Comparison of the vaginal flora in sexually abused and nonabused girls

STROBE-sequencing analysis of the vaginal microecology of 4- to 6-year-old girls in Southwest China

We investigated the vaginal flora diversity of preschool-aged (ie, 4-6-year-old) girls in southwest China.Fourteen preschool-aged girls were enrolled in this study. The statuses and differences in their vaginal flora were evaluated by Gram staining, bacterial culturing, and sequencing analysis.Gram staining and microbial culturing showed that the main vaginal flora of the preschool-aged girls were Gram-negative bacilli, whereas the main vaginal flora of healthy adult controls were large Gram-positive bacilli such as Lactobacillus crispatus. Shannon and Simpson indexes indicated that the bacterial diversity tended to decrease with age. The species abundance heat map showed that the vaginal microecology of the girls differed slightly at different ages but mainly comprised Pseudomonas, Methylobacterium, Sphingomona,s and Escherichia. The functional abundance heat map indicated that the bacterial functions increased with age.The vaginal microecology of preschool-aged girls differs from that of adults. A comprehensive understanding of the vaginal flora diversity of preschool-aged girls will aid in clinically diagnosing vulvovaginitis in preschool-aged girls.

Ureaplasmas and mycoplasmas in vaginal samples from prepubertal girls and the reasons for gynecological consultation

OBJECTIVES

The aim of the study was to evaluate vaginal colonization with Ureaplasmaurealyticum (UU) and Mycoplasma hominis (MH) in prepubertal girls and reason for gynecological consultation.

PATIENTS AND METHODS

All prepubertal girls sent for consultation for medical issues to a pediatric gynecology department. Vaginal swabs were obtained for culture and were seeded using specific media. Patients colonized with genital mycoplasmas (GMs) were evaluated by a psychologist to rule out sexual abuse (SA).

RESULTS

A total of119 patients were included. The mean age was 5.9 y. Reasons for consultation were vulvovaginitis in 78 (66%), SA before study entry in 19 (16%), labial adhesion in 8 (7%), genital bleeding in 8 (7%), suspected sexual abuse in 3 (3%) and 1 patient was sent for consultation for labial adhesion but had a normal examination (1%), physical neglect in 1 (1%), and genital ulcers in 1 (1%). UU was isolated in 14 (12%) MH was isolated in 3 (3%). UU was isolated in 9 patents (47%) with SA before study entry. Five patients colonized with UU that had consulted for other reasons were evaluated by a pediatric psychologist; 4 disclosed SA. One patient colonized with UU did not disclose SA. Patients with GMs were more likely to disclose sexual abuse (UU P < .0001. MH P < .0065).

CONCLUSION

GMs were isolated more in SA cases. Patients colonized with GMs and consulted for other issues than SA were more likely to disclose SA.

The epidemiology of bacterial vaginosis in relation to sexual behaviour

BACKGROUND

Bacterial vaginosis (BV) has been most consistently linked to sexual behaviour, and the epidemiological profile of BV mirrors that of established sexually transmitted infections (STIs). It remains a matter of debate however whether BV pathogenesis does actually involve sexual transmission of pathogenic micro-organisms from men to women. We therefore made a critical appraisal of the literature on BV in relation to sexual behaviour.

DISCUSSION

G. vaginalis carriage and BV occurs rarely with children, but has been observed among adolescent, even sexually non-experienced girls, contradicting that sexual transmission is a necessary prerequisite to disease acquisition. G. vaginalis carriage is enhanced by penetrative sexual contact but also by non-penetrative digito-genital contact and oral sex, again indicating that sex per se, but not necessarily coital transmission is involved. Several observations also point at female-to-male rather than at male-to-female transmission of G. vaginalis, presumably explaining the high concordance rates of G. vaginalis carriage among couples. Male antibiotic treatment has not been found to protect against BV, condom use is slightly protective, whereas male circumcision might protect against BV. BV is also common among women-who-have-sex-with-women and this relates at least in part to non-coital sexual behaviours. Though male-to-female transmission cannot be ruled out, overall there is little evidence that BV acts as an STD. Rather, we suggest BV may be considered a sexually enhanced disease (SED), with frequency of intercourse being a critical factor. This may relate to two distinct pathogenetic mechanisms: (1) in case of unprotected intercourse alkalinisation of the vaginal niche enhances a shift from lactobacilli-dominated microflora to a BV-like type of microflora and (2) in case of unprotected and protected intercourse mechanical transfer of perineal enteric bacteria is enhanced by coitus. A similar mechanism of mechanical transfer may explain the consistent link between non-coital sexual acts and BV. Similar observations supporting the SED pathogenetic model have been made for vaginal candidiasis and for urinary tract infection.

SUMMARY

Though male-to-female transmission cannot be ruled out, overall there is incomplete evidence that BV acts as an STI. We believe however that BV may be considered a sexually enhanced disease, with frequency of intercourse being a critical factor.

Vaginal microbiocoenosis and cytology of prepubertal and adolescent girls: their role in health and disease

BACKGROUND

Clinicians and investigators often do not appreciate the importance of vaginal microbiocoenosis and vaginal cytology in the health of prepubertal and adolescent girls.

DATA SOURCES

Based on recent publications in human medicine and our own experience with vaginal cytology and microbiology in children and adolescent girls, we review the principles of vaginal microbiocoenosis and cytology and their roles in disease prevention in prepubertal and adolescent girls.

RESULTS

The main role of vaginal microbiocoenosis and cytology in diagnosing as well as developing vulvovaginitis is demonstrated. Clinicians can identify states of vaginal health and disease by important well-known diagnostic tools, including vaginal cytology. Lactobacilli are infrequently observed in the prepubertal girls, but become more abundant in adolescent girls. Three basic types of vaginal smears are presented in addition to a classification of inflammatory urogenital diseases. Management of common types of vulvovaginitis is also considered.

CONCLUSIONS

This essential shift in vaginal biocoenosis is important to prevent the growth of potentially pathogenic flora in the vagina. The detection of vaginal microbiocoenosis problems and recognition of changing cytology in vaginal development can provide helpful clues to identifying and preventing vaginal diseases in this pediatric population.

Evidence for sexual transmission of genital herpes in children

INTRODUCTION

Genital herpes in a prepubertal child presents a child protection clinician with a difficult problem: how likely is it that transmission occurred as a consequence of sexual abuse? Published guidelines on the management of sexually transmitted infections in children provide varying recommendations and refer to a limited literature.

OBJECTIVE

To review the evidence for the likelihood of sexual transmission in a child with proven genital herpes.

METHODS

Structured literature search for reports of series of children presenting with genital herpes where an assessment for possible sexual transmission or child sexual abuse had been made.

RESULTS

Five suitable papers were identified. Although just over half of reported cases of genital herpes in children had evidence suggestive of a sexual mode of transmission, the quality of assessment of possible sexual abuse was too weak to enable any reliable estimation of its likelihood. Sexual transmission is reported more commonly in older children (aged > or =5 years), in children presenting with genital lesions alone and where type 2 herpes simplex virus is isolated.

CONCLUSIONS

Child protection clinicians should be aware of the weakness of the evidence on the likelihood of sexual transmission of genital herpes in prepubertal children. The US guidance that child sexual abuse is "suspicious" reflects the evidence better than the UK guidance that it is "probable". A larger, more up-to-date, methodologically sound, population based study is required.

Sexually transmitted infections in alleged sexual abuse of children and adolescents

AIM

To describe the prevalence of sexually transmitted infections (STI) in children and young people aged 0-17 years seen for suspected sexual abuse in Auckland, New Zealand.

METHODS

Retrospective review of consecutive medical records over a 7-year period from December 1991 to December 1998.

RESULTS

A total of 2162 children and young people had a genital examination related to concerns about possible sexual abuse, of whom 1909 (88.3%) had some form of screening test for STI. Sixty children and young people (2.8%) had STI, diagnosed either by examination, laboratory investigation, or both. The rate was 5.6% (43/770) in those aged 10 years or older and 1.2% (17/1392) in those aged under 10 years.

CONCLUSION

The prevalence of STI in children and young people referred for suspected sexual abuse is low but significant. Chlamydia and pelvic inflammatory disease were the most common infections. No STI was found in an asymptomatic pre-pubertal child.

Bacterial vaginosis and contraceptive methods

OBJECTIVES The aim of this study was to investigate if bacterial vaginosis is associated with the use of specific contraceptives.

METHODS

The study population consisted of 1314 women attending for periodical preventive examinations at our gynecology unit at the II Institute of Obstetrics and Gynecology of the University 'La Sapienza' in Rome. The patient's history and any current genital symptom were recorded on a structured protocol. Current users of contraceptives were compared with non-users. The chi(2) test and the t-test were used in the statistical analysis; a stepwise logistic regression analysis was performed to assess the simultaneous effect of more than one variable and to identify for possible confounding factors.

RESULTS

Both oral contraceptive and condom use showed a significant protective effect against bacterial vaginosis. Our results also showed a significant increase of BV among IUD users, either before or after adjustments.

CONCLUSIONS

This study showed a significant negative association between BV and OC and condom use, respectively, and a significant positive association between BV and IUD use. Therefore, we suggest that it is advisable to carry out a systematic microscopic evaluation in order to identify BV for IUD users.

[Isolation of Gardnerella vaginalis in the diagnosis of sexual abuse in children]

INTRODUCTION

The study of sexual transmitted diseases is more and more frequent in patient with suspicion of sexual abuse, and this help to the final medical diagnosis. Organisms like Neisseria gonorrhoeae and Treponema indicate a sure sexual contact. However the role of the rest of organisms in the sexual abuse is more difficult of specifying.

OBJECTIVE

To know the role of the Gardnerella vaginalis in the diagnosis of sexual abuse in patient with this possible diagnosis.

METHODS

Retrospective study of 135 girls with suspicion of abuse, visited from May of 1997 to February of 1998. Vaginal swabs were taken from 45 of 135 girls evaluated.

RESULTS

In five patients the vaginal culture were positive to Gardnerella. The characteristics of these five patients are described (age, aggressor, type and duration of the abuse, physical exploration and final diagnosis). All our patients were the pubertal or prepubertal girls. In these patients the final diagnosis settled with the clinical history and the physical exploration, without keeping in mind the result of the culture.

CONCLUSION

It is necessary to discard sexual abuse in all prepubertal girl with a positive culture with Gardnerella vaginalis, being difficult to specify the value of the Gardnerella in the adolescent patients.

Sexually transmitted diseases in sexually abused children: medical and legal implications

Sexually transmitted diseases (STDs) may be transmitted during sexual assault. In children, the isolation of a sexually transmitted organism may be the first indication that abuse has occurred. Although the presence of a sexually transmissible agent from a child beyond the neonatal period is suggestive of sexual abuse, exceptions do exist. In this review I discuss the issues of the transmissibility and diagnosis of STDs in the context of child sexual abuse. Rectal or genital infection with Chlamydia trachomatis among young children may be the result of perinatally acquired infection and may persist for as long as 3 years. A major problem with chlamydia testing in the context of suspected sexual abuse in children has been the inappropriate use of non-culture tests. Although the new generation of nucleic acid amplification tests have shown high sensitivity and specificity with genital specimens from adults, data on use of these tests on any site in children are practically non-existent. Bacterial vaginosis (BV) has been identified among children who have been abused and among those who have not been abused. However, many of the methods used to diagnose BV in adults have not been evaluated in children. Recent studies of perinatal infection with human papillomavirus (HPV) have been inconclusive. HPV DNA has been detected at various sites in children who have not been abused. The relation to the development of clinically apparent genital warts is unclear. Although HIV can be acquired through sexual abuse in children, the exact risk to the child and which children should be screened is still controversial.

Sexual behavior risk factors associated with bacterial vaginosis and Chlamydia trachomatis infection

BACKGROUND AND OBJECTIVES

Few studies have demonstrated that bacterial vaginosis (BV) is associated with sexual behavior risk factors similar to those for other sexually transmitted diseases. The objective of this study was to determine the prevalence of these factors in a multivariate analysis of data from women infected with BV and Chlamydia trachomatis, and noninfected control subjects.

GOALS

To study detailed sexual behavior risk factors reported by women with BV versus genital C. trachomatis infection (CT) and by non-BV-infected controls.

STUDY DESIGN

A cross-sectional study was conducted with 1,011 women (Swedish Women's Health Study) recruited from family planning and youth clinics in Eskilstuna and Stockholm, Sweden (November, 1989-January, 1991). Participants were evaluated for the presence of BV, CT, Neisseria gonorrhoeae, Treponema pallidum, Trichomonas vaginalis, and human immunodeficiency virus, and interviewed in detail with respect to sexual behaviors. Statistical comparisons were made using chi-square test (Pearson and likelihood ratio), t test, and logistic regression multivariate analysis.

RESULTS

Of 956 women eligible for analysis, the prevalence of BV and CT was 13.7% and 8.9%, respectively. The comparison group consisted of the remaining 825 women without BV. After excluding those with concomitant CT infection, there were 118 women with BV who were compared with 72 women with CT infection only. Sexual factors associated with BV versus the comparison group were a short-term relationship before and after sexual debut, high number of lifetime sexual partners, multiple partners during the last month, high orgasm ability, and more frequent history of group sex, sexual abuse, and rape. When the BV group was compared with the CT group, there were no significant differences in sexual activity risk factors, except for a higher frequency of experience of casual sex in the CT group.

CONCLUSIONS

Bacterial vaginosis is associated with sexual behavior risk factors similar to those associated with genital CT infection.

Sexually transmitted diseases in children and evidence of sexual abuse

During the period June 1989 to March 1991, laboratory evidence of sexually transmitted diseases (STDs) was found in 107 patients at the Red Cross War Memorial Children's Hospital in Cape Town. Data was available on 96 patients aged 23 months to 14 years (mean 75.9 months). Vaginal discharge was the most frequent presenting symptom (76%), particularly in those less than 5 years of age (90%). Although a history of abuse was not given on presentation in 62%, evidence of abuse was subsequently elicited in 67% of patients. Neisseria gonorrhoeae was the most common sexual pathogen (61 isolates, 8 penicillin resistant), followed by G vaginalis (17 isolates), Trichomonas vaginalis (7 infections), and T pallidum (9 TPHA positive, 5 with VDRL 1:4 or higher). Chlamydia trachomatis was demonstrated by immunofluorescence in 14 children. Multiple STDs were demonstrated in 10 patients. Although evidence of CSA was not found in all patients with STDs it was likely that the vast majority of patients had acquired these infections by CSA. Symptomatic prepubertal children with G vaginalis isolates should be investigated for CSA. Chlamydial immunofluorescence tests did not assist the diagnosis of CSA in children and should not be used, as they have no medicolegal significance.