Vaginitis Treated with an Antiseptic Buffered Acid Jelly

VAGINITIS TREATED WITH AN ANTISEPTIC BUFFERED ACID JELLY* JOHN

C.

BROUGHER,

lVI.D., F.A.C.S.,

VAXCOUVER, WASH.

HAT leucorrhea remains as a present-day problem is borne out by Polak's statement that 85 per cent of women, married or single, have infected cervices.! Many publications report figures indicating that Trichomonas vaginalis infections are present in 25 to 33 per cent of women. Recently, several papers have appeared in the literature regarding the effective use of buffered acid jellies in the treatment of various vaginal infections. The change to present-day conceptions of vaginal physiology may be summarized by the editor's statement in the Yearbook of Obstetrics and Gynecology, 1943,2 "During the past few years we have come to recognize the importance of the pH of the vagina. Nearly all vaginal infections can be more readily cured by maintaining a Jow pH medium than by any other method of treatment. Regardless of the drugs used, the important consideration is the pH."

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In an extensive and excellent study of vaginal infections, Rakoff and Casper,3 utilizing an original x-ray technique, reported interesting results following the use of different products. It was concluded that water-dispersible jellies. adjusted to the proper acidity (pH 4.0) are preferable as bases for solutions, suspensions, antiseptics, fungicides, sulfonamides and estrogens. Conversely, capsules and tablets were not satisfactory. A practical point is that the medication may be continued by the patient at home. Chrisman,4 using a buffered acid jelly reported excellent clinical response in 100 of 129 cases within seven weeks. These included nonspecific vaginitis, cervicitis, trichomonas vaginitis, cervical erosions, and vulvar and urethral irritations. Definite relief and improvement occurred in one to two weeks. An interesting observation was that the average pH of the posterior fornix prior to therapy was 7.8 and often as high as 8.0 or 9.0. l<'ollowing administration of buffered acid jelly, within six weeks, the mid vaginal pH was 4.0 to 5.0 and the pH of the posterior fornix 4.5 to 5.5. From 1936 to 1940, Roblee 5 reported definite clinical response with the use of anhydrous lactose to create a vaginal environment of pH 4.5. Roblee,6 1943, combined a buffered acid jelly (pH 4.0 to 4.5) with a sulfonamide and obtained satisfactory results in 112 cases of conization of the cervix and 71 eases of vaginitis. He concluded that buffered · acid jellies are of value in the management of cervicitis, vaginitis (especially trichomonas), and monilia infections. ·Caprokol Jelly. which consists of hexylresorelnol 1 :1.000 in a buffered base titrated to a pH of 2.0. was generously supplied for this study by Dr. Earl L. Burbidge. of the Medical Research DiVision of Sharp & Dohme. Philadelphia. Pa.

523

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.\MFJW'AX .JOI·R~AI. OF OBSTI,;TIW ,S AXil (lY:'Il'E( '()I.oC;y

Allpll ami Balllll,7 1~4~ , l'''pOl'tf'd ~s~ patient,;; tl'Nlt(~d by lHPallS of vaginal im;tillatiom; of lH'id bufft'J'rd watel'-soluhl(' j('llles. The pH ctfl well as ml~di('am(> nts wrl'p varied. T}H'~' found that nitrazill(' pap(>!' was snffiriently a('(~uratp to UU'USU1'(l plL til!' )'('slllis having eherked within a range of 0.5 WIWll ('ompan'd wilh tlw Br('kman potentiomeler. The authors coneludc ill pal'l, that a buffpl'ed H(·id jrlly is an effcetive and !H'eeptahl(> method for thr trpalmeni of vag'ill it is, pl'Oviding sym p-

iomatie re1ipr (84 pel' ('ent of' p"iiPllis) and !'HlIsing Hppal'pnt mon ilia ana nonsp('cifir in I'(>(·t ions.

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In 1940, Bland and Rakoff/ 1I::;cd a hnffered arid jell)' at pH 2.;; b 4.6 and round it extJ'('llld~' lIsel'ul in lhe tn'atlllt'nt of 1l011speeifie illfeet ions of the vagina, e('l'vieil is, endoe(' ITi('it is, II':llIllIal ie illjllries and in Ihe alteration of tl1(' vaginal flora. Karmtky/' in all ('xtensi \'(' review s1 ndy, found that the most important fadOl' ill treating' tl'i('homonas Hlginili;;; was Ihe pIT, and that to he efj'(,(·tive, solutions, lahlrls, powdrl's or jpllh's should hp pH 5.0 or low('l'. Vaginal physioloK\' i,; eilaraetrrized h,v eyelie (·!tangps. Tn ehildhood and after ill(' mellOpUlIst', eslrogcni(' production is at a low ]Pvc!. tit!' gly(·ogell ('oni('lIt of the' vaginal epit.helial ('ells is deereased 01' ahsent, and niiderleill's haeilli lllent. therapy lorally ill an attempt to ('(luse a rapid return to normal and physiologie cOllditions within 1he vagina.

In lH:n, Greenhill ' " J'(']lOrted til(' drediv!.' llS(' of hexylrc1 as Iowa pH as tlw preparation used III t.his investigation and those referred to above. 'rhe following types of rHses were treated with this preparation:

BROeGIIEH:

VAGIXI'rI:' THEA TED WITH BUJ:'I<'EHED ACID .JELLY

Trichomonas vaginitis Monilia vaginitis Pruritic vulva Nonspecific vaginiti~ Postpartum ('el'vieiti~ Postpartum vaginitis, without appreciable cervicitis Antepartum vaginitis, of which 10 showed triehomonas Postpartum vaginitis with erosion 'J'emler episiotomy 8(',ar with vaginal hypereIl.ia HenDe vagi IIi ti~ Vaginitis in nullipara with dysmenorrhea Vaginal surgery with postoperative discharge Vpnpreal warts in obstetric patients Hypo-estrinism Vaginitis-nonspecifie treated with Caprokol Jplly and Ht ilbestrol Acute vulvitis

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1:1 :1 5 10 H

12 :16 20

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2 J 3 5 4 12

At the time of the first examination, pH determinations were made using pHydrion paper.· The rontainer for this paper shows color indicators for a pH l'anging from 1 to 11. This paper, when tested wit h the hexylresor('inol jelly showed a pH of approximatdy 1.0. Specimens for estimations of the pH were taken from hoth the ('ervix and vaginal wall with a eolton appli('atol', or with a lmlh 0'1 a glass rod used for aspirating vaginal secretions. Vaginal smears were made and stained in representative types of eases. The appeal'anre of the {'ells and the pH of the vaginal seeretions depends lIT10n the menstrual eycle and the amount of inflammatory reartioll present. The patient is provided with specifie instruetiolls regarding the use of this preparation. She is advised either to boil the glass applicator, or to eleanse it with rubbing aleohol before illserting into the vag-ina. The jelly is instilled twiec daily, morning and evening, during the arnte stage or an infection. One application consists of approximately 5 e.('. of the preparation. Should the vaginal dif'!eharge he extensive, a perineal pad may be used. Hapid improvement o('('urs, within one to two weeks and the instillation of the jelly ('an bl~ redueed to one application daily. A boric acid dour he is advised before the patient reports for examination and follow-ulJ study. The earliest t he jelly has been given to pregnant patients was in the second month and the latest, the eighth month. The jelly may he used without danger of intl'odueing illi'ertion whi('h might o('cur when an irrigation or douche is employed. Patients with pelvic pathology other than {'cnieitis and vaginitis were exeluded from this study. Hexylresorcinol jelly has been utilized in a wide variety of rOllditions. ~umerollS reports are available including various types of medi('atioIl used in the treatment of vagilla1 infections. In postpartum cervicitis, it was found that tIl{' nwuleated jelly with a pH of 2.0 controlled the infection promptly and as effieiently as douches, tampons or powders. In four of fonrteen patients, it wa..'l necessary to "Manufactured by the Central Scientific Co.

526

"\MERICAN JOURNAl, OF OBSTETRICS AND GYNECOI,oGY

coagulate the cervix. In twenty cases of postpartum vag-initis with ('ervical erosion at the six weeks' l'xamination period, all bnt one had a complete reversal of the pathologic condition after a course of treatmen1 with the jelly. It has been observed that in comparison with other methods used to correct the majority of vaginal infections, the preparation llsed in this study has been the most effective agent yet available in healing erosions and allied infections. It must be noted, however, that a certain per(~elltage of patients has prespnted rceul'rences of infections and during the wartime shifting of population, it has been difficult to follow most patients long enough to be ('ertain of permanent results. Ten per cent of patients found to have acquired a 1'I"ichomonas vaginalis infection have shown recurrence or reinfection, and have returned for further therapy with the jelly. Additional evidence that this jelly is a valuable addition to our armamentarium is the faet, that patients who have used various douches, powders and other agents have stated that nothing else has given as rapid relief, or is as easy to use as is the hexylresorcinol preparation. Postpartum vaginal discharge appears tl) oeeur more frequently in nervous individuals. Our findings in these eases show a hyperemic and tender mueosa, exeessive ceni('al secretions and usnally an alkaline pH. The results in die ate that the medicated jelly employed throughout this investigation is probably most useful during the antepartum and postpartum period. As pregnancy progresses, there is a marked increase in alkaline cervical secretions. Immediately post partum for a few weeks, this is also true. It requires approximately six weeks following delivery before the vagina aequires an aeid reaetion and returns to the normal physiologic condition. The use of this preparation in the antepartum and postpartum periods is of definite aid ill counteraeting and controlling the infections whieh are prone to develop as the vaginal pH increases. Ko cases of toxieity or reaetion to the jelly were eneollntered.

Oonclusi-ons 1. A series of 145 patients presenting a variety of infections has been studied. 2. "Caprokol" Jelly is a definite aid in the treatment and control of these infections. 3. Normal vaginal physiology is more easily maintained and pathologie conditions reversed. 4. A buffered acid jelly with a pH in the range of 2.0 or less and possessing antiseptic, mildly analgesic and antipruritic properties offers definite advantages in the treatment and control of vaginal infections.

BlWUGHER,:

VAGINITIS TREATED WITH BUFFERED ACID JELLY

527

References 1. Polak, John 0.: Gynecological and Obstetrical Monograms, Xew York, 1921, D. Appleton & Co., Vol. IX, pp. 14, :15, 40. 2. Editor's Note: Yearbook of Obstetrics and Gynecology, Chicago, 1943, '1'he Year Book Publishers, Inc., p. 542. 3. Rakoff, A. E., and Casper, S. L.: '1'he 'l'echnique of Vaginal Medication, Pennsylvania M. J. 46: 582, 1943. 4. Chrisman, R. B., Jr.: Clinical Results With the rse of a Buffered Acid Jelly, pH 4.5 and Other .Tellies of Varying pH, in Gynecological Infec· tions: Study of 129 cases, J. Tennessee M. A. 35: 455, 1942. 5. Roblee, M. A.: Vaginitis and Cervicitis, .T, Missouri M. A. 34: 285, 1937. 6. Roblee, M. A.: The Local Use of Acid :'Ifedia and Sulfa Drugs in the Management of Cervicitis and Vaginitis, AM. J. OBST. & GYSEC. 46: 400, 1943. 7. Allen, E., and Baum, H. C.: The Treatment of Vaginitis, A:.\1. J. OBST. & GYNEC. 45: 246, 1943. 8. Bland, P. B., and Rakoff, A. E.: Leucorrhea: Diagnosis and Treatment, M. World 58: 562, 1940. 9. Karnaky, K. J.: Treatment of Trichomonas Yaginalis, Am. J. Surg. 48: 216, 1940. 10. Greenhill, J. P.: The 'l'reatment of '1'richomonas Vaginalis Vaginitis, J. A. :'If. A. 96: 1862, 1931. 11. Moore, A. H.: The Treatment of Vaginitis, Am. J. Clin. :'lied. 48: 74, 1941.