The treatment of vaginitis

TI3E

TREATMENT

OF VAGINITIS”

EDWARD ALLEN, M.D., AND HUGO (1. BXI:M, (From

the Depnrtment

of

Obstetrics

ant7 G.y~wcoloy:y,

CHICAGO. ILL. .Prssbyterinnhlospital)

M.D.,

T

HE treatment of vaginitis is still a common problem in gynccologic practice. The multiplicity of methods reported in the literature is prima facie cvidencc that no treatment. t,hus far described has proved to be adequate. In this report, covering a period of one and one-half years, we would like to give the results obtained in the study of 282 patients, treated by a single method, namely, the instillation of a buffered acid, water dispersible jelly into the, vagina.+ The acidity of this vaginal jelly was varied and also its composition hy adding varying conc.entrations of sulfathiazole, sulfanilamide, gentian violet,, or iodine. MJe have tried to evaluate our causes of failure or success on the basis of adequacy of treatment, or the r61e of primary and secondary foci of re-infection. The general plan of investigation followed these main line#s, All patients entering the dispensary or office, presenting symptoms or abnormal findings in the vaginal secretion, were studied. TABLE 1: ---. -_I_---

-

Total number studietl Private Clinic (Central Free Xspensary and Presbyterian Hospitzl Obstetrical Clinila ) --- ---------___ Kwe White Negro -___ Pregnant Nonpregnant, --_~ -_I Age 20-30 15-20 30-40 40-50 50-60 60-70 70-71

___-

50

_-._____ 292

-

23:! -.--~----. 016 66 1: i: 99 48 21 2 1 __-.-

-_-._-.--

I_----_

A detailed history with special emphasis on the nature of vaginal, urinary and gastrointestinal tract s?;mptoms was taken. The vast majority of these patients presented combinations of the usual sympt,oms of vaginitis, such as profuse discharge, vnlvar irrit,ation. dysparcunia, backache, or irregular bleeding. The infect,ion in a considerable num*Presented at a meeting of the Chicago Gynecological Society, April 17, 3942. tThe jelly and technical service for this investigation were supplied by the Ortho Products, Inc.. Linden, N. .I, We also wish to thank Miss Gertrude L. Shorter for her excellent laboratory assistance.

ALLEN

AND

BAUM

:

TREATMENT

OF

VAGISITIS

247

ber was an incidental finding in routine physical examination. Symptoms referable to the urinary tract, such as dysuria, frequency, urgency, nocturia, and occasionally incontinence, were almost as common as the vaginal discomfort. Many patients in whom urinary tract symptoms were present did not have microscopic, cultural, or cystoscopic evidence of infection. Patients without urinary symptoms, however, occasionally did have positive findings. These histories confirmed the usual finding that the onset or return of symptoms frequently preceded or followed the menstrual flow. A large number of recurrences, however, were immediately preceded by intestinal disturbance; in fact, many of these patients were chronic sufferers from a so-called irritable bowel, manifested by recurrent attacks of loose stools. Physical findings varied. The vulvar skin manifestations of infection ranged from normal skin to that of widespread vulvitis, including perirectal irrita.tion and occasionally condylomata acuminata. The vaginal mucous membrane occasionally wa,s normal in appearance but usually revealed evidence of congestion or mucosal petechiae, often with localized evidence of infection about Skene’s glands or the opening of the Bartholin ducts. Frequently cervical erosions, polyps, Nabothian cysts, or other common causes of leueorrhea were found as incidental Tender indurated sacrouterine ligaments were a rather pathology. common finding, especially in the acute stages of the infection, and probably account for much of the dyspareunia or backache. Unlubricated speculum examination always preceded any other manipulation. In like manner, pH determinations were next made, using either a Beckman potentiometer or nitrazine paper. The glass electrode of a Beckman pH meter was inserted either directly into the vagina or if a sufficient quantity of discharge was present to fill the specimen cup (3 to 4 cc.) the readings were made in this secretion. For all practical purposes the nitrazine ‘paper seemed sufficiently accurate, checking with the potentiometer readings within a range of 0.5 pH. identification of the type of vaginitis was accomplished by microscopic examination of an unadulterated wet smear and gram stain. In questionable cases the secretion was cult.ured. All urine examinations were made on catheterized specimens. TrichoNot until the exammonas were seldom found in the whole specimen. ination was confined to the last few drops of the residual urine (2 to 4 cc.) were trichomonas found with any degree of regularity. The catheter was not removed until after the specimen was obtained to obviate, if possible, contamination from the urethra. Concentration of the sediment by lightly centrifuging aided in finding the Trichomonas Determinations of pH, wet and stained smears and cultures were made of the urine. Whenever possible, cystoscopic examinat,ions were made and repeated when indicated. Cystoseopic findings of infection usually were characterized by changes around the bladder neck. The mucosa

2‘4s

4MERICAN

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OBSTETRIC&

AiYD

GYNECOLOGY

in this region varied in appearance from slight. to acute injection to what of chronic cystitis cystica with hypertrophy of i-he anterior bladder neck glands. Acute infection was frequently associated with petechial hemorrhages about the trigone resembling acute trichomonas infection of the vagina. TAme

IT

L--1 . ‘hi

r~homonss

Pregnant Nonpregnant 2. Trichomonas rind Pregnant Nonpregnant

monilia

3. Monilia Pregnant, Nonpregnant, 4. Nonspecific Pregnant Nonpregnant

.?I7

-__-__.

Sputum and stool specimens were esamincd. blow dif%uIty was encountered with the collection of bowel mat.crial at 11~ ljroprr’ tiulc, than with any other phase of t,his work. We do not believe that l.hc examination of a formed stool or stool removed with t,hr InbricMcd tingcr will reveal the true incidence of intestinal trichomonas.

---.-

--IF I’RF.GFANT

Total With With

vaginal bladder

symptoms symptoms

1

i/R

Patients catheterized and clrine Total Trichomonas found Streptocowus, st,aphyloc~ol.cos,

Patients

Oyst0800pPa

Total Bladder

changes

Total With With

39 0 ‘, --

NT

yi

e~anviiwd : 7 3.5 2s iw/$;)

26 IO (40%) xncl

colon

lwillus

9 (36~$,~

;iz

( ?x;.9,%

:

-

PREGNANT ____-I__12 12 2

--_vaginal bladder

IN NONPlXCiNA ___-__137 104 I

symptoms symptoms

Patients catheterized and wrine exnmincd : Total Trichomonas found Streptococcus, staphylococcus, :wl colon bacillus Patients oystoscoped Bladder ‘changes

PREGNANT

4 I I

founrl

: 1

2

I

0

)

A4LLEN

AND

BAUM

:

TRE.4TMENT

249

OE’ VAGINITIS

These examinations gave the classification Table II. Our findings associated with Trichomonas III.

of patients

as shown

are summarized

IN PREGNANT

Total With With Patients Total Urine

vaginal bladder

symptoms symptoms

catheterized

Total Urine

were

negative.

VI.

/

NONSPECIFIC

vaginal bladder catheterized

and arinc

IN NONPREGNANT

/

IN PREGNANT

3 z: 9

f

examined:

negative

10 10

1

jelly with pH 4.5 (Ortho Vegetable gum Glycerin Boric acid Ricinoleic acid ProPyl ester parahydroxybenzoic Oxyquinoline sulfate Water to PH adjusted with acetic acid

I

0”

VII 178 10

7.0

1

79 1: Inc.)

Products,

acid to

3

282

Bladder treatments 5% argyrol, oz. 1, twice weekly Rulfathiazole by mouth TJrotropin and sodium acid phosphate orthogynol

2

INFECTION

i ‘C” (basic iellv)” pH 4.5 Basic jelly adjusted-to pH 7.0 ( ‘ C ’ ’ containing sulfanilamide “C” containing sulfathiazole Rulfanilamide, aulfathiazole, and “C” “C” contaimng gentian violet 1% i ‘C” containing iodine 1% Gentian violet and ‘(C” Iodine and “C” Iodine and basic jelly adjusted to pH 7.0 ‘(C” and basic jelly adjusted to pH 7.0 Gentian violet and jelly adjusted to pH 7.0 Gentian violet, “C” and jelly adjusted to pH Gentian violet, “ C ’ ’ and sulfanilamide Iodine and jelly adjusted t,o pH 7 and “C” Iodine, ‘(C” and 3% sulfanilamide Cream

‘C”

1

’

symptoms symptoms

TABLE

*‘

::

examined:

1

Patients

IN NONPREGNANT

1 examinations

1’anr.E

Total With With

in Table

3430 5

and urine

pH

4.5

in

250

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AXD

The patients infected with monilia alone [Iresent a somewhat, different picture and arc summarized in Table TV. We have included under the general heading of nonspecific caginit,is the patients in whom gonorrhea, Irichomonas, and nionilia wcrc not. found, hut whose sympi oms apparel1 t Iy w(‘l’c GIUSN~ by staphyloc*c bc*cxi. streptococci, or the colon bacillus. Table VII shows t.hc proportional USC 01’ l.he primary jelly at1;1 modifications. Measured amounts (5 CC.) of jelly were instilled deep into tht: vagina at bedtime or twice daily by means of a plastic syringe. This offers a greater opportunity for the patient to treat herself adequately than previous methods we have used. A tabulation of t,hc urinary tract findings is given in Table VIII, TABLE

VIII

__-

=z I

-

TRICItONONAS __I. 28 25

(pregnant) Nonspecific (nonpregnant) Nonspecific (pregnant) Total number Number with

66

0

12

0I

19

0

1

I)

10

46

TOTA r,

/

137

‘1-

10

4

I)

I ./-

-_I__ CYSTOSCOPIC / -.. / BLADDER NUMBER UNDIKGS -__

0 -~

40 patients with trichomo nas trichomonns found in catheterized

176 4.

specimen

ZZ.t?(&

incidence

A &urn6 of 3,323 stool examinations of about 1,100 paCents hy direct microscopic study and culture in the general laboratory of the Presbyterian Hospital revealed the results as shown in Table IX.

TRICHOMONAS

Stool examination ~ultnre Both (direct stool es&nation and culture)

A summation Table X.

/

of the results

ENDAMOEBA IIISTOLYTICA

54 9R ii

--

79

TRICH. AND E. HIST.

s

Au-

-

I_-

I”7 ‘1

169

6.3

2

I of this study

of vaginitis

is shown

in

ALLEN

AND

BAUM:

TREATMENT TABLE

/

TOTAL STUDIED

NO. 282

1 __

TAG.

Trichomonas Trichomonas

and

monilia

Xonilia Nonspecific

Reg. Nonpreg. Preg.

Nonpreg.

29 137

BLAD. 1:

26 107

11 53

12

1

4

3

1

251

VAGINITIS

X RELIEVED SYMPTOMS

U-RED

OF

INSUFF. TREAT.* -13

5 42

NOT CURED

42

CORCURED OF TOTAL REOTED CASES % OF STUDIED CASESt -35.837.9 38.6

55.7

10 4

Preg. Nonpreg.

40

26

20

14

38 17

Reg. Nonpreg.

3 37

3 24

3 34

*Contains those patients who abandoned treatment Their ultimate condition at time of discontinuance is had experienced relief of symptoms before discontinuing ?The corrected percentage of cures eliminates those according to our standards.

and could not unknown. Some visits. who had insufficient

be f0110we(l. of the latter treatment

Discussion We believe that the instillation of a vaginal jelly is the most satisfactory method of self-treatment for the patient, and produces results equally ae good as any method we thus far have used in the treatment of trichomonas. Additions of various chemicals have not appreciably increased the ultimate cures. Increased irritation was caused not infrequently by the addition of 1 per cent gentian violet. The addition of sulfanilamide or sulfathiazole in amour& varying from 3 to 30 per cent was no more efficacious than the basic jelly, except that the smears seemed to show a more rapid disappearance of cocci. Absorption into the blood stream of these sulfonamides could not he demonstrated, although as much as one ounce was instilled daily for a period of five days. The paradoxical cure of the monilia vaginiti’s by an acid jelly in such a high percentage of cases is hard to explain. It was more effective for monilia than for trichomonas in this series. We plan to investigate further the r6le of the separate components of the basic jelly. The jelly offers, we believe, a safe method of treating vaginitis during pregnancy as no untoward resuk were noted in our patients. In general, the shift of pH was toward normal vaginal acidity. Our observations confirm those of ot.her investigators, that the pH of the vagina varies in its different portions as well as in the different phases of the menstrual cycle or amount of cervical secretion. We are not convinced that changing the pH of the vaginal secretion is the prime factor in freeing the vagina of infection, though symptoms are usually relieved. In support of these statements, 115 were considered cured as gauged by our standards while 239 of the total were symptom free. The standard for cure chosen was three consecutive negative smears obtained at the end of at least a three-month period of treatment. This criterion of cure, however, is only arbitrary, since a recent follow-up reveaIed that the vaginas of many of the patients still harbored infection.

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They did not return of their own acrord l~cnnse they no longer had Symptoms of vaginitis. Relief of syniptoms is not synonytnolls witli cure. These facts indicat,e either incaomplctc (‘IIIY’ or rc-infcctioll. From this study we are inclined to believe I hat rc-inl’ection is rnoxi ~~~~ol~al~ly from the bladder. This does not explain, howevc~~. IIW init,ial inl’cc~t ion of the vagina which we believe follows pcriotls of intestinal inCcc?tiota. The male prostate serves as a primary focus in some instanccx This leaves other unknown sources yet to bc determined. Due to the pr~alence of urinary tract contamination a similar invasion of the llpper Miillerian tract probably does occur more frequently than has brcxr~ intlicated in the literature. Our experience in private practice with acute or chronic pelvic. infection has been that t,llcJp are more often associated with trichomonas or non-specific organisnts, than they arc witI1 Sonorarhea. These pelvic infections ma.y IW tlar lo the bacteria asscj(hialcd with the trichomonas as WC never have been ahlc t,o isolate the tricbomonas from aspirated material. The fluid from two Rartholin q7st.s contained trichomonas and in our opinion is a :frcqnent cause of ;~utc bartholinitis. A study of secretions obtained from above the est,wnal OS might offer important information concerning re-infection. I’,)- 1110 same inference, more careful st.udy of upper urinary tract pal hology will probably accorcl to t,hesc infections affecting the trigone a more important r&e than at present.. WC are impressed by the filet I Ililt those patients in whom bladder changes were found generally ha<1 a more patulous urethra than normal. The ulkwy meatus in some of’ the111 was :ihlOSt fll~l7~c~l sll~p~tl. 1T1Xlt Ill.ill clischascx sll~ll gt*;IIlrll;lt ioilx or partial stricture, W(‘l’(’ ~W~ilSiO11illI~ l’Otl?ld. Sli

Conclusions 1. A buffered acid jelly is iI11 clft’eclixxt at~ct ac~c~)tablc method I’OY the treatment of vaginitis. 2. A shift in vaginal pH can l)robably be produced by a buffurctl acid jelly. 3. Symptomatic relief can be obtained in a high pcrcentagc (~84 IWI cent of patients) by this method. 4. A large number of apparent cures of monilia and nonsgerific iufection are reported. 5. The percentage of cures obta.ined compared favorably with mothods we previously have employed. 6. Final cure has not been as frequent in our hand9 by any metShod as has been reported in many clinics. 7. Treatment of concomitant urinary tract infection has helped to We feel that this has been a increase our number of good results. rather neglected aspect of the treatment of vaginitis. 8. Cooperative effort between the genitourinary and gynecologic specialties would benefit the patient.

BLLEN

AND

TREATMENT

BAUM:

9. Greater interest on the part doubtedly give added information.

OF

253

VAGINITIS

of the gastroenterologist

would

WI-

References Bland, Pascal Brooke, and Rakoff, A. E.: J. 9. M. Hesseltine, H. C. : AK J. OBST. & GYNEC. 35: 1085, Idem: AM. J. OBST. & GYNEC. 34: 439, 1937. Idem: J. A. M. A. 109: 768, 1937. Trussell, R. E., and McNutt, S. H.: J. Infect. Dis. Allen, E. D., Jensen, L. B., and Wood, I. H.: Anr. Allen, E. D.: Am. J. Surg. 33: 523, 1936. 55 EAST

WASHINGTON

A. 115: 1938.

1013,

69: IS, 1941. J. Oust. R:

1940.

GYNEC.

30:

565, 1935.

STREET

Discussion DR. H. C. HESSELTINE.-Much of what Dr. Allen and Dr. Baum have presented agrees sufficiently with some of our views that we cannot offer very divergent opinions. The fact that they presented their data withcut correction may explain why 16 per cent of their vaginal trichomoniasis patients did not obtain relief by a single method of treatment. A careful survey of the literature or a critical study with a sufficient number of patients would bring one most likely to a somewhat similar conclusion. The results may be made to vary from a very favorable report to an average one depending upon the criteria for cure. The more rigid the criteria, the less favorable the result. As the essayists have pointed out, the patients should be followed for some time after apparent cure if one is to be certain of the results. It is especially important to examine the patients immediately after the completion of the catamenia. Whenever one plans a new therapy it may be well to investigate the great number of medicaments and procedures which have received at least temporarily From violent scrubbing of the vagina to some support and perhaps popularity. the simple topical application, from frequent to infrequent office visits, from liquids to powders the pendulum has swung and returned, Allen, Jensen and Wood, in 1935, pointed out the importance of the patient’s own urinary tract as a focal site. We agree that too little attention is paid to such sites as the patient’s urethra and bladder, cervix and gastrointestinal tract, and even to her husband. Instances occur in which both the prostatic secretion and the patient’s own urinary tract may be focal sites. Bowers and I have data which confirm some of these previous reports and emphasize even more the significance of these sites as sources of recurrence. Obviously then therapy must be directed at the vaginal condition and at all other involved areas. Fortunately most of the mild or early cases yield to many and various treatments. Drastic or extreme procedures upon the cervix and other structures will be indicated rarely and only after due consideration. The old question of the importance of the Trichomonad and the associated bacterial flora persists. Recently Wolter, Campbell, and I observed that experimental production of vaginal triehomoniasis in human beings was much more likely when there was an abnormal bacterial flora present. If it is the increased acidity that is beneficial then any sufficiently acidic substance would produce the same response. Perhaps the value may rest with other substances in the jelly, as tragacanth, glycerin, or the preservative in it. Many members of this Society have their favorite therapies. It is recommended that enthusiasm be tempered with balance and control, and without carrection of data. Let US all follow the example of Allen and Baum in making a thorough and complete study, just as they are in the process of doing. Likewise, Let us know what our prepalet us not be premature in arriving at conclusions. rations are and evaluate ea.ch substance in them. -And let us not forget the likelihood of re-infection from the difRcuIt cases.

254

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.ZE\‘D

GTNECOLOUT

DR. AJJJ3N (closing’).--If we study there C’:LSCS over :t long period of time, wt: will find a great many of them recur. Whether that is due to lack of primnr,v cure or re-infection is dill to be determinecl. TV? are impressed also vith the number of cases of pelvic abscess and salpingitis that are probably due to triohomoniasis or associated infection with yeast.

THE

~%Wl!H

IMiPORTANCE OF THE RH BLOOD IN ERYTHROBLASTOSIS” il.

%lTER,

ALLAN

(Prom

the Depurtment The Chicago

&!t.I)., B.

CRUNDEN,

ISRX%

I)h\.II)SOHX, KD.,

( IIHIC.\G?O,

Obstetrics and Gpecoloyy, The L:yi,ng-In Hospital and thr Pnthological of th.e Mount Situi Uospittcl) of

FACTOR

&I.l).,

ANI)

ILL. lixi,versity

of

(:hka,qo

and

Lnboratoriis

T

HE Rh blood factor recently tlernonstrated by Landsteiner, Wiener. and Levine and his associates is 01 great. clinical importance, because of its possible relation to severe or fatal transfusion reactions Several recent, publications’-’ and to the etiology of eryt,hroblastosis. have described this factor and the relation it seems to bear to these two conditions, so that it is unnecessary to review the material in detail. Suffice it to say t,hat, the 1Ch factor is an antigenic substance found in human blood cells which is similar in some ways to other prrviously described antigenic factors, the ~r~ost important of which are A, B, M and N. .It, is inherited a.s :I hlendelian dominant as are thr others. It occurs only in the red l~lc~otl culls as do M and N. a,lcl is not found in tissues and secretions as art’ ;I and 1~. No spotltaneousl> occurring agglutinins for the R,h fac+or have been demonst,rated and in this respect it resembles M and N : such agglut,inins are present, for* A and B. When cells containing the Rh factor (Rh+) are introduced into the blood stream of a person it, whom the factor is absent, (Rh-.-), agglutinins against it may be developed (i.e., it, has iso-immunizing ability). Agglutinins are never produced for the M or N factor. Pot this reason the M and N factors art’ of no itnpodancc iI1 blood l-ran+ fusions while the Rh factor is of 111ncll itlrlxjvtnllce. 11’ blood containing the Rh factor is introduced into an individual who is Rh negat,ive, and antibodies are produced which are capable of agglutinating Rh *Read

at

a

meeting

of

the

Chicago

Gynecological

Society,

April

17.

1942.