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.

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.

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.

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.

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.

Comparison of cefotetan and cefoxitin as prophylaxis in cesarean section.

A study comparing the efficacy of cefotetan versus cefoxitin for prophylaxis in patients undergoing cesarean section was carried out at the University of Iowa. After institutional review, 36 subjects who met the study criteria and agreed to participate were entered into the study; of these, 29 were evaluable for efficacy. Twenty subjects received a single 2 gm dose of cefotetan, and nine subjects received three 2 gm doses each of cefoxitin. Both antibiotics were administered intravenously at the time the umbilical cord was clamped. The subsequent doses of cefoxitin were given intravenously at four and eight hours after the initial dose. Clinical and bacteriologic responses were evaluated; there were no statistically significant differences between the two groups, and both antibiotics provided effective prophylaxis against infection. It appears that cefotetan is a satisfactory antibiotic choice for cesarean section prophylaxis. Further, in this small study it appears that a single dose of cefotetan is as effective as three doses of cefoxitin. This implies that cefotetan would not only decrease administration time and supplies but would decrease the cost to the patient while maintaining very acceptable infection rates.

Qualitative and quantitative changes of the vaginal microbial flora during the menstrual cycle.

Knowledge of the normal vaginal microbial flora is essential in understanding the etiology of female genital tract infections. This study was done to investigate both qualitative and quantitative differences that occur during the menstrual cycle. We studied 34 reproductive age women longitudinally. Quantitative cultures were obtained during menses and following the cessation of menses. A greater variety of organisms were found during menstruation. The effect was not selective with respect to aerobes or anaerobes. The total number of bacteria between the two culture periods did not change significantly.

Clindamycin levels in reproductive tissues.

Clindamycin is widely used in a variety of obstetric and gynecologic infections. Despite in vitro and clinical evidence of activity against anaerobes, genital organ tissue levels resulting from intravenous administration of the drug have not previously been reported. Following a single intravenous infusion of 600 mg of clindamycin phosphate, tissue levels were determined in operative specimens obtained from ten women. Specimens of cervix, uterus, fallopian tube, and ovary were obtained, and mean Clindamycin levels for each site were: cervix, 2.63 micrograms/ml; endometrium, 5.58 micrograms/ml; myometrium, 2.39 micrograms/ml; fallopian tube, 2.96 micrograms/ml; and ovary, 3.74 micrograms/ml. The mean serum level was 6.26 micrograms/ml at the time of uterine artery interruption. The clindamycin concentrations at all sites exceeded the usual therapeutic minimal inhibitory concentration, substantiating the usefulness of clindamycin in obstetric and gynecologic anaerobic infections.

Ultrastructural alterations of term human amnionic epithelium following incubation with group B beta-hemolytic streptococci.

The association between the group B beta-hemolytic streptococcus (GBBHS) and premature labor, premature rupture of the membranes, and chorioamnionitis with intact membranes is well known. However, the mechanisms involved in this association remain unclear. In this study we incubated term chorioamniotic membranes from patients undergoing elective repeat cesarean section in double-armed incubation vessels that isolated the maternal from the fetal surfaces. The GBBHS was placed adjacent to the maternal surface and incubated for 2, 4, 8, 12, and 24 hr. Control membrane specimens from the same patient were incubated under identical conditions for identical time periods but without the presence of GBBHS. Examination of the specimens by transmission electron microscopy revealed progressive nuclear and basement membrane alteration in the study group that was maximal at 12 hr. There was also a progressive decrease in desmosome counts in the study membranes. These in vitro changes support the in vivo association of GBBHS with the aforementioned obstetric complications.

Influence of estrogen and normal flora on vaginal candidiasis in the rat.

The vaginal epithelium of randomly bred albino rats normally does not contain yeast. This study demonstrated that estrogen-primed, castrated rats could be colonized by Candida albicans following intravaginal challenge, whereas rats not treated with estrogen remained resistant to colonization. The bacteriologic conditions of the vagina were also studied in yeast-colonized and non-yeast-colonized rats. No evidence of bacterial interference with yeast colonization was obtained from this study since the vaginal flora of the estrogen-treated, yeast-colonized rats was more abundant and diverse than that of the non-estrogen-treated rats, which were resistant to yeast colonization. Scanning electron microscopy of the vaginal epithelium of yeast-colonized rats showed that C. albicans entered the mycelial phase during colonization of the vagina. It also appeared that the mycelia penetrate the cornified vaginal epithelial cells.

Amniocentesis in the identification of inapparent infection in preterm patients with premature rupture of the membranes.

Twenty-nine preterm patients with premature rupture of the membranes who were not in labor and who did not have clinical chorioamnionitis underwent successful amniocenteses. Nine fluids were positive for bacteria. Subsequent clinical chorioamnionitis and shorter latency periods were more common in these 9 patients than in the 20 with sterile amniotic fluid. Positive fluids were more likely to be obtained from patients tapped within 48 hours of membrane rupture. In most patients with heavy bacterial growth, clinically apparent infection and/or labor soon supervened.

Bacterial attachment to the chorioamniotic membranes.

Intra-amniotic infections are believed to result from bacteria of cervical and vaginal origin which gain access to the amniotic sac. The logical sequence in this process would be bacterial attachment to the maternal surface, followed by migration through the chorioamniotic membranes to the fetal surface. Fresh sterile chorioamniotic membranes were interposed between two arms of specially constructed incubation vessels. Bacteria (Escherichia coli, group B streptococci, or Neisseria gonorrhoeae) were inoculated into the arm (containing a basal salt medium) contiguous with the maternal surface. The arm contiguous with the fetal surface of the membrane contained pseudoamniotic fluid. At intervals up to 24 hours after inoculation, the membranes were removed, washed, fixed in glutaraldehyde, and examined by means of scanning and transmission electron microscopes. The ability of group B streptococci and E. coli to attach to and invade the chorioamniotic membranes was demonstrated by this technique. It appeared that group B streptococci had a greater capacity to attach and invade than did E. coli, whereas N. gonorrhoeae predictably failed to attach.

Endotoxin enhancement as a possible etiology of early-onset group B beta-hemolytic streptococcal sepsis in the newborn.

Group B streptococcal cells, either viable or heat-killed, contain a substance that induced fever in rabbits with maximal responses occurring four hours after intravenous injection. In contrast, supernatant fluids failed to induce significant fever. Group B streptococcal cells also enhanced host susceptibility to lethal shock by endotoxin as much as 40,000-fold. A graph of log streptococcal cell dose used for pretreatment versus log LD50 endotoxin gave a straight line with a slope of approximately -1. Rabbits that received both streptococcal cells and endotoxin showed initial fever followed by hypothermia, labored breathing, watery diarrhea, evidence of vascular collapse, and finally death. Animals that received streptococcal cells or endotoxin alone showed only fevers and mild diarrhea. A possible theory for the cause of death in the neonate infected with group B streptococci is presented.