Psychosexual aspects of vulvar vestibulitis.

OBJECTIVE: To explore the psychological, interpersonal and sexual correlates of vulvar vestibulitis via qualitative and quantitative analysis. STUDY DESIGN: Sixty-nine women diagnosed with vestibulitis were recruited from a vulvar/vaginal disease clinic to complete a comprehensive quantitative and qualitative questionnaire designed to assess general health concerns, mental health, sexual functioning and interpersonal relationships. RESULTS: The majority of participants reported drastic changes in sexuality associated with the onset of vestibulitis. Upon developing vestibulitis, 88% reported decreased interest in sexual activity, 87% indicated that they were less willing to participate in sexual activity, and 94% maintained that they were less able to participate in sexual activity. High levels of frustration and symptoms of depression also were frequently reported. CONCLUSION: Vulvar vestibulitis is associated with significant changes in sexuality, intimate relationships and psychological well-being. When treating women with vestibulitis, medical professionals should consider the psychological and sexual aspects of the disease in addition to physical concerns.

Psychological and sexual functioning in women with vulvar vestibulitis.

OBJECTIVE: The purpose of the study was to compare psychological and sexual functioning in women with vestibulitis with healthy controls. It was hypothesized that women with vestibulitis would experience greater psychological stress and sexual dissatisfaction than controls. STUDY DESIGN: Fifty-two women with vestibulitis recruited from a vulvovaginal disease clinic and 46 healthy controls recruited from an outpatient gynecology clinic completed five standardized measures of psychological and sexual functioning. Multivariate analyses of variance and covariance were used to examine group differences. RESULTS: Women with vestibulitis reported significantly higher scores than controls on the measures of depression (p < or = 0.001), psychological distress (p < or = 0.001) and sexual depression (p < or = 0.001). They reported significantly lower scores on the measures of sexual satisfaction (p < or = 0.001), sexual behavior (p < or = 0.001) and sexual self-esteem (p < or = 0.01). CONCLUSION: The results of this study highlight the importance of addressing psychological distress and sexual dissatisfaction in women with vestibulitis.

Metronidazole for bacterial vaginosis. A comparison of vaginal gel vs. oral therapy.

OBJECTIVE: To compare the efficacy and safety of 0.75% metronidazole vaginal gel with oral metronidazole for the treatment of bacterial vaginosis (BV). STUDY DESIGN: Nonpregnant women with BV were enrolled in a multicenter, randomized, investigator-blind treatment trial. Patients were randomly assigned to either 0.75% metronidazole vaginal gel (5 g twice daily for five days) or oral metronidazole (500 mg twice daily for seven days). Follow-up visits occurred approximately two and five weeks after initiation of therapy. RESULTS: BV was clinically eliminated at the first follow-up visit in 83.7% (36/43, 95% CI 72.3-95.1%) of the intravaginal group and 85.1% (40/47, 95% CI 74.6-95.6%) of the oral group. At the final visit, BV was eliminated in 70.7% (29/41, 95% CI 56.3-85.1%) of the intravaginal group and 71.1% (32/45, 95% CI 57.4-84.8%) of the oral group. Significantly more patients in the oral treatment group (51.8%) reported gastrointestinal complaints as compared to the intravaginal treatment group (32.7%, P = .04). CONCLUSION: The efficacy of 0.75% metronidazole vaginal gel twice daily for five days in treating BV was similar to that of standard oral metronidazole treatment and was associated with fewer gastrointestinal complaints.

Natural killer cell function in women with vestibulitis.

OBJECTIVE: To assess natural killer (NK) cell activity in patients with vestibulitis. STUDY DESIGN: Twenty-two patients who met the International Society for the Study of Vulvar Disease criteria for vestibulitis and 17 age-, sex- and race-matched controls were recruited. NK cell activity was examined using a standard, four-hour 51Cr-release assay, freshly and after stimulation with interleukin 2 (IL2) or alpha interferon (IFN alpha). RESULTS: The subject samples had significantly decreased fresh NK cell activity (mean lytic units [LU]/10(6) peripheral blood leukocytes [PBLs] of 0.93 vs. 4.19, P < .001). This activity was augmented in response to either IFN or IL2. However, it remained significantly lower than in the control samples (12.07 vs. 20.6 LU/10(6) PBL, P = .007 for IL2 and 5.98 vs. 15.33 LU/10(6) PBL, P < .001 for IFN). This difference was not universal since the major histocompatibility-nonrestricted T killer cell activity of the subject samples was not significantly different from that in the control samples. CONCLUSION: This pilot study suggests that patients with vulvar vestibulitis have markedly decreased NK cell activity. Although this activity is increased in response to IL2 or IFN, it remains significantly impaired in comparison to the control samples.

Comparative study of intravaginal metronidazole and triple-sulfa therapy for bacterial vaginosis.

OBJECTIVE: We sought to compare the efficacy of metronidazole gel vs. triple-sulfa cream in the treatment of bacterial vaginosis (BV). METHODS: In a double-blinded study, 247 women with symptomatic BV were randomly assigned to receive either 5 g of 0.75% metronidazole gel twice daily for 5 days or triple-sulfa cream twice daily for 5 days. There were 205 (96 treated with metronidazole and 109 treated with triple-sulfa) evaluable patients to compare efficacy at the final visit. Approximately 60% of these patients had been previously treated for BV, reflecting the recurrent nature of the disease in this patient population. RESULTS: At the first (12-16 days) return visit, 81/103 (79%) patients in the metronidazole group were cured compared with 80/113 (71%) patients in the triple-sulfa cream group (P = 0.333). At the final (28-35 days) return visit, 63/96 (66%) in the 96 metronidazole group remained cured compared with only 51/109 (47%) in the triple-sulfa group (P = 0.02). An intent-to-treat analysis similarly showed that the cure rate with metronidazole was superior to triple-sulfa (P < or = 0.02). The clinical diagnosis demonstrated a high correlation (88%) with the diagnosis made by an independent assessment by Gram's stain. The side effects reported by the patients using metronidazole gel were infrequent and mild and were similar to those reported with triple-sulfa. CONCLUSIONS: Metronidazole gel is a safe, effective, and well-tolerated treatment for BV.

Colonizing populations of Candida albicans are clonal in origin but undergo microevolution through C1 fragment reorganization as demonstrated by DNA fingerprinting and C1 sequencing.

The genetic homogeneity of nine commensal and infecting populations of Candida albicans has been assessed by fingerprinting multiple isolates from each population by Southern blot hybridization first with the Ca3 probe and then with the 0.98-kb C1 fragment of the Ca3 probe. The isolates from each population were highly related, demonstrating the clonal origin of each population, but each population contained minor variants, demonstrating microevolution. Variation in each case was limited to bands of the Ca3 fingerprint pattern which hybridized with the 0.98-kb C1 fragment. The C1 fragment was therefore sequenced and demonstrated to contain an RPS repetitive element. The C1 fragment also contained part or all of a true end of the RPS element. These results, therefore, demonstrate that most colonizing C. albicans populations in nonimmuno-suppressed patients are clonal, that microevolution can be detected in every colonizing population by C1 hybridization, and that C1 contains the repeat RPS element.

Evolution and replacement of Candida albicans strains during recurrent vaginitis demonstrated by DNA fingerprinting.

Southern blot hybridization with the Ca3 probe and the C fragment of the Ca3 probe was used to assess the genetic relatedness of Candida albicans strains from one patient with recurrent C. albicans infection in whom the same strain was maintained, one patient in whom the infecting strain was replaced, and their male sexual partners. In the patient in whom the infecting strain was maintained, the infecting strain exhibited a minor genetic change in each successive episode of Candida vaginitis. These genetic changes occurred in the C-fragment bands of the Ca3 hybridization pattern. In the patient in whom the infecting strain was replaced by another infecting strain, a transition infection involved a genetically mixed infecting population, and the replacement strain appeared to have originated from the oral cavity of the male partner. The results demonstrate that the infecting strains of recurrent Candida vaginitis are not genetically stable, that drug treatment can result in the selection of variants of the previously infecting strain or replacement by a genetically unrelated strain, and that the male partner can be the source of a replacement strain.

Genetic dissimilarity of commensal strains of Candida spp. carried in different anatomical locations of the same healthy women.

Candida spp. carriage and strain relatedness were assessed in 52 healthy women at 17 anatomical locations by using an isolation procedure which assesses carriage intensity and by using a computer-assisted DNA fingerprinting system which computes genetic similarity between strains on the basis of the patterns of Southern blots probed with the moderately repetitive sequence Ca3. Candida spp. were cultured from 73% of the test individuals, most frequently from the oral (56%), vulvovaginal (40%), and anorectal (24%) regions. Half of the test individuals with Candida spp. carried the organism simultaneously in more than one of the three general areas of carriage. Isolates from different body locations of the same individual were either completely unrelated, identical, or highly similar but nonidentical. In 11 cases in which Candida spp. were simultaneously isolated from the oral cavity and vaginal canal, seven pairs of isolates were genetically unrelated and four pairs were similar but nonidentical. In the latter cases, the isolate pairs each appear to have arisen by genetic divergence from a single progenitor. A comparison of the genetic relatedness of isolates from different individuals further uncovered a single strain which was vaginospecific in the Iowa City, Iowa area and reduced genetic diversity among vulvovaginal strains compared with those isolated from other body locations. These results suggest that strains adapt to different anatomical locations and, conversely, that in a healthy individual there is anatomical selection of vaginotropic, anotropic and orotropic strains of Candida spp.

The challenge of prophylaxis in cesarean section in the 1990s.

Physicians have evaluated the role of antibiotics in the prevention of perioperative infections since these drugs were discovered, but not until it was determined that antibiotics prevented staphylococcal wound infections in the animal model did surgeons consider their use for prophylaxis. In the 1970s, improved techniques in isolating and identifying anaerobic microorganisms and the unacceptably high incidence of infection-related complications convinced obstetricians to study, and ultimately accept, the use of perioperative antibiotic administration to prevent these infections. Recent progress has included refinement of the guidelines for patient selection and drug regimens. Although a single dose of an antibiotic given to the patient undergoing primary cesarean section has been demonstrated to be effective prophylaxis when administered after clamping the umbilical cord, this practice has not been widely accepted. With the discovery of cephamycins the role of these broad-spectrum antibiotics in obstetric and gynecologic surgery was investigated. One of the studies compared the efficacy of cefmetazole with that of cefotetan in preventing post-cesarean section infection. Eighteen patients in each group received a 2-g dose of one of the two drugs when the umbilical cord was clamped. Predetermined elevations in temperature were used to evaluate the presence of ensuing infections. Four subjects in each group developed some type of morbidity. Postoperative complications included wound infection, endometritis, bladder infection and cellulitis. Cefmetazole and cefotetan seemed equally effective in preventing post-cesarean section infections.

Persistent vaginitis caused by metronidazole-resistant trichomonas.

Persistent trichomonal vaginitis is usually considered the result of either patient noncompliance with therapy or reinfection. Drug-resistant trichomoniasis may also cause continued infection despite repeated courses of conventional metronidazole therapy. We report two cases of exceptionally persistent and prolonged infection despite repetitive and varied treatments, including parenteral metronidazole. An unconventional approach combining oral and topical therapy resulted in clinical and microbiologic cure in both cases.

Methanogenic bacteria in human vaginal samples.

Twelve vaginal samples were collected from separate patients, processed anaerobically, and added to methanogenic enrichment medium. Methanogenic activity was detected in two samples, both of which were from patients with bacterial vaginosis. None of the samples from healthy patients yielded positive methanogen cultures. One sample from a patient with bacterial vaginosis did not show any detectable methanogenic activity. Two methanogen isolates were obtained from one of the methanogen-positive samples, and both were identified as Methanobrevibacter smithii on the basis of morphological, cultural, and immunological features.

Comparison of single-dose cefmetazole and cefotetan prophylaxis in women undergoing primary caesarean section.

The efficacies of a single 2 g intra-operative iv dose of cefmetazole or cefotetan in women undergoing non-elective Caesarean section were compared. Thirty-six women (18 in each group) completed the double-blind protocol. Both antibiotics were equally effective as agents for prophylaxis of post-Caesarean infections. Combined data suggest that routine multi-dose antibiotic prophylaxis regimens could be replaced by a single dose regimen.

Switching of Candida albicans during successive episodes of recurrent vaginitis.

Strain relatedness and switching were monitored in Candida albicans strains isolated from different body locations through three episodes of recurrent vulvovaginal candidiasis separated by two treatment-latency periods in a single patient. Strain relatedness was assessed by comparing Southern blot hybridization patterns with the relatively immobile mid-repeat sequence Ca3. The following conclusions are demonstrated. (i) Three different strains of C. albicans colonized the mouth, the area under the breasts, and the vulvovaginal, anal, and rectal regions, respectively, at the time of the first infection. (ii) The same strain of C. albicans was responsible for the three vaginal infections. (iii) Switching of colony phenotype occurred with each new vaginal infection. (iv) Enrichment of drug-resistant switch phenotypes (assessed in vitro) was unlikely the basis for the changes in the switch phenotypes of the strain found in the vulvovaginal, anal, and rectal areas after treatment of the first infection with clotrimazole. (v) The same strain of C. albicans was responsible for the recurrent increases in mouth colonization and was distinct from the recurrent vaginal strain. The results of this case study demonstrate the need for further detailed analyses of full-body mycofloras, strain relatedness, switching repertoires, and changes in drug susceptibility during successive episodes of recurrent vulvovaginal candidiasis.

Results of a multicenter comparative study of single-dose cefotetan and multiple-dose cefoxitin as prophylaxis in patients undergoing cesarean section.

A study to compare the prophylactic efficacy of a single 2 g dose of cefotetan with multiple 2 g doses of cefoxitin in reducing the incidence of postcesarean section infection was evaluated in a multicenter trial of 269 women. No significant differences in clinical or bacteriologic response were detected between the two groups. A successful clinical response rate was achieved in 139 of 162 of the evaluable subjects given cefotetan (86 percent) and in 71 of 79 patients (90 percent) given cefoxitin. The respective satisfactory bacteriologic response rates were 91 percent (135 of 148 patients) and 93 percent (68 of 73 patients). The incidences of endometritis for cefotetan and cefoxitin (12 percent and 5 percent, respectively) and of postoperative wound infection (3 percent and 5 percent, respectively) were also not significantly different. Bactericidal levels of cefotetan were maintained in plasma in the immediate postpartum period. Both drugs were well tolerated. Single-dose prophylaxis with cefotetan was comparable to multiple doses of cefoxitin in reducing infectious morbidity in women undergoing cesarean section.

Vaginal colonization by bacteria and yeast.

A number of different factors have been found to influence the microflora of the vagina. Studies showing an increased rate of colonization associated with pregnancy, menses, oral contraceptive use, and estrogen replacement therapy illustrate the influence of hormones, glycogen content, and pH on vaginal colonization. The microorganisms found in the vagina may also be dependent on the existence of specific attachment sites, which may differ in the various areas of the vagina. Vaginal colonization appears to be altered in patients with diabetes mellitus, those receiving steroid therapy, and immunosuppressed individuals. Surgical manipulation of the vagina and the use of broad-spectrum antibiotics may also contribute to the growth of organisms in the vaginal tract.

Comparison of cefotetan and cefoxitin prophylaxis for abdominal and vaginal hysterectomy.

The safety and efficacy of parenteral prophylaxis with either cefotetan or cefoxitin were evaluated in a prospective, randomized study of 355 subjects undergoing abdominal or vaginal hysterectomy. Each subject received either a single 1 gm dose of cefotetan intravenously 30 to 60 minutes before operation or three 2 gm doses of cefoxitin, the first 30 to 60 minutes before operation and subsequent doses 6 and 12 hours later. Prophylaxis was successful in 69 of 70 (98.6%) receiving cefotetan and 32 of 33 (97.0%) receiving cefoxitin who underwent vaginal hysterectomy. Prophylaxis was successful in 160 of 169 (94.7%) receiving cefotetan and in 79 of 83 (95.2%) receiving cefoxitin who underwent abdominal hysterectomy. Both drugs were well tolerated and without serious side effects or complications. On the basis of these findings, we conclude that a single 1 gm dose of cefotetan given before operation is as safe and effective as a multiple-dosing regimen of cefoxitin in subjects undergoing vaginal hysterectomy and in those undergoing abdominal hysterectomy at institutions where prophylaxis is indicated.

High-frequency switching in Candida strains isolated from vaginitis patients.

High-frequency switching and strain variability at the site of infection was assessed in 11 patients with acute Candida albicans vaginitis. By cloning cells directly from the site of infection, it was demonstrated that 4 of the 11 isolates contained multiple-switch phenotypes at the site of infection and that 9 of the 11 isolates were in a high-frequency mode of switching (10(-2) to 10(-3)). Isolates could be separated into four general categories of switching repertoires. To demonstrate that multiple phenotypes at the site of a single infection represented the same strain, EcoRI digests of total cell DNA were separated on agarose gels, and Southern hybridization patterns with two cloned midrepeat sequences were compared.

Changing concepts in obstetric antibiotic prophylaxis.

The evolution of antibiotic prophylaxis in cesarean section is traced from the discovery of sulfa compounds in the 1940s to the present. Prolonged courses of antibiotics, initiated before the surgical incision, have given way to shorter, three-dose and even single-dose regimens administered after clamping of the umbilical cord. Several factors have been proposed to help identify patients at greatest risk of infection. Guidelines for antibiotic prophylaxis are reviewed. The effects of antibiotics on host flora are described, and the implications of bacterial resistance for selection of a prophylactic agent, particularly with respect to induction of the Richmond-Sykes type I beta-lactamase enzyme, are discussed.

Trimethylamine: the substance mainly responsible for the fishy odor often associated with bacterial vaginosis.

The vaginal discharge of women with bacterial vaginosis often has a prominent fishy odor. Intensification of this fishy odor by the addition of strong base to the vaginal discharge suggests that it could be due to trimethylamine, the substance responsible for the characteristic odor of spoiling fish. Samples were collected from 11 women with a vaginal discharge having a fishy odor and from 10 women with no detectable odor. Gas chromatographic analysis of headspace samples of alkalinized vaginal discharges indicated the presence of trimethylamine in all 11 samples with the fishy odor but not in the other samples. The chemical identity of trimethylamine was confirmed by gas chromatography-mass spectrometry of headspace samples from two vaginal discharge samples. It is concluded that trimethylamine is the primary cause of the fishy odor associated with bacterial vaginosis.

Aztreonam concentrations in human tissues obtained during thoracic and gynecologic surgery.

The concentrations of aztreonam in human tissues obtained during surgery were measured after a single 2-g intravenous dose. The average concentration in the skeletal muscle, atrial appendage, lung, sternum, pericardial fluid, endometrium, myometrium, fallopian tube, and ovary varied from 3 to 33 micrograms/g (or microgram/ml). These concentrations significantly exceed the MIC for 90% of strains for most members of the family Enterobacteriaceae.