Further observations, mainly serological, on a cohort of women with or without pelvic inflammatory disease.

An analysis was undertaken of data pertaining to over 100 women with lower abdominal pain who were laparoscoped. Prior to laparoscopy, 11 of the women were considered to almost certainly have salpingitis, of whom six (55%) had salpingitis at laparoscopy; 17 to probably have salpingitis, of whom six (35%) did; 28 to possibly have salpingitis, of whom five (18%) did; and 56 to be very unlikely to have salpingitis, of whom five (9%) did. Of the 22 women who had salpingitis at laparoscopy, 14 (64%) had a Chlamydia trachomatis IgG antibody titre of >or=1:128 and might reasonably be regarded as having chlamydial disease on this basis; six without such a titre probably did not have chlamydial disease as C. trachomatis could not be detected at any genital site. At laparoscopy, 18 women had adhesions without obvious tubal inflammation; clinically, 15 of them had been regarded as possibly having salpingitis or unlikely to have it, with 12 having chronic pelvic pain. Twelve (67%) of the 18 women had a chlamydial IgG antibody titre of >or=1:128. IgM antibody was also detected most often in the 'salpingitis' group. Of 49 women without any abnormality detected at laparoscopy, nine (18%) had a high chlamydial IgG antibody titre. Overall, a woman who had a high titre of chlamydial IgG antibody and acute pelvic pain, together with a clinical picture of pelvic inflammation, was more likely to have salpingitis than adhesions alone. Likewise, a woman who had a high titre of chlamydial IgG antibody and chronic pelvic pain, together with a clinical picture suggesting that salpingitis was unlikely, was more likely to have adhesions alone than acute chlamydial salpingitis. However, while antibody measurement and seeking cervical C. trachomatis may help in formulating a diagnosis, there seems no simple way of detecting the small proportion of women who are infected by C. trachomatis in the upper genital tract but whose laparoscopic findings indicate normality. So far as patient care is concerned, the only way of preventing damage to the upper genital tract is to treat early on the basis of suspicion.

The role of the nurse in screening asymptomatic male and female patients in a sexual health clinic.

We allocated 278 patients, who said they were asymptomatic and agreed to be randomized to a nurse or doctor clinic, to appointments using a random number system. In all, 35 patients did not attend and 16 were excluded because they did not meet the entry criteria. We used a screening protocol which excluded microscopy from the immediate assessment of patients. The outcome measures were completeness of documentation, proportion of patients accepting HIV tests, infections detected and patient satisfaction. Overall, 3% of items were not completed by doctors and 6% by nurses. HIV tests were carried out on 65% of patients who saw a doctor and 52% who saw a nurse. Thirteen infections were detected by doctors and 27 by nurses. No new cases of gonorrhoea, syphilis or HIV infection were identified. Eighty-eight patients completed a questionnaire after their attendance. Almost all patients were very satisfied with the service and most were prepared to see a nurse on a subsequent visit. We concluded that there are few differences between the performance of doctors and nurses in routine screening of asymptomatic patients.

Audit of HIV partner notification in a district general hospital.

We evaluated partner notification for HIV in a district general hospital over a two-year period. The majority of current partners were notified and 60% were found to be HIV-positive. No previous partners were successfully notified. We make recommendations intended to improve the rate of notification and testing.

The acceptability of the introduction of a type specific herpes antibody screening test into a genitourinary medicine clinic in the United Kingdom.

OBJECTIVE: To determine the uptake of a type specific herpes simplex antibody test if it were offered as part of routine screening in a genitourinary medicine clinic in a district general hospital in the United Kingdom. METHODS: Stage 1. A series of 207 consecutive new attenders and 205 patients who had attended the clinic previously were given written information about the test and asked whether they would want to have the test if it were available. They were asked whether they would wish to discuss it further with a counsellor before making a decision. Stage 2. Another series of 434 consecutive patients were offered the test after reading an information leaflet detailing the advantages and disadvantages of being tested. They were also offered the opportunity to see a counsellor for further information. RESULTS: In stage 1 of the study, 51% of men and 54% of women said they would want the test if it were available. 32% of men and 40% of women requested counselling. In stage 2, when the test was offered, 41% of men and 37% of women chose to have it, and 23% of men and 7% of women requested further information from the counsellor. 20 patients were herpes simplex virus type 2 (HSV-2) positive-four of whom would have been diagnosed on clinical grounds at the time of presentation. A further 12 men and 20 women excluded themselves from the study because they were known to have genital herpes. Therefore, type specific serology contributed 30% to total diagnoses in this population-16 out of a population of 52 would have remained undiagnosed without having had the test. CONCLUSION: In this population, the uptake of the type specific herpes simplex antibody test was much less than expected and screening was of limited benefit in identifying large numbers of previously unrecognised HSV-2 positive patients.

Managing the very young patient: a conflict between the requirements of the Children Act and the VD regulations?

We describe the case of a 12 year old girl who presented requesting screening for sexually transmitted infections and discuss a conflict between concerns of clinicians to maintain confidentiality and concerns of social workers to investigate the possibility of sexual abuse.

Response to treatment in dysaesthetic vulvodynia.

Thirty-three women (mean age 45 years) attending a vulval pain clinic based in a department of genitourinary medicine were followed-up for a minimum of 6 months. All women had dysaesthetic vulvodynia and 11 (33%) also had features compatible with vulval vestibulitis. Thirty-two patients were treated with a tricyclic antidepressant drug and a complete response was recorded in 47%. Only four patients obtained less than 50% improvement in their symptoms. Treatment with tricyclic drugs was part of a package of interventions including intensive support and the opportunity to take up counselling. Under these circumstances, it is difficult to attribute the success of treatment to the effect of the medication alone and there is a need for well-designed randomised controlled trials to evaluate this and other therapeutic approaches.

Clinical uses of herpes simplex virus type-specific serology.

Type-specific serological tests to distinguish between infection with herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2) have largely been used for studies which have contributed to our knowledge of the epidemiology and natural history of these infections. Such tests could be used as diagnostic tools in clinical situations provided that clinician and patient are aware of the test characteristics, which may result in false negative and false positive results. The use of serological tests in the screening of populations or sub-populations, such as pregnant women, has been advocated to attempt to halt the worldwide spread of the infection. However, there is little evidence currently to support this strategy.

Encouraging HIV testing in GUM clinics--can we dispense with the pre-test discussion? Genitourinary Medicine.

In a genitourinary medicine (GUM) clinic on the periphery of the London conurbation, HIV testing was promoted during a one-month period by offering testing without preliminary pre-test discussion to patients who assessed themselves to be low risk. The testing rate rose from 5.9% to 10.8% in women and 12.6% to 20% in men. One new HIV-positive patient was identified.

Pemphigus vulgaris localized to the vagina presenting as chronic vaginal discharge.

Involvement in pemphigus vulgaris of the female genital tract including the vulva, vagina and cervix has previously been described. In all these cases other cutaneous and mucosal sites have also been affected at some time. We describe a case of pemphigus vulgaris which only involved the vaginal mucosa. The patient presented with a persistent vaginal discharge and examination showed extensive vaginal erosions. Histology of vaginal biopsies was non-diagnostic. The recognition that the vaginal changes may represent an immunobullous disease led to further vaginal biopsies on which direct immunofluorescence studies were performed. These biopsies showed IgG and C3 in the intercellular epidermis, suggesting a diagnosis of pemphigus vulgaris. During the 3-year period that the patient has been under review there have never been any other cutaneous or mucosal lesions. To our knowledge, this is the first case of pemphigus vulgaris localized exclusively to the vaginal mucosa. There was considerable delay in diagnosis and this case highlights how important it is to recognize that chronic mucosal lesions at genital sites may be caused by immunobullous diseases such as cicatricial pemphigoid and pemphigus, and to institute appropriate investigations.

A pilot study of the use of a low oxalate diet in the treatment of vulval vestibulitis.

Thirty-one women with vulval vestibulitis were evaluated for evidence of abnormal dietary oxalate intake and a wide range of dietary intakes was recorded. No woman was found to have abnormal urinary excretion. Sixteen women agreed to undertake a low oxalate diet and there was an apparent response in six (37%).

Role of type specific herpes simplex virus serology in the diagnosis and management of genital herpes.

OBJECTIVES: To investigate the indications for the use of a type specific antibody test for herpes simplex virus in a department of genitourinary medicine in the United Kingdom. METHOD: Retrospective analysis of case records of 127 patients who accepted the test during a 20 month period. RESULTS/CONCLUSION: The test contributed to patient management in 79% of patients with recurrent genital ulceration of unknown cause. It was also useful for counselling a number of patients with initial episodes of disease and the asymptomatic partners of some patients when the partners were shown to possess antibodies specific to herpes simplex virus type 2. When evaluating sexual partners, the test was difficult to interpret if an isolate from the index case had not been typed. Access to viral typing may therefore be a greater priority than serological testing. As adverse psychological sequelae may follow the identification of an asymptomatic chronic infection, guidelines for the use of a type specific serological test are proposed.

A comparison of PCR with virus isolation and direct antigen detection for diagnosis and typing of genital herpes.

Patients attending the genitourinary medicine clinic at Watford General Hospital, UK, were examined for clinical signs of genital herpes infection. Genital swabs were taken from 194 patients (126 female, 68 male) who presented with genital ulceration or symptoms which were suggestive of genital herpes infection. Swabs from these patients were tested by three methods: (i) Detection of herpes simplex virus (HSV) antigen by direct HSV enzyme immunoassay (EIA), (ii) HSV isolation in Vero cell culture and (iii) HSV polymerase chain reaction (PCR). HSV was detected in 76 patients (39%) by EIA, in 93 (48%) by isolation in cell culture, and in 115 (59%) by PCR. Isolation by cell culture has been considered as the "gold standard" for the detection of HSV in genital lesions, but in this study HSV PCR was significantly more sensitive. Comparison of the three methods was as follows: Cell culture vs. PCR: Sensitivity 93/115 (80.9%), Specificity 79/79 (100%). HSV EIA vs. PCR: Sensitivity 75/115 (65.2%), Specificity 78/79 (98.7%). HSV EIA vs. Cell culture: Sensitivity 75/93 (80.7%), Specificity 100/101 (99%). EIA was less effective in detecting HSV among recurrent than among first episode infections, in comparison to culture or HSV PCR. This is the first comparison of HSV PCR with two other routine diagnostic methods for confirming genital herpes infection in a symptomatic population. The infecting HSV type was identified by restriction digestion of 108 HSV amplicons: HSV-1:37/108 (34%), HSV-2:71/108 (66%). In this population HSV-1 causes a significant proportion of genital herpes cases, and HSV-1 genital infection was detected in significantly more first episode infections (40.3%) than among recurrent infections (22.2%).

Clinical aspects of pelvic inflammatory disease.

Pelvic inflammatory disease (PID) is a common and poorly managed condition. Untreated or inadequately treated, it leads to tubal infertility, ectopic pregnancy and chronic pelvic pain. Diagnostic difficulties are compounded by the wide variety of clinical presentations and the insensitivity and poor specificity of laboratory tests. Better recognition of mild and atypical disease needs a high index of suspicion whenever young, sexually active women present with gynaecological symptoms. Laparoscopy supplemented by microbiological tests and fimbrial minibiopsy should be regarded as the diagnostic 'gold standard' for research studies; new studies are required to identify techniques which might reduce under- and over-diagnosis. Early treatment reduces the risk of an adverse effect on fertility. Any therapeutic regimen selected should be effective against the common aetiological agents Chlamydia trachomatis, Neisseria gonorrhoeae, genital mycoplasmas and aerobic and anaerobic bacteria. Since at least 60% of cases of PID can be attributed to infection with a sexually transmitted organism, partner notification forms an essential part of management.

Asymptomatic shedding of herpes simplex virus from the genital tract: uncertainty and its consequences for patient management. The Herpes Simplex Virus Advisory Panel.

A frequent component of the management of patients with genital herpes concerns the possibility of asymptomatic shedding and potential sexual transmission of the virus. Approaches intended to provide supportive counselling and reassurance of patients about these issues need now to be modified in the light of increasing data of the frequency of asymptomatic detection of virus and the effects of antiviral therapy on this phenomenon. Further studies to delineate the relationship between asymptomatic detection of HSV in the genital tract and the mechanism of sexual transmission of this virus need to be conducted before clinicians instigate antiviral suppressive treatment primarily to prevent sexual transmission of HSV. However, it is important that the new data and our greater understanding of the natural history of genital herpes is translated into accurate and comprehensible information for our patients.

Infrequent detection of Chlamydia trachomatis in a longitudinal study of women with treated cervical infection.

OBJECTIVE: To determine how often Chlamydia trachomatis cervical infections are detected in women following completion of a currently recommended treatment regimen and the reason for recurrence. METHODS: A longitudinal follow-up study of 43 initially C trachomatis-positive women for periods of up to two years. RESULTS: C trachomatis was detected in three women, 19, 16 and about four months, respectively after completion of treatment. All specimens from the other 40 women which were taken during visits two to seven, that is periods of three to 700 days after treatment, were chlamydia-negative. CONCLUSION: Although C trachomatis is usually eradicated from the genital tract by conventional treatment, occasionally it may be found again. It is difficult to determine whether detection after treatment is due to persistence or reinfection and further studies are required.

Abdominal pain in women attending a genitourinary medicine clinic: who has PID?

Eighty-one women who presented to a genitourinary medicine clinic with mild to moderate acute or chronic abdominal pain were studied in order to compare the clinical features of those who had pelvic inflammatory disease (PID) and those who did not. The diagnosis was made by laparoscopy, and PID was detected in 14%, adhesions in 11% and endometriosis in 16%. Women with PID were clinically indistinguishable from women with other diagnoses or no obvious cause.