The demographic and clinical profiles of women presenting with vaginal discharge syndrome at primary care facilities in South Africa: Associations with age and implications for management

Background. Current South African guidelines for the management of vaginal discharge syndrome (VDS) do not recommend treatment for sexually transmitted infection (STI) pathogens for women aged ≥35 years whose partners do not have male urethritis syndrome. The guideline assumes that older women are unlikely to have an STI and that their partners do not have asymptomatic infections.Objectives. To describe the demographic, behavioural and clinical characteristics of women with VDS, comparing older women (≥35 years) with younger women, and to determine the performance of age alone as a criterion for predicting the presence of STI.Methods. This was a cross-sectional study at seven primary healthcare centres taking part in the aetiological surveillance of STIs between January 2015 and December 2016. Eligible women presenting with VDS were enrolled and completed a nurse-administered questionnaire. Genital swabs and blood specimens were collected for laboratory testing. Data were entered into surveillance-specific databases and exported into Stata 14 for analysis. Descriptive statistics were used to compare demographic and clinical profiles of older with younger women. A receiver operator curve (ROC) was used to determine the age cut-off that would best differentiate between women who had infection with STI pathogens and those without.Results. Of 757 women enrolled, 157 (20.7%) were aged ≥35 years. HIV positivity was 46.6%, and higher in older than younger women (54.9% v. 44.5%; p=0.02). Of those enrolled, 283 (37.4%) had bacterial vaginosis (BV) and/or Candida infection only, 232 (30.7%) had BV or Candida with STI pathogens detected, 98 (13%) were infected with STI pathogens only, and 144 (19.0%) did not have any detectable STI or non-STI causes. Although older women were less likely than younger women to have Neisseria gonorrhoeae, Chlamydia trachomatis or Mycoplasma genitalium infection (23.6% v. 38.2%; p<0.01), the burden in older women was not negligible. The area under the ROC for age was 57.5% (95% confidence interval 53.2 - 61.8%), which implies suboptimal performance.Conclusions. Although older women with VDS were less likely than younger women to have STIs, a significant proportion of them did have an infection with STI pathogens. Age alone was not a good criterion for discriminating between women with and without infection with STI pathogens. Other ways of improving the VDS algorithm performance are needed, as is better integration of HIV and STI prevention and treatment

Corrimentos vaginais em gestantes: comparacao da abordagem sindromica com exames da pratica clinica da enfermagem / Flujo vaginal en gestantes: comparacion entre el abordaje sindromico y las pruebas en la practica clinica de enfermeria / Vaginal discharge in pregnant women: comparison between syndromic approach and examination of clinical nursing practice

Estudo avaliativo de abordagem quantitativa, com amostra de 104 gestantes, com o objetivo de comparar os achados de infecções vaginais em gestantes obtidos por meio do fluxograma de corrimento vaginal com exames presentes na prática clínica da Enfermagem. Os dados foram coletados por meio de entrevista e exame ginecológico realizados de janeiro a julho de 2011. O fluxograma não se mostrou eficaz na identificação de candidíase e tricomoníase, apresentou baixa sensibilidade (0,0%; 50%) e valor preditivo positivo (0,0%; 3,6%) para as duas infecções e baixa especificidade para tricomoníase (46%). Mostrou-se satisfatório para vaginose bacteriana, com alta sensibilidade (100%), valor preditivo negativo (100%) e acurácia (74%). Conclui-se que o emprego do fluxograma precisa ser reavaliado, visto que não foi eficaz em identificar infecções importantes em gestantes. Os esforços para o desenvolvimento de testes eficazes devem ser contínuos, com intuito de prevenir a disseminação de infecções e reduzir tratamentos desnecessários.

Estudio evaluativo con enfoque cuantitativo, con una muestra de 104 gestantes, cuyo objetivo fue comparar los resultados de infecciones vaginales en las gestantes, obtenidos a partir del diagrama de flujo vaginal y las pruebas presentes en la práctica clínica de enfermería. Los datos fueron recolectados por entrevista y examen ginecológico, realizados de enero a julio del 2011. El diagrama de flujo no fue eficaz en la identificación de candidiasis y tricomoniasis, presentando baja sensibilidad (0,0%; 50%) y valor predictivo positivo (0,0%; 3,6%), para las dos infecciones y baja especificidad para tricomoniasis (46%). Para vaginosis bacteriana, se mostró satisfactoria, con alta sensibilidad (100%), valor predictivo negativo (100%) y precisión (74%). Se concluye que el uso del diagrama necesita ser revisado, ya que no fue eficaz en la identificación de infecciones importantes en las gestantes. Los esfuerzos para desarrollar pruebas efectivas deben ser continuos, con el objetivo de prevenir la propagación de infecciones y reducir tratamientos innecesarios.

This is a study for assessment of a quantitative approach in pregnant women (N=104), in which findings of vaginal infection were compared. The findings were obtained by two means, flowchart of vaginal discharge, and typical examinations in the clinical nursing practice. Data were collected from January to July 2011 through interviews and gynecological examinations. The flowchart showed no efficacy to identify candidiasis and trichomoniasis. Furthermore, it showed low sensitivity (0.0%; 50%) and positive predictive value (0.0%; 3.6%) for both infections, and low specificity for trichomoniasis (46%). The flowchart was shown to be satisfactory for bacterial vaginosis, with high sensitivity (100%), negative predictive value (100%), and accuracy (74%). We conclude that use of the flowchart should be reassessed, as it was not able to identify important infections in pregnant women. A continuous effort must be directed for development of effective tests in order to prevent the spread of infection and reduce the number of unnecessary treatments.

Prevalência e fatores associados à percepção de ocorrência de corrimento vaginal patológico entre gestantes / Prevalence of self-reported vaginal discharge and associated factors in pregnant women

Este estudo teve por objetivo medir a prevalência e identificar fatores associados à percepção de corrimento vaginal patológico por gestantes residentes em Rio Grande, Rio Grande do Sul, Brasil. Aplicou-se questionário padronizado a todas as parturientes nas maternidades do município em 2007. Utilizou-se teste do qui-quadrado para comparar proporções e análise multivariável por regressão de Poisson. A prevalência de corrimento vaginal foi de 40 por cento. Análise ajustada mostrou as seguintes razões de prevalência: 1,6 (1,4-1,8) para adolescentes; 1,3 (1,1-1,6) para aquelas com até oito anos de escolaridade; 1,3 (1,1-1,5) para aquelas que ingeriram álcool; 2,0 (1,8-2,2) para aquelas que referiram corrimento vaginal em gestação anterior; 1,4 (1,3-1,6) para infecção urinária na gestação atual; prematuridade em gestação anterior mostrou-se protetor com RP = 0,8 (0,7-0,9). Os serviços de saúde deveriam priorizar diagnóstico e tratamento de corrimento vaginal entre gestantes adolescentes, de baixa renda familiar e escolaridade, com história prévia de corrimento em gravidez anterior e infecção urinária na gravidez atual.

This study aims to determine the prevalence self-reported abnormal vaginal discharge and to identify associated risk factors in pregnant women in the municipality of Rio Grande, Rio Grande do Sul State, Brazil. A standardized questionnaire was applied to all pregnant women admitted for delivery in local maternity hospitals. The chi-square test was used to compare proportions, and Poisson regression was applied using multivariate analysis. Prevalence of vaginal discharge was 40 percent. Adjusted analysis showed the following prevalence ratios for vaginal discharge: 1.6 (1.4-1.8) for adolescents; 1.3 (1.1-1.6) for 8 years of schooling or less; 1.3 (1.1-1.5) for alcohol consumption; 2.0 (1.8-2.2) for vaginal discharge in the previous pregnancy; 1.4 (1.3-1.6) for urinary tract infection in the current pregnancy; and 0.8 (0.7-0.9) for history of prematurity. Local health services should target adolescent women, those with low schooling or low family income, and those with a history of vaginal discharge in the previous pregnancy or urinary tract infection in the current pregnancy.

Evaluation of adjunctive tests for cervical cancer screening in low resource settings.

BACKGROUND: Visual inspection of cervix after application of acetic acid (VIA) is an effective screening tool for cervical cancer in low resource settings, but its low specificity leads to high referral rates. Adjunctive testing may overcome this drawback. AIMS: This pilot study was aimed to assess test performances of VIA, human papillomavirus (HPV) testing and Pap smear, individually and in simulated combinations, to determine the probable best screening option. SETTING AND DESIGN: Gynecology outpatient department (OPD); cross-sectional study. MATERIALS AND METHODS: One hundred women with complaints of irregular vaginal bleeding or discharge, post coital bleeding or unhealthy cervix on examination underwent Pap smear, HPV testing, VIA, colposcopy and biopsy, if indicated, in this screening order. STATISTICAL ANALYSIS: Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each of the tests with a biopsy result of > or =HSIL taken as the gold standard. Simulated parallel and sequential combinations for VIA/Pap, VIA/HPV and HPV/Pap were calculated and compared with individual test performance. RESULTS: Prevalence of abnormal Pap smears was 5%, VIA positive 51% and HPV positive 16%. Sensitivity and specificity of VIA were 100% and 53.3% respectively. For HPV and Pap tests corresponding figures were 85.7%, 89.7% and 50%, 98.9% respectively. The best simulated combination with a balance of sensitivity and specificity was of VIA followed by HPV testing (sensitivity 85.7%, specificity 95.4%). CONCLUSION: Addition of HPV testing to VIA can increase the specificity of VIA, thereby reducing the referral rates without compromising the sensitivity of the test.

Program issues in delivering targeted STI services through the public sector in the Greater Mekong region.

This review discusses the delivery of targeted STI services for both female sex workers (FSWs) and other high-risk groups through the public sector in the Greater Mekong region. Vaginal discharge algorithms for the general population are also discussed. High STI rates that justify targeted interventions have been reported recently amongst FSW in Cambodia, Lao PDR and Vietnam. Such interventions need to take into account the different patterns of sex work in the three countries. In Cambodia, there are large numbers of brothel-based FSWs although this pattern is changing as more brothels are closed by the authorities. In Lao PDR, services targeted towards reducing the burden of HIV/STI in FSW/service women are probably best delivered through NGO-led clinics. In Vietnam, commune based district health centers appear to offer better services for FSW than STI clinics. Male clients of FSW are an important group to target, but reaching such a heterogeneous population is difficult. Provision of quality STI drugs to those places where men present with STI symptoms should be a priority. The optimal way to manage STIs in FSWs is still unclear in this region. Clinical and laboratory specialists are keen to promote laboratory tests for STIs but there is an over reliance on direct staining techniques. In areas with high STI prevalences, periodic presumptive treatment could offer an effective option to reduce STI levels in high-risk groups until syndromic management algorithms are evaluated for local use. Social patterns of sex work are changing continually and require close monitoring in the future so that services can be adapted to these changes.

Syndromic management of vaginal discharge and pelvic inflammatory disease among women in a rural community of Haryana, India: agreement of symptoms enquiry with clinical diagnosis.

World Health Organisation (1984) advocated syndromic approach for management of reproductive tract infections/sexually transmitted diseases. Some investigators have cautioned against using this approach to diagnose and treat vaginal discharge and pelvic inflammatory disease. The prevalence of RTIs in rural areas of Haryana is high and availability of per-speculum examination facility is scarce. The scope for laboratory diagnosis of RTI in rural areas is remote in near future. A community-based study was conducted to assess the agreement of symptoms enquiry with the syndromic diagnosis of RTIs/STDs (based upon per speculum examination). A total of 812 women were interviewed by ANMs and were examined by a lady doctor. History based ANM's diagnosis was found to be having high sensitivity (80.5%) and high positive predictive value (81.3%). However it had low specificity (48.6%) and low negative predictive value (47.5%) compared to clinical diagnosis. Level of agreement was found to be fair (Kappa = 0.28, 95% CI = 0.20-0.36). The chances of over treatment for vaginal discharge and pelvic inflammatory disease were only 16% and 15% respectively. However, history based syndromic protocols need revision. Proposed protocol is discussed in this paper.

Visual inspection for cervical cancer screening: evaluation by doctor versus paramedical worker.

BACKGROUND: In the absence of an effective cervical cancer screening programme, efforts are being made to explore the feasibility of using the existing infrastructure to develop effective low-cost screening methods. AIMS: To evaluate and compare test performance of visual inspection of the cervix by a doctor and a paramedical worker. SETTING AND DESIGN: Gynaecology outpatient department (OPD), All India Institute of Medical Sciences, New Delhi; cross-sectional study. MATERIAL AND METHODS: One hundred women with complaints of vaginal discharge, irregular bleeding, post coital bleeding or unhealthy cervix underwent visual inspection with acetic acid (VIA) and Lugol's iodine (VILI) by a doctor and nurse, followed by colposcopy and biopsy. STATISTICAL ANALYSIS USED: Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each test and compared. Concordance was determined by kappa statistics. RESULTS: VIA by nurse had a higher sensitivity (100% versus 87.5%), but lower specificity (53% versus 63%) when compared with the doctor, but it was not statistically significant. There was moderate agreement between their VIA findings (kappa=0.56). VILI findings were comparable to that of the VIA, both by the doctor and nurse. There was almost perfect agreement (kappa=0.89) between VILI by the doctor and nurse. CONCLUSION: Visual inspection can be performed reliably by trained paramedical workers and doctors and is an effective screening option in low resource settings.

clinical study on Sailan-ur-Reham [vaginl discharge]. A review

Sailan-ur-Reham is a well-known ailment. It is well described by various eminent Unani physicians. Vaginal discharge is a symptom of many diseases, like vaginitis, cervicitis, cervical erosion, endometritis, gonorrhoea etc. Any discharge which passes through vagina and is abnormal in amount, consistency, composition and character is considered as vaginal discharge. According to Tibb-e-Unani a number of drugs are prescribed for the patients either locally or orally. The vaginal discharge is discussed in this paper according to the Unani Tibb as well as modern medicine