Reappraisal of Gram-staining and cultural techniques for the diagnosis of gonorrhoea in women.

A retrospective study of 209 consecutive cases of gonorrhoea showed that more than 98 per cent. of cases were detected by two sets of examinations at weekly intervals. This was compared with earlier results obtained at this clinic when only 86 per cent. of cases were detected by two examinations. It is believed that modifications in culture techniques were responsible for the improvement and that two tests are now sufficient to screen for gonococcal infection in the majority of patients when an efficient microbiological service is available. Because of the high incidence of infection in contacts of men with gonorrhoea, a third test is recommended for the small number of such patients who have negative results of their first two tests. This also serves to monitor the efficiency of the culture techniques. The majority of women with gonorrhoea attended because they were believed to be contacts of men with the disease but many attended of their own accord because they had symptoms. Mild symptoms were described by as many as 53-5 per cent. of all infected women. Nine cases of gonorrhoea were detected during the follow-up period. Three of the four cases which were thought to be due to treatment failure were detected at the first test, in contrast to the cases which were thought to be due to re-infection, the majority of which were diagnosed at subsequent tests. Constant surveillance of the accuracy of the diagnostic methods used in the detection of gonorrhoea in women is of great importance if errors are to be reduced to a minimum.     

Gonorrhoea in 1972. A 1-year study of patients attending the VD Unit in Uppsala.

During 1972 a total of 2,090 men and 1,489 women were seen in the VD clinic in Uppsala, Sweden. The most frequent diagnosis among the men was non-gonococcal urethritis (38 per cent.) and among the women non-gonococcal vaginitis (34 per cent.), N. gonorrhoeae was found in 22 per cent. of the men and in 33 per cent. of the women, 68 per cent. of the men with gonorrhoea attended because of symptoms, but 67 per cent. of the men without gonococcal infections came for the same reason. 39 per cent. of the women with gonorrhoea attended after being told by their sexual partner; it was found that women coming because of symptoms were most likely to have non-gonococcal infection. Gonorrhoea without subjective symptoms was found in 23 per cent. of the men and 50 per cent. of the women. Gonorrhoea was found in association with scabies in 9 out of 18 men and in 3 out of 5 women. A rising incidence of pharyngeal gonococcal infections has been noticed at the clinic and the figures for 1972 were 6 per cent. of the men and 9 per cnet. of the women with gonorrhoea. The route of infection was usually oro-genital contact, but in some cases other routes had to be considered. It was not possible to define a promiscuous group of patients suitable for a planned study of prophylactic treatment, as only 2 per cent. of the men and 1 per cent. of the women had had nore than one gonococcal infection during the preceding year. The standard treatment for genital gonorrhoea (ampicillin 2 times 1 g. orally with a 5-hour interval) was very satisfactory and gave a 98 per cent. cure rate. This was possible because there were few gonococcal strains with decreased panicillin sensitivity. There were considerable problems in treating the pharyngeal infections, the standard treatment failing in 61 per cent.     

Isolation of Chlamydia from women attending a clinic for sexually transmitted disease.

Cervical swabs for Chlamydia culture were collected from 638 unselected women attending a sexually transmitted diseases clinic with a fresh complaint. Chlamydia were isolated from 76 (12 per cent.) of the women. When the results were related to the patients' diagnoses, Chlamydia were present in 44 per cent. of women with gonorrhoea and in 22 per cent. of women who were contacts of men with nonspecific urethritis (women who may be regarded as having non-specific genital infection). Chlamydia were uncommon in women with no evidence of genital infection. Significant correlations were found between the presence of Chlamydia and cervical erosion, cervical cytological inflammatory change, and absence of symptoms. Isolates were obtained more frequently from women with non-specific genital infection who were primary contacts than from women who were secondary contacts. These findings support the concept that Chlamydia are pathogens in the genital tract and are sexually transmitted.     

Isolation of Chlamydia from women attending a clinic for sexually transmitted disease.

Cervical swabs for Chlamydia culture were collected from 638 unselected women attending a sexually transmitted diseases clinic with a fresh complaint. Chlamydia were isolated from 76 (12 per cent.) of the women. When the results were related to the patients' diagnoses, Chlamydia were present in 44 per cent. of women with gonorrhoea and in 22 per cent. of women who were contacts of men with nonspecific urethritis (women who may be regarded as having non-specific genital infection). Chlamydia were uncommon in women with no evidence of genital infection. Significant correlations were found between the presence of Chlamydia and cervical erosion, cervical cytological inflammatory change, and absence of symptoms. Isolates were obtained more frequently from women with non-specific genital infection who were primary contacts than from women who were secondary contacts. These findings support the concept that Chlamydia are pathogens in the genital tract and are sexually transmitted.     

Frequency of N. gonorrhoeae, T. vaginalis, and C. albicans in female venereological patients. A one-year study.

The frequency of Neisseria gonorrhoeae, Trichomonas vaginalis, and Candida albicans has been studied over a period of one year in women attending a venereal diseases clinic. A total of 1,347 women were investigated, all coming from the same catchment area. Gonorrhoea was established at the first visit in 506 patients (38 per cent.), who constituted 97.5 per cent. of the total number of cases of gonorrhoea. Trichomonas vaginalis was found in 272 (20 per cent.) and Candida albicans in 233 (17 per cent.). 176 patients (13 per cent.) had more than one pathogen. Of the patients attending, 22 per cent. (292 women) were so-called "named contacts". The frequency of gonorrhoea established at the first visit in these patients (64 per cent.), was significantly higher, but the frequency of symptoms did not differ from that in other gonorrhoea patients. The number of asymptomatic cases was so large that a single compulsory examination is undoubtedly very useful from the epidemiological point of view, but the value of repeated specimen collections for gonorrhoea is debatable. Complications of gonorrhoea were observed in 29 patients (6 per cent.) at the first visit.     

Diagnosis of gonorrhoea in women.

250 consecutive female contacts of men with gonorrhoea were examined in Lydia Department of Genito-urinary Medicine, St Thomas' Hospital, London, and 165 (66 per cent.) were found to be positive for gonorrhoea. Over 99 per cent. of the positive results were found by the first two sets of genital investigations. These results are compared with earlier and more recent results from our own and other centres and it is postulated that the higher early diagnosis rate is due to the introduction of a highly selective but non-inhibitory culture medium (VCNT), combined with a new incubator which accurately regulates temperature, humidity, and CO2 content. Reasons for the negative findings in 35 per cent. of the female gonorrhoea contacts are discussed.     

The role of the urban community hospital in gonorrhoea surveillance.

In a progressive surveillance programme designed to detect gonococcal infection in females, 113,063 women were screened for gonorrhoea in Memphis-Shelby County, Tennessee, during a 2-year period. The importance of including the urban community hospital in the surveillance programme is emphasized by the contribution of the City of Memphis Hospital where 53-3 per cent. of all positive cases of gonorrhoea were detected in only 34-2 per cent. of all tests done. The City of Memphis Hospital emergency room was an especially productive surveillance area, giving 29-0 per cent. of all positives with only 6-1 per cent. of all tests performed. The importance of taking routine cultures for gonococci from women presenting for prenatal care, delivery, or for genitourinary complaints in an urban hospital is stressed.     

Gonorrhoea in women and exposure to risk.

Data are presented on the characteristics of women with newly diagnosed gonorrhoea who attended Lydia Clinic, St. Thomas' Hospital, during a 6-month period. Although gonorrhoea in women is largely asymptomatic, there was strong circumstantial evidence to suggest that some women had attended because they had been exposed to risk. The proportion of women thus motivated was largest among those women who had attended a clinic for sexually transmitted diseases before--in which up to 40 per cent. of women had apparently attended entirely of their own accord. Women born in the West Indies differed from their counterparts born in the United Kingdom in three respects: they were younger, recorded fewer contacts, and referred themselves less frequently to the clinic for a first visit. Implications for health education and for future research are discussed.     

Gonorrhoea in women and exposure to risk.

Data are presented on the characteristics of women with newly diagnosed gonorrhoea who attended Lydia Clinic, St. Thomas' Hospital, during a 6-month period. Although gonorrhoea in women is largely asymptomatic, there was strong circumstantial evidence to suggest that some women had attended because they had been exposed to risk. The proportion of women thus motivated was largest among those women who had attended a clinic for sexually transmitted diseases before--in which up to 40 per cent. of women had apparently attended entirely of their own accord. Women born in the West Indies differed from their counterparts born in the United Kingdom in three respects: they were younger, recorded fewer contacts, and referred themselves less frequently to the clinic for a first visit. Implications for health education and for future research are discussed.     

Culture of urinary sediment for the diagnosis of gonorrhoea in women.

1,001 consecutive women seen in a V.D. clinic were screened for gonorrhoea by cultures of urinary sediment, the endocervix, and anal canal. Recovery of Neisseria gonorrhoeae on culture of urinary sediment was 81-7 per cent. as productive as culture of the endocervix, and 79-2 per cent. compared to endocervical and anal canal culturing. Urogenital symptoms were present in 55-1 per cent. of women with negative cultures and 64-6 per cent. of those with gonorrhoea. A complaint of dysuria increased the likelihood of a positive urinary sediment or endocervical culture. Culture of urinary sediment is less sensitive than culture of the endocervix. However, the ease with which specimens are obtained and the relative simplicity of the technique could make this method an acceptable tool for screening large numbers of women for gonorrhoea.     

Direct immunofluorescent test for the detection of gonorrhoea.

In the course of 4 years we have examined a total of 1,100 women with chronic gynaecological complaints. The direct fluorescent antibody test was used successfully for the detection of gonorrhoea. In Group 1 (200 patients) we found 39-1 per cent. with gonorrhoea. In group 2 (220 patients) the percentage fell to 27-7 per cent, in Group 3 (220 patients) to 23-2 per cent., in Group 4 (220 patients) to 12-3 per cent., and in Group 5 (220 patients) to 11-8 per cent. By employing a consistent programme of diagnosis and therapy we succeeded in reducing the incidence of gonorrhoea in the Prague 3 District from 39-1 per cent. in 1970 to 11-8 per cent. in 1973-74. In all we discovered 251 female patients suffering from gonorrhoea, who would otherwise have escaped observation and registration. When patients are not registered as sources of gonococcal infection, special cultures are not performed as a routine, and these women would therefore infect the same number of men at least. The immunofluorescent method proved to be of great value. The direct FAT is a superior test; even in cases in which, because of damage by such factors as antibiotics, Neisseria gonorrhoeae does not grow on artificial media, gonorrhoea can be detected by this method.     

Yeasts and circumcision in the male.

Sixty-six circumcised men and 69 uncircumcised men, both heterosexual and homosexual, had specimens taken from the coronal sulcus and meatus of the penis. Yeasts were isolated at similar rates in both the circumcised (14%) and uncircumcised (17%) men. The circumcised men had significantly fewer symptoms (P = 0-0058). Therefore the female partners of both circumcised and uncircumcised men are exposed to similar rates of yeast infection despite the absence of symptoms in circumcised men. Eighty per cent of the female contacts of yeast-positive men had yeast infection while 32% of the contacts of yeast-negative men were affected. This difference was statistically significant (0-05 greater than P greater than 0-025). Men with non-specific genital infection seemed more likely to carry yeasts than men with gonorrhoea or normal men.     

Yeasts and circumcision in the male.

Sixty-six circumcised men and 69 uncircumcised men, both heterosexual and homosexual, had specimens taken from the coronal sulcus and meatus of the penis. Yeasts were isolated at similar rates in both the circumcised (14%) and uncircumcised (17%) men. The circumcised men had significantly fewer symptoms (P = 0-0058). Therefore the female partners of both circumcised and uncircumcised men are exposed to similar rates of yeast infection despite the absence of symptoms in circumcised men. Eighty per cent of the female contacts of yeast-positive men had yeast infection while 32% of the contacts of yeast-negative men were affected. This difference was statistically significant (0-05 greater than P greater than 0-025). Men with non-specific genital infection seemed more likely to carry yeasts than men with gonorrhoea or normal men.     

Seroepidemiological study of gonorrhoea in Ethiopian women. 1. Prevalence and clinical significance.

OBJECTIVE--To measure the prevalence of gonorrhoea in Ethiopian women attending gynaecologic, obstetric and family planning clinics: to determine the reliability of patient self history of sexually transmitted disease (STD); to correlate the serological diagnosis of gonorrhoea with clinical evidence of pelvic infection in order to define a reliable clinical diagnosis of gonorrhoea in a country where pelvic inflammatory disease is very common but where routine laboratory culture and serological tests for gonorrhoea are unavailable. SUBJECTS--1851 Ethiopian women: 50% symptomatic, 50% asymptomatic. SETTING--Gynaecological outpatient department, antenatal, postnatal and family planning clinics (Ethiopian Family Guidance Association (EFGA)), in two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia. METHODS--The indirect haemagglutination test with gonococcal pilus antigen as an epidemiological tool was used in a cross-section study to screen 1851 sera for evidence of past or current gonococcal infection. The gonococcal antibody test (GAT) seropositivity was correlated with patient's history of STD, age, clinic attended and the clinical evidence of infection in "gonococcal target organs" urethra, salpinges or Bartholin glands. RESULTS--Fifty nine per cent of the study group were seropositive for the gonococcal antibody test, 22% with titres greater than or equal to 1/320, indicative of current, recent or recurrent infection. Seropositivity indicating past or present gonococcal infection was highest in those who gave a history of having had treated syphilis (85%), in women aged 40-49 (72%), and family planning attenders (EFGA) (66%) of whom 31% had titres greater than or equal to 1/320. Fifty per cent had clinical evidence of past or present infection in the urethra, salpinges or Bartholin glands. Gonococcal antibodies were present in 54% of women with no evidence of clinical infection, compared with 91% of those with pyosalpinx and 86% of those with triple infection of urethra, salpinges and Bartholin glands. CONCLUSION--The high prevalence of gonococcal antibodies in Ethiopian women, especially in asymptomatic clinic attenders must be of concern for all health workers especially those in gynaecology and obstetrics and the related disciplines of family planning and neonatal paediatrics. While seropositivity was highest in those giving a past history of syphilis, the patient's history of STD was unreliable, as of those who denied having any history of STD, fifty per cent were GAT seropositive. Despite a high correlation between GAT seropositivity with pyosalpinx and clinical evidence of infection in urethra, salpinges and bartholin glands, gonococcal antibodies were present in 54% of women with no clinical evidence of infection. Thus we were unable to define a diagnostic clinical picture of gonorrhoea in Ethiopian women.     

Gonorrhoea of the throat at a venereological clinic. Incidence and Results of Treatment.

Among 3,271 consecutive cases of gonorrhoea seen during the years 1971 to 1974, the incidence of tonsillar gonorrhoea was 3-6% in men and 5-8% in women. Oro-genital intercourse was admitted by 34% of men and 33% of women. Among these patients the incidence of tonsillar gonorrhoea was 7% in men and 16% in women. Only two cases of gonococcal septicaemia were seen, and there were no other complications. Few patients experienced symptoms from the throat. Tonsillar cultures was positive on the first examination in only 74%, it was negative until after single-dose treatment had been given in 18%.     

Gonorrhoea of the throat at a venereological clinic. Incidence and Results of Treatment.

Among 3,271 consecutive cases of gonorrhoea seen during the years 1971 to 1974, the incidence of tonsillar gonorrhoea was 3-6% in men and 5-8% in women. Oro-genital intercourse was admitted by 34% of men and 33% of women. Among these patients the incidence of tonsillar gonorrhoea was 7% in men and 16% in women. Only two cases of gonococcal septicaemia were seen, and there were no other complications. Few patients experienced symptoms from the throat. Tonsillar cultures was positive on the first examination in only 74%, it was negative until after single-dose treatment had been given in 18%.     

Blood ethanol concentrations in patients attending special clinics in Glasgow.

Blood samples for measurement of ethanol concentration were taken on a routine basis from 543 male and 158 female patients attending Special Clinics in Glasgow. Ethanol was detected in 56 (10-3 per cent.) of the men and eight (5-1 per cent.) of the women, and at concentrations in excess of 0-1 g./l. in 37 (6-8 per cent.) and three (1-9 per cent.) respectively. In nine men and one woman, the blood ethanol concentration was over 0-8 g./l. when they attended the clinic. The majority (84 per cent.) of positive findings were obtained in specimens collected after 2 p.m. and one-quarter on Tuesday afternoons, the local half-day. The other peak periods related to attendance at football matches on Wednesday evenings, and to receiving wages on Friday mornings. Male new patients attending a clinic for the first time had the highest incidence, 32 (11-6 per cent.) having detectable amounts of ethanol among whom 26 (9-4 per cent.) had levels in excess of 0-1 g./l., compared with only 4-1 per cent. among those either returning to the clinics with a fresh infection or on surveillance. Only 5 per cent. of female patients attending for the first time and 3 per cent. of those on surveillance had detectable amounts of ethanol in the blood, compared with 9 per cent. of those few returning with fresh infections. Levels in excess of 0-1 g./1. were only found in promiscuous women. Those with concentrations in excess of 0-8 g./1. were unreliable attenders. Only one, a known alcoholic, completed surveillance; one defaulted after his fourth visit, four after the second, and four after the first visit.     

Blood ethanol concentrations in patients attending special clinics in Glasgow.

Blood samples for measurement of ethanol concentration were taken on a routine basis from 543 male and 158 female patients attending Special Clinics in Glasgow. Ethanol was detected in 56 (10-3 per cent.) of the men and eight (5-1 per cent.) of the women, and at concentrations in excess of 0-1 g./l. in 37 (6-8 per cent.) and three (1-9 per cent.) respectively. In nine men and one woman, the blood ethanol concentration was over 0-8 g./l. when they attended the clinic. The majority (84 per cent.) of positive findings were obtained in specimens collected after 2 p.m. and one-quarter on Tuesday afternoons, the local half-day. The other peak periods related to attendance at football matches on Wednesday evenings, and to receiving wages on Friday mornings. Male new patients attending a clinic for the first time had the highest incidence, 32 (11-6 per cent.) having detectable amounts of ethanol among whom 26 (9-4 per cent.) had levels in excess of 0-1 g./l., compared with only 4-1 per cent. among those either returning to the clinics with a fresh infection or on surveillance. Only 5 per cent. of female patients attending for the first time and 3 per cent. of those on surveillance had detectable amounts of ethanol in the blood, compared with 9 per cent. of those few returning with fresh infections. Levels in excess of 0-1 g./1. were only found in promiscuous women. Those with concentrations in excess of 0-8 g./1. were unreliable attenders. Only one, a known alcoholic, completed surveillance; one defaulted after his fourth visit, four after the second, and four after the first visit.     

Shigellosis. Another sexually transmitted disease?

Following the clinical observation that there appeared to be an association between shigellosis and male homosexuality, the medical records of 113 patients at The New York Hospital were reviewed retrospectively. Of the 38 males studied who were between the ages 19 and 61, seventeen were homosexual (44-7 per cent.). Only one of the matched controls was homosexual. Of the men with shigellosis who had a history of foreign travel, 10 per cent. were homosexual; however, among the patients without a travel history, 57-1 per cent. were homosexual (P less than 0-05). For male patients with shigellosis who do not have an appropriate travel history, the physician should expand his epidemiological investigation to include sexual contacts. Men and women who perform rectal intercourse should be cautioned to abstain from this activity until their stool cultures are negative for shigella. If a male patient with shigellosis is homosexual, he should be screened for other sexually transmitted diseases such as syphilis, gonorrhoea, hepatitis B, and amoebiasis.     

Shigellosis. Another sexually transmitted disease?

Following the clinical observation that there appeared to be an association between shigellosis and male homosexuality, the medical records of 113 patients at The New York Hospital were reviewed retrospectively. Of the 38 males studied who were between the ages 19 and 61, seventeen were homosexual (44-7 per cent.). Only one of the matched controls was homosexual. Of the men with shigellosis who had a history of foreign travel, 10 per cent. were homosexual; however, among the patients without a travel history, 57-1 per cent. were homosexual (P less than 0-05). For male patients with shigellosis who do not have an appropriate travel history, the physician should expand his epidemiological investigation to include sexual contacts. Men and women who perform rectal intercourse should be cautioned to abstain from this activity until their stool cultures are negative for shigella. If a male patient with shigellosis is homosexual, he should be screened for other sexually transmitted diseases such as syphilis, gonorrhoea, hepatitis B, and amoebiasis.