Human Reproduction vol.7 no.9 pp.1330-1334, 1992
Sexually transmitted diseases
P.G.Crosignani, E.Dkzfalusy1, J.Newton2 and B.Rubin3 II Department of Obstetrics and Gynaecology, University of Milan, Italy, 'Department of Reproductive Endocrinology, Karolinska Institute, Stockholm, Sweden, 2Department of Obstetrics and Gynaecology, University of Birmingham, UK and 3Via Lipari 4, Milan, Italy The recommendations of the ESHRE workshop on 'Sexually Transmitted Diseases', held in Anacapri, August 30-31, 1991 are given below. P.G.Crosignani, E.Diczfalusy, J.Newton and B.Rubin prepared the guidelines on behalf of the group. Speakers: J.Cohen (France), E.Diczfalusy (Sweden), K.Diedrich (FRG), M.Ghione (Italy), E.Houang (UK), J.Newton (UK), J.Orfila (France) Invited discussants: G.Benagiano (Italy), R.G.Edwards (UK), M.Seppala (Finland), A.Van Steirteghem (Belgium)
there are 60—80 million infertile couples. Perinatal maternal deaths are still too high at 0.5 million, and infant and child mortality comprises 13 million. There are 51 million deaths per annum worldwide. Each year there are some 250 million new cases of STDs; among those are 120 million cases of trichomoniasis, 50 million of genital chlamydia and 30 million of genital papilloma virus, 25 million cases of gonorrhoea and 20 million of genital herpes. Furthermore, some 3.5 million new cases of syphilis, 2.0 million cases of chancroid and more than a million human immunodeficiency virus (HTV) infections are reported to WHO each year. WHO predicts that over the next 8 years, the cumulative number of adults and children infected with HIV will triple, or quadruple, rising from the current 9 - 1 1 million to 30-40 million by the turn of the century. Indeed, issues related to reproductive health constitute a major part of the health problems of most countries (Sadik, 1990; Fathalla, 1991). Biological background
The Workshop was an ESHRE meeting organized under the auspices of the National Research Council of Italy and sponsored by Schering (Italy). Aim of the Workshop The purpose of the Workshop was to review the available data on sexually transmitted diseases (STDs) with particular emphasis on prevention and clinical investigation. Recommendations are also made with regard to treatment of the common STDs. However, as an ESHRE workshop, the recommendations for antibiotic use reflect those available to European countries. When choosing an appropriate treatment, local availability may ultimately determine the final choice of drug. We have attempted to produce simple guidelines to a rapidly growing, medically important yet complicated area of prevention and treatment. Introduction Public health The four fundamental pillars of reproductive health policy are family planning, maternal care, child care and the control of sexually transmitted diseases. Recent estimates of the most important global indicators of reproductive health by the World Health Organization suggest that in 1990, 400 million couples had no access to family planning and that 40—60 million induced abortions were carried out per year (WHO, 1990). In addition 1330
Immediately after World War JJ, only four types of STD were known: syphilis, gonorrhoea, chancroid and Lymphogranuloma venereum (LGV). Today the list of STDs includes infections by bacteria (Neisseria, Chlamydia, Treponema, Gardnerella, Haemophilus, Donovania, Mycoplasma, Enterobacteria), viruses (human immunodeficiency virus, HIV; herpes simplex virus, HSV; cytomegalo virus, CMV; human papilloma virus, HPV; molluscum contagosium, hepatitis virus), protozoa (Trichomonas, Giardia, Entamoeba, Cryptosporidium) and fungi (e.g. candidiasis). Until recently, the diagnosis and treatment of STDs have been divided among various disciplines on the basis of the topography of the main or most conspicuous lesions, the historical referral patterns for treatment in different countries, and the taxonomy of the parasites or the hosts' disease symptoms, with little or no attention to biological aspects. This means that the referral of suspected STDs is divided among the 'domains' of urologists, gynaecologists, dermatologists, specialists in infectious diseases, and most recently, microbiologists. A unifying framework is clearly needed. The pathogenesis and disease course are often modulated by the host immune response. This is well known for systemic diseases, but it is also known that strictly localized infections of the lower genital tract (such as trichomoniasis and Gardnerella) can elicit a systemic immune reaction (Ghione etal., 1989a). The lower genito-urinary mucosal surfaces are normally colonized by many species of microorganisms which can be either transient or resident. For the upper tract, the major determinant is the ability of the microorganism to adhere to mucosal cells. © Oxford University Press
Sexually transmitted diseases
Under normal conditions, organisms which cannot attach are washed away by the continuous or intermittent stream of fluids (transudate, mucus, glandular secretions and urine). A number of factors can interfere with this physiological process. One of these is rnalformations, others are associated with stagnant vaginal fluid which favours the multiplication of bacteria. In addition, bacteria adhere tenaciously to fibres and particularly to the encrusted ones (Ghione et al., 1989b). The result is that the prevalence of lower genital tract infections with apparently trivial opportunistic organisms is increasing. Clearly, prevention of STD is the most efficient way to decrease its prevalance.
examination. Despite the primary complaint often being a lower or upper genital tract infection, it is important to examine adjacent orifices (anus and urethra) and other common sites of infection (e.g. skin and mouth). Warning signs which suggest genital tract infection include purulent vaginal discharge, lower abdominal or pelvic pain, cervical excitation pain, fever, adnexal mass, dyspareunia and/or dysurea, and symptoms in the partner of an as yet asymptomatic female. Eighty per cent of all genital tract infections in women < 25 years of age are sexually transmitted. However, it is worth remembering that there may be other causes, e.g. tuberculosis.
Risk factors
Vaginal infections Following a full and complete history and examination, it is important to prepare a wet film for immediate microscopy and then to take appropriate swabs for culture. The technique and timing of taking swabs is important if reliable results are to be obtained. These include high vaginal and cervical canal swabs (together with swabs from urethra, rectum and mouth when appropriate). Prior to taking the cervical canal swabs, excess mucus must be removed. Lubricants, except clear water, should be avoided and a disposable vaginal speculum can be used if available. For the diagnosis of chlamydia, cells are required and therefore a cervical scrape or endometrial sample will be required. Swabs should be placed in the appropriate transport media and taken to the laboratory immediately (Taylor-Robinson and Thomas, 1991). For the diagnosis of individual causative agents, the following schedule is recommended: Wet film. For immediate examination, it may be necessary to dilute thick secretions with a few drops of sterile water. This film will usually allow confirmation of trichomoniasis and candidiasis. Laboratory confirmation may be needed for certain subclinical infections and to type organisms and fungi. It is advisable for patients not to use tampons or vaginal douching for a few hours prior to the examination. Potassium hydroxide test. A drop of potassium hydroxide (10%) is added to a separate drop of vaginal secretion on a slide. Liberation of an offensive odour indicates bacterial vaginosis. If gonorrhoea is suspected, all the appropriate swabs are taken into transport medium. The swabs should include high vaginal and cervical canals, anus and urethra and, where appropriate, oral cavity. Chlamydia. Serum antibodies are useless for diagnosis, since they may reflect a past infection. By the age of 15 years, 50% of women have antibodies to Chlamydia pneumoniae. Chlamydia antigens nowadays are generally detected by an enzyme-linked immunosorbent assay (ELJSA) or immunofluorescent method, depending on the source of the specimens. Cell culture is still the reference method and may be needed (Taylor-Robinson and Thomas, 1991). Syphilis. Diagnosis is made by serology (Venereal Disease Research Laboratory, VDRL). If only negative results are obtained in the above screening tests, it is usually worthwhile to take specialized specimens for mycoplasma and ureaplasma, before beginning treatment. If viruses are suspected, then it is worthwhile screening the patient for herpes, which is best done by tissue culture. However,
Risk factors for STDs are: 1. Living in an endemic area. 2. An inappropriate life-style; this includes poor hygiene, drug abuse, early onset of and frequency of sexual activity and number of partners, of age
Sexually transmitted diseases
P.G.Crosignani, E.Dkzfalusy1, J.Newton2 and B.Rubin3 II Department of Obstetrics and Gynaecology, University of Milan, Italy, 'Department of Reproductive Endocrinology, Karolinska Institute, Stockholm, Sweden, 2Department of Obstetrics and Gynaecology, University of Birmingham, UK and 3Via Lipari 4, Milan, Italy The recommendations of the ESHRE workshop on 'Sexually Transmitted Diseases', held in Anacapri, August 30-31, 1991 are given below. P.G.Crosignani, E.Diczfalusy, J.Newton and B.Rubin prepared the guidelines on behalf of the group. Speakers: J.Cohen (France), E.Diczfalusy (Sweden), K.Diedrich (FRG), M.Ghione (Italy), E.Houang (UK), J.Newton (UK), J.Orfila (France) Invited discussants: G.Benagiano (Italy), R.G.Edwards (UK), M.Seppala (Finland), A.Van Steirteghem (Belgium)
there are 60—80 million infertile couples. Perinatal maternal deaths are still too high at 0.5 million, and infant and child mortality comprises 13 million. There are 51 million deaths per annum worldwide. Each year there are some 250 million new cases of STDs; among those are 120 million cases of trichomoniasis, 50 million of genital chlamydia and 30 million of genital papilloma virus, 25 million cases of gonorrhoea and 20 million of genital herpes. Furthermore, some 3.5 million new cases of syphilis, 2.0 million cases of chancroid and more than a million human immunodeficiency virus (HTV) infections are reported to WHO each year. WHO predicts that over the next 8 years, the cumulative number of adults and children infected with HIV will triple, or quadruple, rising from the current 9 - 1 1 million to 30-40 million by the turn of the century. Indeed, issues related to reproductive health constitute a major part of the health problems of most countries (Sadik, 1990; Fathalla, 1991). Biological background
The Workshop was an ESHRE meeting organized under the auspices of the National Research Council of Italy and sponsored by Schering (Italy). Aim of the Workshop The purpose of the Workshop was to review the available data on sexually transmitted diseases (STDs) with particular emphasis on prevention and clinical investigation. Recommendations are also made with regard to treatment of the common STDs. However, as an ESHRE workshop, the recommendations for antibiotic use reflect those available to European countries. When choosing an appropriate treatment, local availability may ultimately determine the final choice of drug. We have attempted to produce simple guidelines to a rapidly growing, medically important yet complicated area of prevention and treatment. Introduction Public health The four fundamental pillars of reproductive health policy are family planning, maternal care, child care and the control of sexually transmitted diseases. Recent estimates of the most important global indicators of reproductive health by the World Health Organization suggest that in 1990, 400 million couples had no access to family planning and that 40—60 million induced abortions were carried out per year (WHO, 1990). In addition 1330
Immediately after World War JJ, only four types of STD were known: syphilis, gonorrhoea, chancroid and Lymphogranuloma venereum (LGV). Today the list of STDs includes infections by bacteria (Neisseria, Chlamydia, Treponema, Gardnerella, Haemophilus, Donovania, Mycoplasma, Enterobacteria), viruses (human immunodeficiency virus, HIV; herpes simplex virus, HSV; cytomegalo virus, CMV; human papilloma virus, HPV; molluscum contagosium, hepatitis virus), protozoa (Trichomonas, Giardia, Entamoeba, Cryptosporidium) and fungi (e.g. candidiasis). Until recently, the diagnosis and treatment of STDs have been divided among various disciplines on the basis of the topography of the main or most conspicuous lesions, the historical referral patterns for treatment in different countries, and the taxonomy of the parasites or the hosts' disease symptoms, with little or no attention to biological aspects. This means that the referral of suspected STDs is divided among the 'domains' of urologists, gynaecologists, dermatologists, specialists in infectious diseases, and most recently, microbiologists. A unifying framework is clearly needed. The pathogenesis and disease course are often modulated by the host immune response. This is well known for systemic diseases, but it is also known that strictly localized infections of the lower genital tract (such as trichomoniasis and Gardnerella) can elicit a systemic immune reaction (Ghione etal., 1989a). The lower genito-urinary mucosal surfaces are normally colonized by many species of microorganisms which can be either transient or resident. For the upper tract, the major determinant is the ability of the microorganism to adhere to mucosal cells. © Oxford University Press
Sexually transmitted diseases
Under normal conditions, organisms which cannot attach are washed away by the continuous or intermittent stream of fluids (transudate, mucus, glandular secretions and urine). A number of factors can interfere with this physiological process. One of these is rnalformations, others are associated with stagnant vaginal fluid which favours the multiplication of bacteria. In addition, bacteria adhere tenaciously to fibres and particularly to the encrusted ones (Ghione et al., 1989b). The result is that the prevalence of lower genital tract infections with apparently trivial opportunistic organisms is increasing. Clearly, prevention of STD is the most efficient way to decrease its prevalance.
examination. Despite the primary complaint often being a lower or upper genital tract infection, it is important to examine adjacent orifices (anus and urethra) and other common sites of infection (e.g. skin and mouth). Warning signs which suggest genital tract infection include purulent vaginal discharge, lower abdominal or pelvic pain, cervical excitation pain, fever, adnexal mass, dyspareunia and/or dysurea, and symptoms in the partner of an as yet asymptomatic female. Eighty per cent of all genital tract infections in women < 25 years of age are sexually transmitted. However, it is worth remembering that there may be other causes, e.g. tuberculosis.
Risk factors
Vaginal infections Following a full and complete history and examination, it is important to prepare a wet film for immediate microscopy and then to take appropriate swabs for culture. The technique and timing of taking swabs is important if reliable results are to be obtained. These include high vaginal and cervical canal swabs (together with swabs from urethra, rectum and mouth when appropriate). Prior to taking the cervical canal swabs, excess mucus must be removed. Lubricants, except clear water, should be avoided and a disposable vaginal speculum can be used if available. For the diagnosis of chlamydia, cells are required and therefore a cervical scrape or endometrial sample will be required. Swabs should be placed in the appropriate transport media and taken to the laboratory immediately (Taylor-Robinson and Thomas, 1991). For the diagnosis of individual causative agents, the following schedule is recommended: Wet film. For immediate examination, it may be necessary to dilute thick secretions with a few drops of sterile water. This film will usually allow confirmation of trichomoniasis and candidiasis. Laboratory confirmation may be needed for certain subclinical infections and to type organisms and fungi. It is advisable for patients not to use tampons or vaginal douching for a few hours prior to the examination. Potassium hydroxide test. A drop of potassium hydroxide (10%) is added to a separate drop of vaginal secretion on a slide. Liberation of an offensive odour indicates bacterial vaginosis. If gonorrhoea is suspected, all the appropriate swabs are taken into transport medium. The swabs should include high vaginal and cervical canals, anus and urethra and, where appropriate, oral cavity. Chlamydia. Serum antibodies are useless for diagnosis, since they may reflect a past infection. By the age of 15 years, 50% of women have antibodies to Chlamydia pneumoniae. Chlamydia antigens nowadays are generally detected by an enzyme-linked immunosorbent assay (ELJSA) or immunofluorescent method, depending on the source of the specimens. Cell culture is still the reference method and may be needed (Taylor-Robinson and Thomas, 1991). Syphilis. Diagnosis is made by serology (Venereal Disease Research Laboratory, VDRL). If only negative results are obtained in the above screening tests, it is usually worthwhile to take specialized specimens for mycoplasma and ureaplasma, before beginning treatment. If viruses are suspected, then it is worthwhile screening the patient for herpes, which is best done by tissue culture. However,
Risk factors for STDs are: 1. Living in an endemic area. 2. An inappropriate life-style; this includes poor hygiene, drug abuse, early onset of and frequency of sexual activity and number of partners, of age
