Vaginal microbiological flora, and behavioural and clinical findings in women with vulvar pain.

OBJECTIVE: To study genital symptoms and signs in women with vulvar pain, and the association with potential risk factors such as microbiological agents, sexual behaviour and genital hygiene. DESIGN: Prospective cohort study of apparently healthy women attending for contraceptive advice. SETTING: Two family planning clinics and one youth clinic in Sweden. POPULATION: Out of 996 women recruited, 79 women (7.9%) had, on request, complaints of current burning and smarting vulvar pain and/or superficial dyspareunia (our definition of vulvar pain) while 917 women without such symptoms served as controls. RESULTS: Complaints of dysmenorrhoea, vaginal discharge, genito-anal pruritus, dysuria, and abdominal pain were more frequent in the study group, than in the control group. In the women with vulvar pain, erythemas, superficial ulcerations, and fissures were found significantly more frequently. Vaginal candidosis was the only current genital infection that occurred more often in the study group, than among the controls. There were no differences in the history of gonorrhoea, genital chlamydial infection, genital herpes, genital warts, and candidosis between the two groups. The sexual debut of the women with vulvar pain occurred later in life, compared with the control group. Control subjects were more likely to use tampons for menstrual sanitation, than the women with vulvar pain. CONCLUSIONS: Neither infectious conditions caused by current known agents, with the exception of candidosis in some cases, nor behavioural factors, such as sexual behaviour and genital hygiene habits could in this study explain vulvar pain.

Symptoms and signs in single and mixed genital infections.

OBJECTIVE: To compare symptoms and signs in women with single and mixed genital infections. METHODS: The study population comprised 996 apparently healthy women. Gynecological symptoms and signs were looked for and diagnostics for the most prevalent gynecological infections were made. RESULTS: When co-infections were excluded, chlamydial infections, bacterial vaginosis and cervical human papillomavirus infections were associated with a fishy malodor; for the two former conditions an easily bleeding ectopy was also found. Vaginal candidosis showed characteristic symptoms and signs. Genital warts were associated with dysuria, general and lower abdominal pain. Out of 494 women with a genital infection, 112 (22.7%) had a mixed infection, which in some cases influenced symptoms and signs. CONCLUSION: Many women who consider themselves gynecologically healthy, may nevertheless harbor one or more infectious agents. The need to exclude multiple infections is obvious. Positive predictive values were for specific symptoms and signs were generally low.

History, clinical findings, sexual behavior and hygiene habits in women with and without recurrent episodes of urinary symptoms.

BACKGROUND: To compare women with and without a history of recurrent symptoms suggestive of a urinary tract infection but a current negative urine culture regarding symptoms and signs of a genital infection, carriership of sexually transmitted agents and vaginal flora changes, sexual behavior and genital hygiene practice. SETTINGS: Contraceptive attendees at family planning and youth clinics. MATERIALS AND METHODS: Two hundred and seventeen women who reported recurrent symptoms of dysuria, frequent micturition, and urgency and had a negative bacterial urine culture were recruited as cases. Seven hundred and ten culture-negative women lacking such symptoms served as controls. A careful record was made including details about gynecological symptoms, sexual behavior and genital hygiene practice. Gynecological signs were noted at gynecological examination. Genital infections, including sexually transmitted diseases, were diagnosed. RESULTS: The mean age of the two groups studied was 26.2 and 25.8 years, respectively. Symptoms, such as dysmenorrhea, vaginal discharge, genital pruritus, abdominal pain and superficial dyspareunia were more frequent in the study group than among the controls. On examination, only erythema was observed more often. However, the cases more often had a history of genital herpes and vulvovaginal candidosis. They used tampons only for menstrual purposes, and soap for genital hygiene, but more often used low-pH solutions and took hot baths less frequently. The women with recurrent urinary symptoms more often masturbated and more often had experience of anal sex and sex during menstruation than the control group. CONCLUSIONS: Sexual behavior and genital hygiene habits may play an etiological role in the lives of women with recurrent episodes of urinary symptoms with a negative bacterial urine culture.

Clinical manifestations and diagnosis of bacterial vaginosis in a clinic of sexually transmitted diseases.

BACKGROUND: The aim of the present study was to evaluate the prevalence of bacterial vaginosis (BV) and correlate it with the data from the patient history and clinical manifestations in women attending an STD clinic and to compare two methods of diagnosis. MATERIAL AND METHODS: On hundred and fifty-six women, aged 15 to 45, attending the STD clinic of the Higher Medical Institute in Plovdiv, Bulgaria were enrolled in the study. All women were evaluated for the presence of BV using standard criteria and Gram stain of vaginal secretions. Symptoms, clinical manifestations, methods of contraception and sexual life and smoking were analyzed. RESULTS: Using clinical criteria and Gram's stain, BV was diagnosed in 59 women (37.8%). BV was associated with age younger than 25 years, risk sexual behaviour, e.g. lack of a permanent sexual partner during the preceding 6 months, use of an intrauterine device, other STDs and smoking. Symptoms are not a reliable way of diagnosing BV, but the presence of a homogeneous vaginal discharge on examination, a positive amine test and pH > or = 4.7 are common in BV. A negative correlation was found between the number of lactobacilli and BV. CONCLUSIONS: BV is common in women attending STD clinic and is associated with other STDs, e.g. infection with Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, human papilloma virus. The Gram stain method is inexpensive and easy to perform for the laboratory diagnosis of BV; it can be used reliably as an indicator of the changes preceding BV.

Prevalence, epidemiological and clinical correlates of genital Chlamydia trachomatis infection.

OBJECTIVE: To evaluate the prevalence of genital infection with Chlamydia trachomatis in different groups of patients in the region of Plovdiv, Bulgaria, over a period of four years (1992-1995) and to establish epidemiological and clinical correlates of infection. MATERIAL AND METHODS: Five groups were enrolled in the study: group A-990 symptomatic male sexually transmitted disease (STD) patients, group B-1023 symptomatic female STD patients, group C-253 gynaecological patients, and asymptomatic groups D-276 men and group E-231 women. Urethral samples from men and cervical and urethral samples from women were examined for C. trachomatis antigen by direct immunofluorescence assay (DFA) or enzyme immunoassay (EIA) confirmed by DFA at the STD outpatient clinic of the Medical Institute in Plovdiv. RESULTS: The prevalence rates for genital infection with Chlamydia trachomatis were 25.1% in group A, 21.8% in group B, 15.4% in group C, 4.3% in group D and 6.1% in group E. Infection with C. trachomatis was more common in patients who were < or = 25 years of age, unmarried, and with risk sexual behaviour, as well as in those who had signs and symptoms suggestive of infection. CONCLUSION: The study shows a relatively high prevalence of infection with C. trachomatis in STD and gynaecological patients. Symptoms and signs correlated with C. trachomatis infection, but were not specific or reliable indicators of infection. C. trachomatis detection should be included in standard STD and gynaecological examination.

Gynaecological and microbiological findings in women attending for a general health check-up.

Two hundred apparently healthy sexually active women, 17-34 years of age, who had presented for a general health check-up at the Clinic of Dermatology and Venereology, Medical University, Plovdiv, Bulgaria, were asked about genital symptoms, sexual behaviour, contraceptive use and smoking habits, and examined for signs of genital infections. They were searched for genital chlamydial infection, gonorrhoea, trichomoniasis, bacterial vaginosis (BV) and vulvovaginal candidosis, syphilis and HIV. Polymerase chain reaction (PCR) was used for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in urine samples and the results were compared with direct immunofluorescence (DFA) and enzyme immunoassays (EIA) for C. trachomatis in urethral, cervical and urine samples. In 56 (28%) women, an STD and/or an STD-related condition were diagnosed. The prevalence of genital chlamydial infection, trichomoniasis, BV and vulvovaginal candidosis was 4.5%, 0.5%, 17.5% and 7.5% respectively. On direct questioning 39 (19.5%) women reported symptoms suggestive of an infection, while 58 (29%) had signs that may have been caused by genital infection. In urine the PCR tests detected more (3.5%) chlamydia-positive women than the DFA (2.5%) and EIA tests (1.5%). The urine PCR test was as sensitive as the DFA when testing cervical samples. The chlamydia-positive women and women with BV were less likely to have a steady partner than the controls. No woman had syphilis or HIV infection. The women with BV were more frequent users of an intrauterine device and were more likely to smoke heavily compared with other women. STDs and STD-related conditions are common among adult women who consider themselves gynaecologically healthy. Screening for genital infections among women in reproductive age attending for health check-up could improve women's reproductive health.

Demographic data on prostitutes from Bulgaria--a recruitment country for international (migratory) prostitutes.

The study was aimed at investigating the conditions and circumstances for the recruitment of prostitutes, as well as their reproductive history, working conditions, knowledge of and attitudes to sexually transmitted diseases (STDs), and use of prophylactic antibiotic therapy of these diseases. Two hundred prostitutes were investigated by in-depth interviews at STD clinics, private practices and hotels. Of the 200 prostitutes, 8 (4%) were less than 15 years old and 32 (16%) more than 25 years old. Most of the women came from rural villages. Half of them were gypsies. Most had a boyfriend (often the pimp). One-quarter had been or were on their way abroad to prostitute. Half were migrating within Bulgaria to prostitute. They claimed a high rate of condom use with customers, but seldom with their pimps or boyfriends. About one-tenth used antibiotics prophylactically. They had knowledge of classical STDs and HIV/AIDS but only in exceptional cases had they heard about chlamydial and human papillomavirus infections. They often cohabited with a female friend also often practising prostitution. It was concluded that recruitment is often easy as the prostitute can earn more from only one contact with a customer than their parents earn from work in a month. Symptoms suggestive of STD were very common in the prostitutes, i.e. in 43%. Bulgaria is a recruitment area for international prostitutes.

Detection of Chlamydia trachomatis in first-void urine from men and women as an alternative to swabs.

BACKGROUND: Ideally, an effective preventive strategy for the control of Chlamydia trachomatis infection should take into account the following attributes: rapid and simple specimen collection, low cost and noninvasive test processing. Therefore, we compared the performance profile of urine-based detection of C. trachomatis antigen in first-void urine with that of testing urethral and endocervical samples in men and women. MATERIAL AND METHODS: Urethral and endocervical samples and first-void urine from 285 men and 192 women attending the Sexually Transmitted Diseases Outpatient Clinic at the Medical University in Plovdiv, Bulgaria were tested using direct immunofluorescence assay (DFA) (MicroTrak, Syva, Palo Alto, CA, USA). RESULTS: Seventy (25%) of all men tested were positive for C. trachomatis antigen in either urethral or urine samples. 65 men (93%) had both a positive urethral and urine sample, three men (4%) had only a positive urethral sample and two (3%) had only a positive urine sample. Thirty-five women (18%) had C. trachomatis infection. Twenty-six women (74%) had both a positive endocervical and urethral sample, 6 (17%) had only a positive endocervical sample and 3 (8%) had only a positive urethral sample. All women with positive urethral samples tested positive on their urine samples. Two of the women with a negative urethral sample and a positive endocervical sample had a positive urine sample. CONCLUSIONS: These results show that using direct immunofluorescence assay on first-void urine samples is a reliable noninvasive method which can replace urethral swabs in the diagnosis of C. trachomatis infection in symptomatic men. Urine-based strategies are also an acceptable alternative for the diagnosis of C. trachomatis infection in symptomatic women when it is not possible to obtain an urogenital sample.