Allergic reactions of the lower genital tract in women: diagnosis, therapy, prevention, and long-term follow-up strategies. A review

Background Schistosoma (S.) haematobium is a neglected tropical disease which may affect any part of the genital tract in women. Female genital schistosomiasis (FGS) may cause abnormal vaginal discharge, contact bleeding, genital tumours, ectopic pregnancies and increased susceptibility to HIV. Symptoms may mimic those typical of sexually transmitted infections (STIs) and women with genital schistosomiasis may be incorrectly diagnosed. An expert consensus meeting suggested that the following findings by visual inspection should serve as proxy indicators for the diagnosis of schistosomiasis of the lower genital tract in women from S. haematobium endemic areas: sandy patches appearing as (1) single or clustered grains or (2) sandy patches appearing as homogenous, yellow areas, or (3) rubbery papules. In this atlas we aim to provide an overview of the genital mucosal manifestations of schistosomiasis in women.Methodology/Principal findingsPhotocolposcopic images were captured from women, between 1994 and 2012 in four different study sites endemic for S. haematobium in Malawi, Zimbabwe, South Africa and Madagascar. Images and specimens were sampled from sexually active women between 15 and 49 years of age. Colposcopic images of other diseases are included for differential diagnostic purposes.SignificanceThis is the first atlas to present the clinical manifestations of schistosomiasis in the lower female genital tract. It will be freely available for online use, downloadable as a presentation and for print. It could be used for training purposes, further research, and in clinical practice.

Gonorrhea is a highly prevalent disease resulting in significant morbidity worldwide, with an estimated 106 cases reported annually. Neisseria gonorrhoeae, the causative agent of gonorrhea, colonizes and infects the human genital tract and often evades host immune mechanisms until successful antibiotic treatment is used. The alarming increase in antibiotic-resistant strains of N. gonorrhoeae, the often asymptomatic nature of this disease in women and the lack of a vaccine directed at crucial virulence determinants have prompted us to perform transcriptome analysis to understand gonococcal gene expression patterns during natural infection. We sequenced RNA extracted from cervico-vaginal lavage samples collected from women recently exposed to infected male partners and determined the complete N. gonorrhoeae transcriptome during infection of the lower genital tract in women. On average, 3.19% of total RNA isolated from female samples aligned to the N. gonorrhoeae NCCP11945 genome and 1750 gonococcal ORFs (65% of all protein-coding genes) were transcribed. High expression in vivo was observed in genes encoding antimicrobial efflux pumps, iron response, phage production, pilin structure, outer membrane structures and hypothetical proteins. A parallel analysis was performed using the same strains grown in vitro in a chemically defined media (CDM). A total of 140 genes were increased in expression during natural infection compared to growth in CDM, and 165 genes were decreased in expression. Large differences were found in gene expression profiles under each condition, particularly with genes involved in DNA and RNA processing, iron, transposase, pilin and lipoproteins. We specifically interrogated genes encoding DNA binding regulators and iron-scavenging proteins, and identified increased expression of several iron-regulated genes, including tbpAB and fbpAB, during infection in women as compared to growth in vitro, suggesting that during infection of the genital tract in women, the gonococcus is exposed to an iron deplete environment. Collectively, we demonstrate that a large portion of the gonococcal genome is expressed and regulated during mucosal infection including genes involved in regulatory functions and iron scavenging.

The prevalence of idiopathic spontaneous premature labor or without an evident clinical cause, has not been reduced with tocolytic treatments, suggesting that premature labor has multiple causes and infections play a not well-defined role. To perform microbiological studies of the amniotic fluid and of the lower genital tract in women with idiopathic premature labor and intact membranes, relating these findings with maternal and neonatal outcomes. Women with pregnancies between 24 and 34 weeks, with premature labor and without an evident clinical cause were enrolled. Amniotic fluid and genital tract samples were obtained for traditional microbiological cultures. This information was related with delivery events and neonatal outcome. Sixty-three patients were included. The overall frequency of microbial invasion of amniotic cavity was 23.8% and of cervical or vaginal infection was 63.5% (in 39.7% there was only cervical or vaginal infection without involvement of the amniotic sac). Absence of infection was documented in 36.5% of women. Compared to patients without infection, women with microbial invasion of amniotic cavity had a higher rate of prematurity (73.3% p < 0.05), a higher rate of prematurity of less than 34 weeks (60% p < 0.01), a higher frequency of preterm rupture of membranes (40% p < 0.001), a shorter admission-to-delivery interval (median 3.0 days p < 0.01) and lower gestational age at delivery (median 33 weeks p < 0.01). Clinical chorioamnionitis and endometritis (20% p < 0.01) was observed only in patients with amniotic cavity infections. Severe asphyxia (26.7% p < 0.05) and neonatal admission to Intensive Care Units (46.7% p < 0.05) were more frequent and neonatal weight was less in the offspring of women with microbial invasion of amniotic cavity (2020 g median p < 0.01). In preterm labor with intact membranes, intraamniotic infection is the most frequent cause of prematurity and is associated with a higher prevalence of maternal and neonatal problems.

Health gains from screening for infection of the lower genital tract in women attending for termination of pregnancy

Persistent human papillomavirus (HPV) infections can cause intraepithelial neoplasia of the lower genital tract. Immune-compromised women have higher rates for all lower genital tract intraepithelial neoplasia. We wish to study the distribution of genital intraepithelial neoplasia in women with and without an immune system. The study consisted of 343 women with an abnormal genital lesion or cervical cytology who were referred to a gynecologic oncologist. All patients underwent vulva, vaginal, cervical and anal colposcopy. Any lesion detected was biopsied. Demographic and medical data were collected. The Chi-square test was used to determine the relationship between immunosuppression status and various variables, including sites of intraepithelial neoplasia. Immune-compromised women (N = 33) are more likely than immune-competent women (N = 310) to have intraepithelial neoplasia of the vulva (p < 0.05) and vagina (p < 0.05), but not more likely to have intraepithelial neoplasia of the anus or cervix. Immune-compromised women are more likely than immune-competent women to have multifocal intraepithelial neoplasia (p < 0.001). In addition, immune-compromised women are more likely to have higher grade disease of the vulva and vagina (p < 0.05), and no more likely to have higher grade disease on the cervix or anus than immune-competent women. Women with conditions suppressing the immune system are at higher risk for HPV-related disease outside of the cervix and for worse HPV-related diseases than immune-competent women. This study highlights the need for vigilant evaluation of the complete lower genital tract in women with immune-compromised systems.

The aim of this paper was to determine the incidence of high-grade squamous intraepithelial lesion (HSIL) and cancer of lower genital tract in patients with anogenital warts and their treatment. Between 1 September 1988 and 30 June 1994, 221 consecutive women with anogenital warts were prospectively examined in the colposcopy outpatient clinic. In 2004, the same group of patients was re-examined. There were abnormal cytological findings in 111 (50.2%) patients; 31 patients (14.0%) had HSIL, and 6 of them (2.7%) had cancer. There were abnormal colposcopic findings in 152 (68.8%) women; 78 women (35.3%) had abnormal histological findings. In the histological findings, HSIL was found in 41 (18.5%) women and cancer in 6 (2.7%). In spite of the fact that anogenital warts are caused by HPV types of low oncogenic risk (6/11), there is an increased incidence of HSIL and cancer in these women. Therefore, women with anogenital warts belong to an increased risk group regarding the cancer of lower genital tract, especially if they are associated with HPV types of a high oncogenic risk.

Nine genera of microbes isolated from the lower genital tract of 187 women in labour in Zaria have been identified. The work was undertaken to establish the nature of microorganisms in the lower genital tract of women in labour as a basis for further study. The isolates in order of prevalence were: Candida albicans (20.9%), Klebsiella sp (15.0%), Escherichia coli (9.1%), Streptococcus faecalis (6.4%), haemolytic streptococci (other than Streptococcus pyogenes (2.7%), Streptococcus viridans (2.1%), Staphylococcus aureus (2.1%), Aeromonas hydrophila (2.1%), Proteus mirabilis (1.1%), Peptostreptococcus putridus (1.1%), Streptococcus pyogenes (0.5%), and Streptococcus pneumoniae (0.5%). Neisseria gonorrhoeae, Haemophilus sp, Lactobacillus sp, and Clostridium sp were sought but not found. Chlamydia, viruses, and T-strains of mycoplasma and trichomonas were not sought. It appears from this study that the lower genital tract of most women in Zaria at the time of labour is heavily colonised by pathogens. For this reason alone prolonged labour and trauma to the genital tract at the time of delivery should be avoided.

Human papillomavirus (HPV) is the most common sexually transmitted infection. An increasing number of scientific works are devoted to studying the role of HPV in reproductive disorders in infertile couples. This virus is one of the most common sexual infections among men and women. Although most studies have focused on the oncogenic properties of HPV, the impact of the virus on fertility and reproductive capacity remains poorly understood.The objective: to assess the clinical significance of the impact of HPV infection in women with infertility based on clinical and laboratory indicators of HPV viral load and the state of the vaginal microbiome.Materials and methods. A survey of 184 women of reproductive age (20–40 years, mean age – 31–35 years) with infertility was conducted. 58 persons of them were diagnosed with infertility, chronic inflammatory processes of the female genital organs and positive HPV status (main group). The comparison group included 50 healthy women of reproductive age without HPV infection.Polymerase chain reaction (PCR) was used to detect HPV, as well as bacterioscopic, bacteriological methods and PCR to determine microbiological status. The results were analyzed using parametric and nonparametric statistical methods.Results. HPV was found in 31.5% of women with infertility, of which 60.3% had high-risk oncogenic strains – the most common were HPV-16, HPV-31 and HPV-53. HPV persistence was determined in 63.8% of cases. Secondary infertility was diagnosed in 74.1% of women in the main group, while primary infertility was diagnosed in 25.9%. A relationship was established between the presence of HPV and an increased risk of pregnancy complications, such as spontaneous abortions (20.7%) and recurrent miscarriage (8.6%).Gynecological examinations revealed a high level of chronic inflammatory processes of the genital organs in patients in the main group: vulvovaginitis (51.7%), inflammation of the appendages (31%), uterus (17.2%), as well as cervical pathologies, including background diseases (22.4%) and precancerous conditions (75.8%). HPV infection was often combined with other infections, such as Chlamydia trachomatis (8.6%), Ureaplasma urealyticum (24.1%), Mycoplasma hominis (27.6%).Imbalance of the vaginal microbiome, manifested by a decreased number of Lactobacillus (87.9%) and an increased amount of opportunistic microflora (Staphylococcus spp., Enterococcus faecalis, Gardnerella vaginalis), correlated with HPV persistence. Women with HPV and bacterial vaginosis had the highest degree of microbiome imbalance.Conclusions. HPV infection and its persistence significantly affect the course of chronic inflammatory diseases of the female genital organs and the reproductive function of women. HPV infection is associated with an increased risk cervical dysplasia, inflammatory diseases and obstetric complications. It is important to introduce HPV vaccination to prevent infection, as well as correct the microbiome imbalance as a component of complex treatment.

Background: Urogenital chlamydia is one of the most prevalent sexually transmitted infections, often asymptomatic and associated with infertility and pregnancy loss. Treating chlamydial cervicitis in women with cicatricial cervical deformity is particularly challenging, as structural abnormalities promote chronic infection and reduce the effectiveness of standard antibiotic therapy.Aims: To improve treatment outcomes for chlamydial infections of the lower genital tract in women with cicatricial cervical deformity through a combined approach that includes reconstructive surgery.Materials and methods: This single-center, nonrandomized, prospective study enrolled 91 women aged 18 to 45 years with laboratory-confirmed urogenital Chlamydia trachomatis infection. Participants were allocated into three groups: group A (n = 30) included women with cicatricial cervical deformity who underwent reconstructive surgery (Eltsov-Strelkov technique) combined with antibiotic therapy (doxycycline, 100 mg twice daily for 21 days); group B (n = 31) consisted of women with cicatricial cervical deformity who received antibiotic therapy alone; group C (n = 30, control) comprised women with normal cervical canal architecture treated with doxycycline only. Recurrence of chlamydial infection was assessed clinically and by polymerase chain reaction (PCR) at 1- and 12-months posttreatment.Results: At 1 month posttreatment, the efficacy of doxycycline monotherapy in women with cicatricial cervical deformity (group B) was 83.3%, compared with 96.7% in patients with normal cervical anatomy (group C). The combined approach in group A achieved a 96.8% success rate. At 12 months, a significant decrease in treatment efficacy was observed in group B, dropping to 76.7% (p&lt;.05), while the outcomes in group A remained stable (96.8%) and were comparable to those in the control group (96.7%).Conclusions: Combining reconstructive surgery with antibiotic therapy significantly improves treatment outcomes for urogenital chlamydia in women with cicatricial cervical deformity by reducing recurrence and enhancing local immune responses.

Sexually transmitted diseases (STDs) in women are of great concern to all health-care providers since many of them are preventable and/or treatable conditions which, if left untreated, could have serious sequelae such as pelvic inflammatory disease, infertility, cervical cancer, systemic disease, etc. They may also become a major public health problem when dealing with diseases such as hepatitis, etc., or in people with human immunodeficiency virus. We present here a comprehensive review of the common causes of STDs and their treatment.

Trichomonas vaginalis is a flagellate protozoan parasite and commonly infected the lower genital tract in women and men. Iron is a known nutrient for growth of various pathogens, and also reported to be involved in establishment of trichomoniasis. However, the exact mechanism was not clarified. In this study, the author investigated whether the 120 kDa protein of T. vaginalis may be involved in pathogenicity of trichomonads. Antibodies against 120 kDa protein of T. vaginalis, which was identified as pyruvate:ferredoxin oxidoreductase (PFOR) by peptide analysis of MALDI-TOF-MS, were prepared in rabbits. Pretreatment of T. vaginalis with anti-120 kDa Ab decreased the proliferation and adherence to vaginal epithelial cells (MS74) of T. vaginalis. Subcutaneous tissue abscess in anti-120 kDa Ab-treated T. vaginalis-injected mice was smaller in size than that of untreated T. vaginalis-infected mice. Collectively, the 120 kDa protein expressed by iron may be involved in proliferation, adhesion to host cells, and abscess formation, thereby may influence on the pathogenicity of T. vaginalis.

Genital chlamydial infections: Epidemiology and reproductive sequelae

Vaginitis, an infection of the lower genital tract in women, is known to be triggered by the overgrowth of the vagina's naturally occurring microorganisms. This study looked at the prevalence of Candida spp. and age-related disparities amongst women presenting with vaginitis at the Obstetrics and Gynaecology (O&G) clinic in a tertiary hospital in Port Harcourt, Nigeria. One hundred high vaginal swabs were collected from pregnant and non-pregnant women and examined microscopically and microbiologically. Age-group 20-29 years had the highest incidence of candidal vaginitis. There was a higher occurrence of yeast cells in pregnant than in non-pregnant participants while the non-pregnant women had a greater level of bacterial cells. Forty (40) of the samples contained yeasts of Candida species representing a 40% prevalence. Three species of Candida were identified with C. albicans dominating. Of the 40 samples positive for Candida spp., 30 (75.0%) were confirmed to be C. albicans. The remaining isolates were C. tropicalis (15.0%) and C. parapsilosis (10.0%). The findings in this study would play a role in the future management of Candida-induced vaginitis.

For the past 30 years our incomplete understanding of perinatally acquired herpes infections has resulted in controversy. The lack of adequate data led to practice recommendations that have recently been changed regarding patients with recurrent herpes infection.^1,2We now recognize that most cases of neonatal herpes infections are not preventable with current approaches.³ From the late 1960s until the mid 1980s, the practice recommendation to prevent neonatal herpes consisted of performing weekly herpes cultures of the lower genital tract in women with a previous history of herpes followed by a cesarean delivery if lesions were present or if cultures were positive at the time of delivery. This practice recommendation was based on a small series of retrospectively gathered cases⁴and was generated without detailed knowledge of the natural history of genital or neonatal herpes (eg, differences between primary episode, nonprimary first episode, and recurrent episodes; and rates

To obtain success in the treatment of gonorrheal endocervicitis through the use of diathermy, one must maintain a clear perspective of the object sought for; i. e., destruction in situ of the thriving gonococcal organisms that are embedded in and protected by the tissues of the cervix. At the same time, the destructive agent should not produce or cause any permanent injury to the endocervical canal. We must accept the fact that carefully controlled clinical and laboratory study has definitely shown that gonorrhea persists in women largely because of the continued presence of the gonococcus in the paraurethral, the cervical and the endocervical glands. This, in the majority of instances, is the cause of the chronically infected lower genital tract in women. OTHER METHODS FOR DESTROYING THE GONOCOCCUS IN SITU Before the introduction of modern methods of heat induction, the favorite method for attempting to destroy the gonococcus in the