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.     

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.     

Screening for sexually transmitted disease in London-based male prostitutes.

OBJECTIVE--To provide a screening service for sexually transmissible infections to male prostitutes working in the London area. DESIGN--An open access service recruiting by a diverse range of methods to avoid over-representation of the more visible elements of this group. SETTING--Department of genitourinary medicine in a London teaching hospital and a community-based clinic at a safe address. RESULTS--During the 10 months following the establishment of the service in June 1990, 57 male prostitutes (38 street based and 19 "escorts") were seen. Of these, 27 men (47%) were found to have evidence of such an infection. Twenty five per cent of the street-based men had serological evidence of previous infection with hepatitis B virus (HBV), 6% had positive syphilis serology, 9% had non-gonococcal urethritis (NGU), 18% had urethral and 13% rectal gonorrhoea. None had gonorrhoea at more than one site. Twenty-seven per cent of these men were HIV 1-antibody positive. Thirty-seven per cent of the escorts had serological evidence of previous infection with HBV, none had positive syphilis serology, 11% had NGU, 5% had urethral and 8% rectal gonorrhoea. None had gonorrhoea at more than one site. Twenty-five per cent of these men were HIV 1-antibody positive. CONCLUSION--Specific targeting of resources at this group of individuals is necessary to promote better health education and use of health care provisions.     

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.     

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.     

Chlamydial infection of the urethra in men.

Chlamydia trachomatis was isolated from the uretha of 125 (52%) of 238 men with non-gonococcal urethritis (NGU). Repeat isolation attempts in 155 of these patients were successful in eight men in whom results had been negative on the initial visit, but they were unsuccessful in eight men who initially had had positive cultures. We must assume that with our present isolation techniques we are missing, at any single visit, at least 9% of chlamydial infections. C. trachomatis was also found in 32 (23%) of 139 men with gonorrhoea. Positive cultures were obtained from 15 (79%) of 19 men, who later developed post-gonococcal urethritis (PGU). Thiamphenicol, used for the treatment of gonorrhoea, was shown to have very little effect on C. trachomatis, which could still be recovered after treatment in 76% of the patients who initially had had a combined infection. The typing of 35 genital isolates by micro-immunofluorescence confirms the previously reported distribution of chlamydial serotypes. In this study a social profile is given of our patients with urethritis and a comparison is made of the duration of symptoms and the nature of discharge in men with gonococcal, chlamydial, and non-specific urethritis. We were able to show a clear difference in clinical symptoms in men with gonorrhoea and NGU, taken as a whole, but found only a slight difference between men with chlamydial and non-specific urethritis.     

Chlamydial infections of the urethra in women.

Cervical and endourethral swabs from 360 untreated women attending a sexually transmitted disease (STD) clinic were cultured for Chlamydia trachomatis and other genitourinary pathogens. The patients included contacts of men with non-gonococcal urethritis, women with gonorrhoea, and those in whom symptoms suggestive of urinary tract infection were the main reasons for their attendance. Chlamydial infection of the urethra was less common than, and seldom occurred in the absence of, cervical chlamydial infection; it was frequently silent, producing no signs or symptoms of urethritis. Only 33/96 women with evidence of urethritis gave chlamydia positive urethral swabs, and 14 of them had other concurrent infections of the genitourinary tract. Chlamydia trachomatis thus does not appear to be a major cause of the signs and symptoms of urethritis commonly found in women attending STD clinics, and there seems to be no indication for taking routine urethral swabs to aid in the diagnosis of chlamydial infection in women.     

Prevalence of rectal and pharyngeal infection in women with gonorrhoea in Sheffield.

The prevalence of gonococcal infection of the rectum and pharynx in 239 consecutive women with gonorrhoea presenting as named contacts was 47% and 10% respectively. In 2% of all patients the rectum and pharynx were each the sole sites of infection. Treatment failure occurred in three patients given a single dose of aqueous procaine penicillin 2.4 megaunits intramuscularly, two of whom had rectal infections; no treatment failures occurred in patients with pharyngeal infections. The incidence of rectal gonorrhoea significantly increased with the duration of infection (P less than 0.001). This suggests that autoinoculation from infected vaginal material is of major importance in the transmission of gonococcal infection to the rectum.     

Chlamydial infection of the urethra in men

Chlamydia trachomatis was isolated from the uretha of 125 (52%) of 238 men with non-gonococcal urethritis (NGU). Repeat isolation attempts in 155 of these patients were successful in eight men in whom results had been negative on the initial visit, but they were unsuccessful in eight men who initially had had positive cultures. We must assume that with our present isolation techniques we are missing, at any single visit, at least 9% of chlamydial infections. C. trachomatis was also found in 32 (23%) of 139 men with gonorrhoea. Positive cultures were obtained from 15 (79%) of 19 men, who later developed post-gonococcal urethritis (PGU). Thiamphenicol, used for the treatment of gonorrhoea, was shown to have very little effect on C. trachomatis, which could still be recovered after treatment in 76% of the patients who initially had had a combined infection. The typing of 35 genital isolates by micro-immunofluorescence confirms the previously reported distribution of chlamydial serotypes. In this study a social profile is given of our patients with urethritis and a comparison is made of the duration of symptoms and the nature of discharge in men with gonococcal, chlamydial, and non-specific urethritis. We were able to show a clear difference in clinical symptoms in men with gonorrhoea and NGU, taken as a whole, but found only a slight difference between men with chlamydial and non-specific urethritis.     

Sexually transmitted diseases. The present situation in Sweden.

Overall in Sweden, variable trends are noted in the number of cases of gonorrhea reported between 1950 and 1976. Among teenagers, a marked decrease was noted between 1971 and 1974. Education and information activities as well as improved treatment may in part be responsible for the decrease. Changing sexual habits, e.g., decreased incidence of multiple partners, may also be responsible. The ratio of men to women with infections has decreased from 1.7:1 in 1961 to 1.1:1 in 1976. However, most patients visiting clinics for the treatment of sexually transmitted diseases (STD) are not suffering from the traditional venereal diseases. Records from 1 STD clinic serving an area of approximately 150,000 inhabitants provides an indication of the incidence of STDs. In the period from 1972-1976, gonorrhea was diagnosed in 16.6% of the men and 27.2% of the women visiting the clinic. The most frequent diagnosis for men was non-gonococcal urethritis (NGU) (35.1%) and for women, non-gonococcal vaginitis was found in 26.7%. Unlike reports from England, no widespread increase in NGU was evident from the clinic records. Complicated gonococcal infections occurred in 14.5% of all diagnosed cases of gonorrhea in women and 1.7% of the cases in men. Records from 1974, indicate that 7% of the men and 9% of the women with genital gonorrhea also had infections on the tonsillar-pharyngeal region. Research into the role of Chlamydia trachomatis in both NGU and salpingitis (the most frequent type of complicated gonorrhea for women) is underway. Recent statements by the Swedish Social Health Board suggest that the number of regulations concerning venereal diseases will be reduced in the near future.     

Risk factors for gonorrhoea: case-control study.

OBJECTIVE: To define risk factors for gonococcal infection. METHODS: A case-control study comparing 200 gonorrhoea cases with 400 patients with non-gonococcal genitourinary infections and 400 patients with various skin diseases, all of them attending City Department for Skin and Venereal Diseases In Belgrade (Yugoslavia) from October 1993 to December 1994. RESULTS: According to multivariate logistic regression analysis the following factors were significantly related to gonorrhoea in men: education level, sexual contact same day as meeting, condom use, history of prior gonorrhoea, and casual and/or new sex partner in the past month. Age, sexual contact same day as meeting, number of partners in the past year, and frequency of sexual intercourse in the past month were independently, significantly related to gonorrhoea in women. Also, in females, gonorrhoea was significantly more frequent in industrial workers and supported people. CONCLUSION: Since sexual behaviour, low education level, younger ages, and low socioeconomic status were found to be related to gonococcal infection, health education at early age seems to be the most appropriate means of altering high risk behaviour.     

Three years'' experience of sexually transmitted diseases in Seville, Spain.

At present there are no reliable statistics on the relative prevalences of sexually transmitted diseases (STDs) in Spain. In a report of the first three years' experience in an STD diagnostic centre between 1977 and 1979 a total of 879 patients (534 men adn 345 women) were seen. They mainly consisted of university students and the mean age was 22 years in 1977 and 23 years in the following two years. All the patients were examined for syphilis and all women for gonorrhoea and trichomoniasis. Investigations for Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, Candida albicans, and Herpesvirus hominis infections were carried out according to the presenting symptoms. Non-specific genital infections occurred most commonly (25.7%); chlamydia were isolated from 30% of the patients with non-gonococcal urethritis (NGU). The second commonest infection was candidosis (13.5%). Gonorrhoea, which was found in 10.6% of the patients, was diagnosed more frequently in men (13.5%) than in women (6%). No strains of beta-lactamase-producing Neisseria gonorrhoeae were detected and all were sensitive to penicillin. Syphilis was diagnosed in 4.4% of patients (2% women and 5% men). Condylomata acuminata were diagnosed in 2.8% of patients and more frequently in men (4%). Herpes genitalis and venereophobia were uncommon (1.9% and 1.2% respectively) and were diagnosed only in men.     

Prevalence of rectal and pharyngeal infection in women with gonorrhoea in Sheffield

The prevalence of gonococcal infection of the rectum and pharynx in 239 consecutive women with gonorrhoea presenting as named contacts was 47% and 10% respectively. In 2% of all patients the rectum and pharynx were each the sole sites of infection. Treatment failure occurred in three patients given a single dose of aqueous procaine penicillin 2.4 megaunits intramuscularly, two of whom had rectal infections; no treatment failures occurred in patients with pharyngeal infections. The incidence of rectal gonorrhoea significantly increased with the duration of infection (P less than 0.001). This suggests that autoinoculation from infected vaginal material is of major importance in the transmission of gonococcal infection to the rectum.     

Single dose ciprofloxacin for treating gonococcal infections in men.

A single oral dose of ciprofloxacin 500 mg was used to treat five men with gonococcal urethritis and five men with gonococcal proctitis, and all were cured. In a subsequent study the dose of ciprofloxacin was reduced to 250 mg, and 54 men with 57 gonococcal infections (47 urethral, seven rectal, and three pharyngeal) were treated; of the isolates of Neisseria gonorrhoeae, four were penicillinase producing strains. All the patients were cured of gonococcal infection. Urethral specimens from nine of the men with gonococcal urethritis yielded Chlamydia trachomatis before treatment. These organisms were isolated again from all these patients seven days after treatment, and from a further seven men who had been chlamydia negative before treatment. It is concluded that a single oral dose of ciprofloxacin is an effective treatment for uncomplicated gonorrhoea, but is ineffective against C trachomatis. Of the 54 men given 250 mg ciprofloxacin, six (11%) showed minor abnormalities of liver function tests after treatment.     

Chlamydial infection of the male urethra.

Urethral specimens from 477 men were collected with endourethral swabs and examined for Chlamydia trachomatis by cell culture on McCoy cells pretreated with idoxuridine. Of these men, 141 had gonococcal urethritis, 262 non-gonococcal urethritis (NGU), and 74 showed no evidence of urethritis. Of 118 men with heterosexually acquired gonococcal urethritis, thirty (25 per cent.), and of 23 men with homosexually acquired gonococcal urethritis, five (22 per cent.), yielded C. trachomatis from the urethra. Urethral specimens from 240 heterosexual men with NGU were examined, and 118 (49 per cent.) yielded C. trachomatis. Of these 240 men, 140 gave a past history of gonococcal or nongonococcal urethritis and 67 (48 per cent.) of these were positive for C. trachomatis; no past history was given by 100 men, of whom 51 were positive for C. trachomatis. Of the 240 heterosexual men with NGU, 81 had had symptoms for 7 days or more before examination, of whom 48 (59 per cent.) yielded isolates of C. trachomatis, and 145 had had symptoms for less than 7 days, of whom 59 (41 per cent.) yielded isolates. Of fourteen asymptomatic men, three were positive for C. trachomatis. Of 22 homosexual men with NGU, seven (32 per cent.) yielded C. trachomatis. C. trachomatis was recovered from the urethra in three (5 per cent.) of sixty heterosexual men without urethritis, and none of fourteen homosexual men without urethritis yielded C. trachomatis.     

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.     

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.     

Epidemiology of gonococcal and chlamydial infections in Harrow and Brent.

OBJECTIVE: To describe the epidemiology and associated clinical features of gonorrhoea and chlamydial infection and to develop a profile of sexually transmitted diseases (STDs) in an outer London health district. DESIGN: Hospital-based retrospective study. SETTING: Genitourinary medicine clinic, Northwick Park Hospital, Harrow and Brent Health Authority. SUBJECTS: 70 male and female individuals with gonorrhoea and 129 with chlamydial infection, diagnosed consecutively over 28 months in 1992-94. RESULTS: More men than women had gonorrhoea (43 versus 27) but more women than men had chlamydial infection (84 versus 45), p < 0.001. There was a clear tendency for cases with either infection to locate along major road and rail transport routes. Foci of gonococcal infection were concentrated mainly in the densely populated areas, whereas chlamydial cases were more evenly spread. There was no significant effect of gender or type of STD on the odds ratio for residence in Harrow, single marital status or attendance for test of cure. However, the odds ratios for women having sexual intercourse with a regular partner only or previous STD were 5 (95% CI 2.4 to 10.2), p < 0.001 and 0.3 (95% CI 0.18 to 0.69), p = 0.002 times the odds for men, respectively. The odds ratios for patients with gonococcal infection being employed or having sex with a regular partner only were 0.5 (95% CI 0.27 to 0.98), p = 0.04 and 0.30 (95% CI 0.15 to 0.60), p < 0.001 times the odds for patients with chlamydial infection, respectively. Of the women with gonorrhoea and previous pregnancy, 68% gave a history of abortion compared with 44% of those with chlamydial infection (p = 0.03). CONCLUSION: The identification of foci gonococcal and chlamydial infection and apparent location of these infections along the major transport routes in our health district require further study. That chlamydial infection, unlike gonorrhoea, is evenly distributed irrespective of population concentration and deprivation, suggests urgent need for a comprehensive local effort to control both STDs.