Repeat infection with Chlamydia trachomatis: a prospective cohort study from an STI-clinic in Stockholm.

BACKGROUND: Infection with genital Chlamydia trachomatis (Ct) is the most common notifiable sexually transmitted infection (STI) in Sweden. A mutated Chlamydia, nvCT, has contributed to the increase. The occurrence of repeat infections is not investigated in Sweden. The current paper presents the study protocol for the first Swedish clinical investigation of repeat Chlamydial infection. The concern of the study is whether a Chlamydia infection at inclusion indicates an increased risk for Chlamydia at follow-up after 6-8 months, gender-specific risk factors for and clinical presentation of repeat infections. METHODS AND DESIGN: Sesam City is a drop-in clinic in the city centre of Stockholm. Patients 20 years and older are admitted. During 2007, the clinic had 15,000 visits, 60% made by men. In December 2007, a cohort study began, and data collection was finished in April 2009. A total of 2,813 study participants aged 20-39 years were recruited. Data collection included an anonymous self-administered paper-and-pen questionnaire on sexual behaviour, reproductive health and history of Chlamydia, and condom use. Chlamydia tests were performed by self-sampled specimens, analyzed by the ProbeTec (Becton Dickinson) method, Ct-positive specimens also analyzed with a nvCT-specific method. Data from medical records were summarized in clinical report forms. Patients positive for Chlamydia were retested 4 weeks after treatment. Contact tracing covered sexual contacts during the last 12 months. At follow-up 6-8 months after inclusion, Chlamydia tests were performed, and a new questionnaire and CRF completed. DISCUSSION: A STI-clinic-based prospective cohort study allowed us to survey 2813 adult patients. The collected data will provide gender-specific information on the occurrence of and risk for repeat Chlamydia infection, the occurrence of nvCT, and clinical data and information on sexual behaviour and reproductive health, risk-taking and condom use.

High occurrence of a new variant of Chlamydia trachomatis escaping diagnostic tests among STI clinic patients in Stockholm, Sweden.

BACKGROUND: In 2006, a genetic variant of Chlamydia trachomatis not detectable with the most commonly used diagnostic tests was identified. Initial reports suggested that as many as 10% to 13% of all chlamydia cases would have remained undiagnosed. The aim of the study was to find the occurrence and clinical findings of this genetic variant among a high-risk population in Stockholm, Sweden. METHODS: Samples were analyzed using the Cobas TaqMan CT test (Roche Diagnostics). To detect the new variant, an additional PCR-analysis, artus C. trachomatis LC MOMP PCR Kit (Qiagen) was performed on all negative samples. Positive results in the artus test were confirmed by a mutant specific PCR. Clinical data were retrospectively collected from medical records. RESULTS: Among 1009 samples analyzed, 115 were positive for C. trachomatis and among those, 27 were found to belong to the genetic altered strain. This variant constituted 23% of all chlamydia cases diagnosed, and 29% were found in the age group 20 to 29 years. Women with the new variant were younger and had more often performed another chlamydia test within the previous 6 months compared with those infected with the wild type. CONCLUSION: These results indicate that a large number of sexually active individuals might be infected despite a negative chlamydia test, thus facilitating a rapid transmission of the new variant. Accordingly, it is of great importance to be aware of limitations of the diagnostic methods used.

Vulvar vestibulitis and risk factors: a population-based case-control study in Oslo.

Vulvar vestibulitis is a major cause of entry dyspareunia in young women. The aim of this study was to evaluate a self-reported history of bacterial vaginosis, candidiasis, use of oral contraception and nulli-pregnancy as risk factors for vestibulitis. A retrospective examination of medical records was performed for 45 patients with vestibulitis from a vulvar clinic in Oslo, median age 24 years, age range 19-49 years. Four controls per case were selected randomly from the same Oslo source population as the cases. Age-matching was not performed, as matching does not control for confounding in the case-control design. Controls anonymously answered a postal questionnaire, response rate 61%. The crude effect for the major potential predictors for vulvar vestibulitis was estimated, and stratification on age for the major potential predictors. The method of Mantel Haenszel was used to quantify confounders, and control for multi-confounders and the gradient effect of different covariates was performed. The major confounder was age. Independent risk factors for vestibulitis were nulli-pregnancy, odds ratio (OR) 8.4 (95% confidence interval (CI) 2.8-25.2) and bacterial vaginosis, OR 3.37 (95% CI 1.06-10.6). Adjusting for age diluted the effect of oral contraception and frequent treatment for candidiasis. This study is the third case-control study identifying bacterial vaginosis as a risk factor for vestibulitis. Thus, it remains to be investigated whether abnormal vulvo-vaginal microbiota belongs to the aetiology of vulvar vestibulitis.

[Experiences with a special vulvar clinic in Oslo]. / Erfarenheter med särskilt vulvamottagning i Oslo.

BACKGROUND: Women with longstanding vulvar problems have difficulties finding medical care. In 2000, a first Norwegian vulvar clinic was opened at the Olafia centre for venereology in Oslo. The initiative was continued in 2003 by a multi-professional team in the dept. of gynaecology and obstetrics at Rikshospitalet University Hospital. METHODS: Medical records from the two Vulva clinics have been reviewed in retrospect. RESULTS: During the period 2000 to 2003, a total of 217 patients had 470 visits to the Olafia clinic, mean age 31.4 years. Vulvodynia was diagnosed in 52% of all patients, 30% had a genital infection, 22% a genital dermatitis or dermatosis and 21% a primary sexual problem. At the multi-professional Rikshospitalet vulva clinic, run by specialists in gynaecology and dermato-venereology, 141 patients had 206 visits in 2003, mean age 42.5 years. Vulvodynia was diagnosed in 38%, 26% had a genital skin condition, 11% primary sexual problems, 10% a genital infection, and 10% a gynaecological problem. A few patients were healthy controls. The difference in diagnostic groups is related to the age of the patients. CONCLUSION: The options for vulvar patients have improved in Oslo. Multi-professional cooperation has been achieved in our department, which serves as a national referral centre.

Longstanding vulval problems and entry dyspareunia among STD-clinic visitors in Oslo-results from a cross-sectional study.

An increasing number of women with vulval problems and pain attend Olafiaklinikken, the centre for sexually transmitted infection (STI) in Oslo. The aim of the study was to investigate the prevalence of long-standing vulval problems and entry dyspareunia in a consecutive sample of STI-clinic visitors in Oslo. A self-administered questionnaire was distributed before and independent of the consultation. Response rate was 89.6% (502/560). Mean and median age were 25.9 and 24.0 years respectively, range 16-65 years. Vulval soreness, burning, dryness and fissures present for at least three months were reported by 23.1% (116/502), entry dyspareunia by 6.9% (34/494). Independent risk factors for dyspareunia were a history of >/=4 treatments for vulvovaginal candidiasis during the last year, reported by 34.6%, odds ratio (OR) 4.45, 95% confidence interval (CI) 1.81-11.0, and a history of bacterial vaginosis, reported by 42.4%, OR 2.34, 95% CI 1.11-4.92. Contraceptive methods, hygienic habits, a history of STIs, depression or sexual abuse were factors unrelated to longstanding symptoms. Investigation with regard to longstanding vulval problems and entry dyspareunia is required for a certain group of sexually transmitted disease-clinic visitors in Oslo, and referral to a special service for vulva patients would be beneficial for selected patients.

The adolescent hymen.

The genital examination is not a routine part of health maintenance assessment in prepubertal and pubertal girls. However, evaluation of minors for suspected sexual abuse has been addressed extensively in the last two decades. In spite of this, normal anatomic variations and developmental changes are not fully investigated. This paper reviews current knowledge about the hymen, with a focus on puberty and adolescence. More is known about the external genitals of prepubertal children than of adolescent girls. No longitudinal studies have been performed among girls older than age 3. Tanner staging does not include detailed genital development. A variety of terms have been used to describe the configuration and/or distortion of the hymen: attenuation, clefts, tears and transections, bumps and notches. No studies have been published on the normal variations of the width of the hymenal rim, although an attenuated and/or narrow rim is categorized as consistent with penetrative sexual abuse according to an international consensus statement. Critiques of the literature on the hymen have been published by experts on forensic medicine, emphasizing the fact that the normal hymenal appearance in adolescents still is not well documented. Few studies on hymenal configuration in nonabused adolescent girls have been performed, including girls with and without experience of consensual vaginal intercourse and use of tampons. Longitudinal investigations are required for a better knowledge of female genital development during puberty, with a special focus on vulvar and hymenal anatomy.

Sexual behaviour in a low-income high school setting in Stockholm.

Teenage abortions and sexually transmitted infections (STIs) are increasing in Sweden, and risky adolescent sexual behaviour is an issue of major concern. The aim of the present cross-sectional questionnaire-based study was to investigate adolescent sexual experience in a low-income high school setting in Stockholm. Among 340 students, 258 participated, response rate=75.9%, mean age=17 years. Homo- or bisexual preference was reported by 11.6% (29/250). Experience of oral sex was reported by 66.3% (163/246), vaginal intercourse by 55.5% (141/254), and anal sex by 10.0% (25/250), with no gender-specific differences. Five or more coital partners were reported by 29.8% (34/114). Condom use at first and most recent intercourse was reported by 61.7% (87/141) and 42.6% (60/141), respectively, and condom breakage by 39.5% (34/86). Truancy, smoking, alcohol and drug use were factors associated with coital experience. Sexual abuse was reported by 2.2% (3/134) of the boys and 13.0% (16/123) of the girls.