Prepubertal and Adolescent Vulvovaginitis: What to Do When a Girl Reports Vaginal Discharge

Vaginitis presents with vaginal discharge, odor, pruritis, and/or discomfort and affects up to 75% of girls and women over the course of their lifetimes, with most women experiencing their first episode during adolescence. Given the prevalence of this disorder, this article aims to provide an overview of vaginitis for the general pediatrician. We start with prepubertal etiologies of vaginitis, then discuss pubertal and normal physiologic discharge, and then focus on the most common etiologies of adolescent vulvovaginitis. The three most common microbial etiologies of vaginitis (bacterial vaginosis, vulvovaginal candidiasis, and trichomonas) are addressed, as well as their diagnosis and treatment in adolescents. [Pediatr Ann. 2020;49(4):e170-e175.].

Performance of syndromic management for the detection and treatment of genital Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis among women attending antenatal, well woman and sexual health clinics in Papua New Guinea: a cross-sectional study

OBJECTIVE

Papua New Guinea (PNG) has among the highest estimated prevalences of genital Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) of any country in the Asia-Pacific region. Diagnosis and treatment of these infections have relied on the WHO-endorsed syndromic management strategy that uses clinical presentation without laboratory confirmation to make treatment decisions. We evaluated the performance of this strategy in clinical settings in PNG.

DESIGN

Women attending antenatal (ANC), well woman (WWC) and sexual health (SHC) clinics in four provinces were invited to participate, completed a face-to-face interview and clinical examination, and provided genital specimens for laboratory testing. We estimated the performance characteristics of syndromic diagnoses against combined laboratory diagnoses.

RESULTS

1764 women were enrolled (ANC=765; WWC=614; SHC=385). The prevalences of CT, NG and TV were highest among women attending ANC and SHC. Among antenatal women, syndromic diagnosis of sexually transmitted infection had low sensitivity (9%-21%) and positive predictive value (PPV) (7%-37%), but high specificity (76%-89%) and moderate negative predictive value (NPV) (55%-86%) for the combined endpoint of laboratory-confirmed CT, NG or TV. Among women attending WWC and SHC, 'vaginal discharge syndrome' had moderate to high sensitivity (72%-78%) and NPV (62%-94%), but low specificity (26%-33%) and PPV (8%-38%). 'Lower abdominal pain syndrome' had low sensitivity (26%-41%) and PPV (8%-23%) but moderate specificity (66%-68%) and high NPV (74%-93%) among women attending WWC, and moderate-high sensitivity (67%-79%) and NPV (62%-86%) but low specificity (26%-28%) and PPV (14%-33%) among SHC attendees.

CONCLUSION

The performance of syndromic management for the detection and treatment of genital chlamydia, gonorrhoea and trichomonas was poor among women in different clinical settings in PNG. New diagnostic strategies are needed to control these infections and to prevent their adverse health outcomes in PNG and other high-burden countries.

Diabetes and balanoposthitis

This review describes the association of balanoposthitis with diabetes. It reviews the multifaceted relationship of both conditions, and summarizes the etiology, clinical features and treatment options for this condition. The commonest etiology of balanoposthitis in males with diabetes is Candida, and the mainstay of treatment is maintenance of hygiene, euglycaemia, and eradication of infection. The review sensitizes diabetes care providers to take a history and perform a physical examination in persons with penile symptoms, and also encourages dermatology care providers to screen for diabetes in such persons.

[Complex personalized therapy of patients with chlamydiosis taking into consideration abnormalities of pro-oxidant-antioxidant and immune systems]

A new original, pathogenetically relevant method of complex differentiated treatment of chlamydial urogenital disorders was developed with the consideration of prooxidant-antioxidant and immune systems statuses. That provides a personalized usage in the treatment plan modern azalide antibiotic azithromycin and immunomodulator herbal drug manax taking into the account clinical course of the disease.

Interval to treatment of sexually transmitted infections in adolescent females

STUDY OBJECTIVE

To describe (1) the treatment interval for adolescent females with Chlamydia trachomatis (CT), Neisseria gonorrhoeae (GC), or Trichomonas vaginalis (TV); (2) the proportion treated in < or =7 days; and (3) factors influencing the treatment interval.

DESIGN AND PARTICIPANTS

Charts of sexually active females from an urban teen health center who participated in a larger study and were positive for CT, GC or TV (N = 58) were retrospectively reviewed for dates of treatment, and compared to demographic and symptom data. The treatment interval was defined as days from visit to treatment. CT and/or GC were analyzed together (CT/GC) because presumptive treatment covered both infections, and the diagnostic test (nucleic acid amplification) differed from that of TV (wet mount or culture).

RESULTS

The median treatment interval was 0 days for TV, 5 days for CT/GC, and 3 days for any STI. Overall, 39 (69%) were treated within 7 days of their visit. Those with TV were more likely than those with CT/GC to receive treatment at their initial visit (58% vs. 6%). Genitourinary symptoms increased the odds of treatment in < or =7 days. The treatment interval was significantly shorter for subjects who had their prescriptions phoned to a pharmacy than for those who returned to clinic for treatment (median 2.5 vs. 8 days).

CONCLUSIONS

Where presumptive treatment was uncommon, providers were more likely to prescribe same-day therapy to symptomatic patients or those with TV on wet mount. Additional strategies are needed to improve the proportion of adolescent females treated in < or =7 days.

[Combined physiotherapy of chronic infectious prostatitis]

Our experience with therapy of 259 outpatients with chronic infectious prostatitis (CIP) aged 16-55 years has demonstrated that combined treatment of CIP with rectal digital massage of the prostate, electrophoresis of chimotripsin solution with dimexide and local magnetotherapy (Intramag unit) significantly raises treatment efficacy, shortens treatment, prevents complications.

Trichomoniasis: clinical manifestations, diagnosis and management

Trichomonas vaginalis was originally considered a commensal organism until the 1950s when the understanding of its role as a sexually transmitted infection (STI) began to evolve. Trichomoniasis has been associated with vaginitis, cervicitis, urethritis, pelvic inflammatory disease (PID), and adverse birth outcomes. Infection with T vaginalis could have an important role in transmission and acquisition of HIV. T vaginalis is site specific for the genitourinary tract and has been isolated from virtually all genitourinary structures. Asymptomatic disease is common in both men and women, thus screening for disease is important. Various sociodemographic factors have been correlated with presence of T vaginalis, and may be used to predict infection. Diagnosis is usually made from wet mount microscopy and direct visualisation, which are insensitive. DNA amplification techniques perform with good sensitivity, but are not yet approved for diagnostic purposes. In areas where diagnostic methods are limited, management of trichomoniasis is usually as part of a clinical syndrome; vaginal discharge for women and urethral discharge for men. A single dose of metronidazole is effective in the majority of cases. Outside of the United States, other nitroimidazoles may be used and are as effective as metronidazole. Metronidazole resistance is an emerging problem, but its clinical importance is not yet clear. Concomitant treatment of sexual partners is recommended.

Trichomoniasis: under control or undercontrolled?

Aside from human papillomavirus, trichomoniasis is the most common sexually transmitted infection in the United States today, yet it has long been regarded as a sexually transmitted infection of minor importance. Medical opinion has traditionally held that it plays little role in health complications in women, and it is rarely seen in men. However, evidence has recently accumulated implicating Trichomonas vaginalis as a contributor to a variety of adverse outcomes among both sexes. Among both women and men, the association of T vaginalis with human immunodeficiency acquisition and transmission has been shown in multiple studies. Among women, trichomoniasis may play a role in development of cervical neoplasia, postoperative infections, and adverse pregnancy outcomes and as a factor in atypical pelvic inflammatory disease and infertility. Among men, trichomoniasis has emerged as a cause of nongonoccocal urethritis and as contributing to male factor infertility. As evidence continues to accumulate, the time has come to increase diagnostic efforts beyond traditional sexually transmitted disease clinic settings.

Post-treatment sexual and prevention behaviours of adolescents with sexually transmitted infections

OBJECTIVE

To evaluate sexual behaviour (including abstinence), sex partner change, and condom use during the 3 month period following treatment for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, or non-gonococcal urethritis.

METHODS

251 14-21 year old participants (83% female; 83% African-American) diagnosed with gonorrhoea, chlamydia, trichomonas, or non-gonococcal urethritis or sexual contacts of infected partners. Participants were clients of a public sexually transmitted diseases clinic or primary care adolescent clinics. Data were collected by structured interview at treatment, 1 month post-treatment, and 3 months post-treatment. At each visit, participants were asked about coital frequency and condom use for each recent partner. At 1 month, participants were asked when coitus occurred following treatment. At each follow up visit, sex partners were compared to partners named at treatment and classified as "same partner(s)," "new partner(s)," or both "same and new partner(s)."

RESULTS

Post-treatment abstinence was reported by 26% and 19% for the 1 month and 3 month visits, respectively. Abstinence was associated with greater likelihood of infection at enrolment although abstainers reported fewer lifetime STI and fewer lifetime sex partners. A substantial proportion of participants reported additional sexual contact with a previous partner. The average proportion of condom protected coital events increased from about 45% at enrolment to 64% at 1 month and 58% at 3 months (p<0.05). Higher levels were sustained for the 3 months following treatment.

CONCLUSIONS

Many adolescents adopt, at least temporarily, risk reduction behaviours such as abstinence or increased condom use. Sexual re-exposure to potentially untreated previous partners may increase risk of subsequent reinfection.

Sexually transmitted infections in Estonia--syndromic management of urethritis in a European country?

Sexually transmitted infections (STIs) are considered a major public health problem, globally. In particular, increasing STI rates have been documented throughout eastern Europe and central Asia. The Russian Federation and adjacent countries have, traditionally, managed STIs on an aetiological basis. This approach is expensive in terms of laboratory costs and it may lead to delayed diagnosis and treatment. To overcome the limitations of the aetiological management of STIs, the World Health Organization (WHO) has placed an increased emphasis on integrated care using syndromic management at the primary care level, especially in developing countries. This article reviews the current aetiology of STIs in Estonia, an eastern European country bordering the Baltic Sea and formerly a part of the Soviet Union, with the aim of defining whether infection with Trichomonas vaginalis is common enough to include its management in a syndromic management protocol. The use of syndromic management, in general, is also discussed.

Subsequent sexually transmitted infection in urban adolescents and young adults

OBJECTIVE

To compare the rates of subsequent infection with Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis in a group of high-risk adolescents and young adults.

METHODS

At the time of treatment, 444 unmarried teenagers and young adults aged 13 to 25 years were enrolled from an urban sexually transmitted disease clinic and 3 community-based primary care clinics. Subjects were infected with C trachomatis, N gonorrhoeae, or T vaginalis, were diagnosed as having nongonococcal urethritis (in men), or were uninfected sexual contacts with one of these infections. Subjects returned at 1, 3, 5, and 7 months.

RESULTS

The rate of subsequent infection was substantial. Forty percent of men and 53% of women who were uninfected contacts at enrollment were estimated to be infected within 7 months; 60% of men and 73% of women infected at enrollment were estimated to be reinfected. Among women, subjects who were infected at enrollment had a shorter time to subsequent infection (median, 140 days) compared with uninfected contacts (median, 209 days) (P =.04). Among men, findings were similar, but the difference in median time to subsequent infection was not significant (P =.08). Baseline characteristics that predicted shorter time to reinfection were female sex and infection at enrollment. When sexual behaviors in the 2 months preceding each subsequent data collection visit were included in the model, only being female and reporting at least one new interval sexual partner were significant predictors of subsequent sexually transmitted infections.

CONCLUSIONS

These data support recent research that has found high rates of subsequent infection among high-risk adolescents and young adults. Contacts of a sexually transmitted infection appear to be at equally high risk for subsequent infection as those with a personal history of infection. Our data suggest that more frequent than annual screening for N gonorrhoeae, C trachomatis, and T vaginalis would be appropriate in at-risk adolescent and young adult populations, including individuals who are uninfected sexual contacts to a sexually transmitted infection.

Can a two-glass urine test or leucocyte esterase test of first-void urine improve syndromic management of male urethritis in southern Thailand?

The goal of this study was to determine whether a urine two-glass test or a leucocyte esterase (LE) test of first-void urine (FVU) improve the sensitivity or specificity of the World Health Organization (WHO) algorithm for the syndromic management of men with urethritis in southern Thailand. A secondary aim was to determine whether infection with Trichomonas vaginalis was sufficiently common to include treatment for it in a syndromic management protocol. One hundred and twenty-nine men with symptoms of urethritis seen at 2 STD clinics in Songkla Province, Thailand were enrolled. Symptoms and signs of each man were recorded and a urethral swab collected for microscopy and culture for Neisseria gonorrhoeae. A two-glass urine test and an LE test of an FVU specimen were performed. The FVU was tested by polymerase chain reaction (PCR) for N. gonorrhoeae, Chlamydia trachomatis and T. vaginalis. Dysuria was a symptom in 78% of men. A urethral discharge was a symptom in 68% but was evident on examination in 95% of the men. The prevalences of infection were 32.6% for N. gonorrhoeae, 23.3% for C. trachomatis, 1.6% for T. vaginalis and 51.9% for any infection. The sensitivities and specificities of urethral discharge on examination, two-glass test and LE test of FVU as indicators of infection with either or both of N. gonorrhoeae or C. trachomatis were 97% and 8%; 57% and 83%; and 59% and 78% respectively. Combinations of urethral discharge on examination and one of the other indicators were more specific but much less sensitive than the presence of discharge alone. Culture for N. gonorrhoeae was found to be only 43% sensitive compared with an expanded gold standard involving a PCR test. Our analysis demonstrates that neither the two-glass test nor the LE test of FVU were useful in improving on the WHO algorithm for management of men with urethritis. T. vaginalis was not common enough to include in a first-line syndromic management protocol for male urethritis. We recommend that, in southern Thailand, men with symptoms of urethritis in whom a urethral discharge is present on examination be offered immediate treatment for both N. gonorrhoeae and C. trachomatis as per the WHO algorithm.

Laboratory studies with the systemic trichomonacide, metronidazole

Laboratory studies with the trichomonacidal agent, metronidazole, show that 66 strains of T. vaginalis were killed in three days by concentrations of 0.0625 mug./ml. to 1 mug./ml. Estimations of serum and urine levels in nine volunteers, the serum levels in 31 women, and the urine levels in 33 women show that metronidazole is rapidly absorbed and excreted in high concentration in the urine. Development of resistance to metronidazole by T. vaginalis has not been demonstrated either in vivo or in vitro. No toxic effect was demonstrated in the blood, liver, or kidney.

Pathogenesis, diagnosis, and management of trichomoniasis in cattle

Trichomoniasis is a disease of the pregnancy, but apparently not of either the cow or the bull, except in the case of postcoital pyometra. Its self-limiting nature in the cow and chronic nature in the bull mean that a positive diagnosis for the herd can more easily be obtained from bulls than from cows. Incubation of preputial scrapings or washings (or pyometritic fluid, if available) in a selective growth medium such as the InPouch system is the diagnostic method of choice. The diagnosis is based on identification of the morphology and characteristic rolling motility of the trichomonad. "High tech" molecular approaches may eventually offer greater diagnostic sensitivity than can culture methods, but currently they are no more accurate. In addition, serologic screening of the female herd (but interestingly, not the bulls) may become possible and may allow the practitioner to at least determine whether exposure has occurred in an unvaccinated herd. Control in an infected herd involves no pharmacologic treatment but rather culling of infected bulls, retention of younger, culture-negative bulls, and segregation of the female herd by reproductive status.

Trichomonas in pleural effusion

Numerous living trichomonads were seen in a parapneumonic pleural effusion, in a patient who was at risk of aspiration pneumonia because of acute alcoholism. Of all the drugs administered, metronidazole had the most favourable therapeutic effect. However, decortication was necessary for the successful outcome.

[The optimal time periods for the treatment of patients with venereal diseases at the hospital and at the outpatient clinic]

Results are reported on a study on treatment time of venereal diseases in conditions of a hospital and out-patient department. A questionnaire was sent to leading authorities in dermato-venereology of the Ukraine. The obtained data were systematized and evaluated. This allowed us to reconsider treatment time which would improve the quality, reduce treatment time with a good economic effect.

Vulvovaginitis

Often trivialized by the medical profession, vaginitis in adult women is not only extremely common but the source of considerable stress, and it often results in marked suffering. Epidemiologic studies described in this article indicate the high prevalence of vaginitis and the large number of causes. Although the majority of infections in women are due to BV, VVC, and trichomoniasis, it is clear that many other causes exist, and we have yet to discover the cause of many clinical syndromes. Considerable progress in understanding the pathogenesis of the three common vaginitides has been made. Although excellent progress has been made by the pharmaceutical industry in providing new drugs for vaginitis, any further progress will require a better understanding of cause and pathogenesis. Vaginitis causes major symptoms and is more than a nuisance problem. Clinicians owe it to their patients to make efforts to make an accurate diagnosis and not to rely on empiric therapy.