wet preparations were positive for T. vaginalis. In one patient the wet preparation of the vaginal discharge was negative for T. vaginalis but showed numerous leukocytes and bacteria. Culture of the vaginal discharge in this patient was negative for Neisseria gonorrhea. In two patients, Papanicolaou's smears of the cervical mucosa showed nonspecific evidence of inflammation. All patients were considered to have vaginitis emphysematosa based on a combination of the clinical presentation and pelvic examination and CT findings. All patients were treated with metronidazole.
Abdominal and pelvic CT scans were obtained using a GE 9800 scanner (General Electric Medical Systems, Milwaukee, WI). All patients received oral contrast material, and three received an IV contrast injection of 150 mL Iopamidol 300 (Bracco Diagnostics, Princeton, NJ) using a power injector (Medrad, Pittsburgh, PA). Dynamic incremental scanning technique was used. Collimation and incrementation of the pelvis were 10 mm at 10-mm increments in two patients, 10 mm at 15-mm increments in one patient, and 7 mm at 7-mm increments in one patient. No vaginal tampons were inserted before scanning. Repeated images of the pelvis at the level of the vagina were obtained in two patients.
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All patients were treated with metronidazole. In three patients, there was resolution of pruritis and irritation and cessation of the vaginal discharge at 7, 9, and 14 days after the CT scans were obtained (and therapy was begun). One patient had no documented clinical follow-up. One patient had an abdominal radiograph performed 4 days after CT that showed persistent vaginitis emphysematosa. One patient had an abdominal radiograph performed 7 days after CT that showed no obvious vaginitis emphysematosa. One patient had a repeated CT scan 3 months later that showed resolution of the vaginitis emphysematosa.
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The cystic lesions are based in the mucosa of the vagina and exocervix and are usually found in the upper two thirds of the vagina [9, 10]. Interestingly two of our patients had cysts extending to the introitus, and one had tiny cysts extending into the labial folds. Lesions are discrete, tense, and smooth, ranging from microscopic to as large as 2 cm in diameter. These gas-filled lesions may produce a popping sound when ruptured during a vaginal examination or sexual intercourse [1, 4, 8]. Histologic findings of vaginitis emphysematosa include an intact squamous epithelium containing cystic spaces in the lamina propria with acute and chronic inflammatory cells including giant cells [3,4,5].
There have been several hypotheses regarding the origin of the gas-filled cysts. One hypothesis suggests an infection caused by gas-forming organisms trapped in mucosal folds or occluded glands as the cause [10]. Indeed, such a microbial mechanism would allow continuous gas production and maintenance of these lesions. In fact, T. vaginalis is capable of producing gaseous substances [7]. Yet, special stains of vaginal tissue fail to show bacteria in the cysts or vaginal wall and argue against this hypothesis [4]. One postulate is that the gas-filled cysts originate from extravasation of blood into the interstitial tissues of the vagina; when the blood coagulates, gas is released. The mechanical theory of air forced into the cervical and vaginal tissue seems unlikely [10]. Whether the cysts originate from any of these processes remains largely unresolved. Nevertheless, analysis of gas collected from the cysts has revealed a high percentage of nitrogen with smaller percentages of oxygen, argon, carbon dioxide, and sulfur dioxide [1].
Conditions associated with vaginitis emphysematosa include diseases that impair the immune response such as alcoholism, corticosteroid therapy, and penetrating abdominal wounds [6, 7]. Indeed, all our patients had an underlying condition known to affect the immune response. Vaginitis emphysematosa may also be found during pregnancy; in fact, some cases have been discovered incidentally during X-ray pelvimetry [1, 2, 9,10,11]. During pregnancy, immunologic alterations occur that are believed to increase the susceptibility to vaginitis emphysematosa.
The radiologic appearance of vaginitis emphysematosa includes multiple discrete or confluent gas-filled cysts in the vaginal wall ranging in size from 2 mm to 2 cm [8,9,10,11]. The cysts create an appearance similar to that of pneumatosis in the gastrointestinal tract. In the superior aspect of the vagina, a rounded defect in the gas pattern may be caused by the swollen cervix projecting into the vagina [8]. Although we believe the identification of gas confined to the vaginal wall is characteristic and diagnostic of vaginitis emphysematosa, it is possible that the CT appearance could be mistaken for emphysematous cystitis, pneumatosis cystoides intestinalis, gas gangrene of the uterus, or rectal gas. Careful attention to the anatomic location of the gas should prevent a misdiagnosis of these conditions. Furthermore, emphysematous cystitis usually occurs in diabetic patients, and pneumatosis intestinalis usually does not involve the rectum. Gas gangrene of the uterus is typically associated with septic abortion, and such patients are extremely ill. The CT appearance could also be confused with a pelvic or perirectal abscess caused by a gas-forming organism. Such confusion could be avoided by recognizing that the gas is located in the vaginal wall and by failing to identify a fluid collection. Finally, benign intraluminal vaginal gas or a gas-containing vaginal tampon could mimic vaginitis emphysematosa. However, in these scenarios, gas is located in the lumen of the vagina rather than in the vaginal wall.
It is important for radiologists to recognize CT findings of gas isolated to the vaginal wall as a benign self-limited condition termed "vaginitis emphysematosa." The condition does not signify the presence of tissue necrosis or a life-threatening infection caused by a gas-forming organism.
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