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Treatment of sexually transmitted diseases begins with prompt and accurate diagnosis. Several new diagnostic techniques allow more rapid or easier testing, however sometimes at a cost. The vast array of diagnostic methodologies available to the office practitioners are discussed with special regard to their sensitivity, specificity, and ease of use.

The effect of metronidazole on anaerobic vaginosis (non-specific vaginitis) was assessed in a double-blind, placebo-controlled study of 40 women. 19 of 20 women given metronidazole 400 mg twice a day for seven days were clinically and microbiologically cured by the time they completed treatment. All 20 women given a placebo were treatment failures, but when they were given a single 2 g dose of metronidazole, 15 showed clinical and microbiological cure a week later. 14 of the responders showed a recurrence of infection a month after treatment; this was probably due to reinfection, although persistence of infection cannot be ruled out. Findings in the clinic correlated closely with subsequent microbiological results in 133 out of 140 patient-visits, which suggests that there is no need for expensive and time-consuming laboratory investigations in this condition.

Bacteriologic culture samples were taken from the cervix in three groups of 10 healthy, sexually active women using barrier contraception, oral contraceptives, or a levonorgestrel-releasing intrauterine contraceptive device. Culture samples for Candida albicans and Trichomonas vaginalis were taken, a cytologic vaginal smear was obtained, and an amine sniff test was performed; these were in addition to a routine gynecologic examination. Multiple bacteria were isolated from the cervix in women using oral contraceptives or an intrauterine contraceptive device, whereas lactobacilli alone dominated the flora of women using barrier contraception. Significantly more anaerobic bacteria were isolated from the cervix in oral contraceptive and intrauterine contraceptive device users when compared with the barrier method users. Symptoms and findings evident of anaerobic vaginosis were associated with the occurrence of anaerobic bacteria in the cervix of three patients using the intrauterine contraceptive device. The results showed that the cervical bacterial flora in sexually active healthy women is rich in anaerobes that can be regarded as a normal finding in women using oral contraceptives or intrauterine contraceptive devices. Barrier contraception with a condom prevents this anaerobic shift and maintains a lactobacilli-dominated flora in the cervix.

The authors describe the methods employed by the Artificial Insemination Section of the Division of Veterinary Services in collaboration with the Reproduction and Bacteriology Section of the Veterinary Research Institute, Onderstepoort when herds are examined for infertility. A "herd" rather than an "individual animal" approach is advocated and certain infectious causes of infertility are discussed.

Vaginal discharge is one of the most common gynecologic problems encountered in the pediatric and adolescent populations and may have many causes. A useful way of approaching the diagnosis of a discharge is by categorizing the patient as being prepubertal of postpubertal. In the prepubertal age group, discharge is generally associated with vulvovaginitis. In the postpubertal age group, discharge may be physiologic, or may associated with cervicitis or vaginitis. In each group, gonorrhea and sexual abuse must be ruled out. A practical approach to therapy is outlined.

Bacterial vaginosis is unlike the "classic" sexually transmitted diseases. Unlike cervical infection with Chlamydia or salpingitis caused by N. gonorrhoeae, no single etiologic agent has been identified, and the organisms which are associated with infection have all been found as members of endogenous vaginal flora, with the possible exception of Mobiluncus species. If, as we suspect, BV is due to interactions among various organisms found in the vagina during vaginal health, we must determine what changes in the microbial or chemical ecology determine the development of BV. If, for instance, BV is simply due to an inversion in the concentrations of various organisms such that the anaerobes which are usually present in low numbers become predominant and the lactobacilli which usually predominate become few in number, we must determine which causes what. That is, does some organism or environmental change allow the anaerobes to overgrow and thereby inhibit the lactobacilli, or does some change inhibit the lactobacilli, thereby, allowing the other flora to overgrow? Answers to questions such as these await further research.

Therapeutic failure in vaginitis can be minimized if all cases are properly diagnosed and specific therapy is given. Use of wet mounts combined with liberal use of cultures, especially for Corynebacterium vaginale, should result in an accurate diagnosis in over 90% of cases. Treatment of choice for candidiasis is nystatin or miconazole nitrate applied topically. For trichomoniasis, metronidazole should be given orally to both sexual partners. Ampicillin, cephalexin, or cephradine are recommended for C vaginale infection.

Detailed history, physical examination, laboratory, and follow-up data were obtained from 821 patients presenting to a primary care clinic over an 18-month period with the symptoms of vaginal infection or urinary tract infection (UTI). Information useful in deciding when to perform a vaginal examination, when to obtain various types of cultures, and when to perform microscopic examination of a saline suspension or Gram stain is presented. Of particular interest were the findings that patients with dysuria more commonly have vaginitis than UTI, the superiority of a saline examination to other means of diagnosing yeast vaginitis, and the rarity of a positive trichomonas preparation when the vaginal discharge had a curd-like appearance.

A study was undertaken to determine which fermentation products in vaginal secretions serve as the best markers for bacterial vaginosis. Three categories of markers had been previously identified, but due to cost considerations it was necessary to accurately determine if analysis for all three were necessary. With the use of vaginal secretions from well-defined patient populations, we applied gas-liquid chromatography to test for both volatile and nonvolatile acid fermentation products. It was found that only the detection of nonvolatile acids was necessary, because no additional patients with bacterial vaginosis were identified by subsequent analysis of volatile acids. Routine analysis of volatile acids to identify patients with bacterial vaginosis is labor intensive and costly and had no clinical diagnostic value.

Trichomonas vaginalis was detected by culture or wet-mount examination in 118 (15%) of 779 randomly selected women attending a sexually transmitted disease clinic. Vaginal trichomoniasis was significantly associated with symptoms of yellow discharge, abnormal vaginal odor, and vulvar itching and with signs of colpitis macularis ("strawberry cervix"), purulent vaginal discharge, and vaginal and vulvar erythema. A logistic regression model was used to adjust for coinfections, as well as for demographic, behavioral, and other possible confounding variables. Trichomonas vaginalis remained significantly associated with symptoms of yellow vaginal discharge (odds ratio [OR] = 2.4) and vulvar itching (OR = 3.0) and with signs of colpitis macularis (OR = 241), purulent vaginal discharge (OR = 8.0), vulvar erythema (OR = 2.5), and vaginal erythema (OR = 4.3). The sensitivity of symptoms and signs associated with trichomoniasis was relatively low. Nevertheless, clinical manifestations can be used to identify those patients for whom a wet-mount examination would likely have high yield. Careful clinical examination and selective use of wet-mount examination together with wider use of more sensitive tests for subclinical infection, such as culture or direct immunofluorescent staining of vaginal fluid, could lead to improved detection and control of this infection.

Vaginitis is one of the most common complaints of women in the United States today. About 90% of patients with this problem suffer from infection of the vagina caused by Candida, Gardnerella, or Trichomonas. The diagnosis and effective treatment of these common infections depend on accurate identification of the entity, effective specific therapy, and restoration of the normal ecosystem of the vagina. At the same time women should be made aware that not all discharge means infection and that any attempts at self-treatment may only worsen their condition. Proper hygiene habits, dietary control, and management of stress are all helpful factors in the control of recurrent vaginal infections.

Genital candidosis is extremely common and its incidence appears to be rising. The epidemiology, clinical features, predisposing factors and treatment of the condition are reviewed.

25 patients with symptoms of non-specific vaginitis have been treated with metronidazole either 2000 mg in a single dose or 400 mg three times daily for 5 days. Diagnosis was settled by 1) identification of G. vaginalis in culture of vaginal secretion, 2) the observation of clue cells in wet smear, 3) a positive amine test on application of potassium hydroxide, and 4) increased pH in the vaginal secretion. Most patients' symptoms and complaints disappeared and at the same time most of the tests used changed from abnormal to normal findings. No side effects were recorded. It is concluded, that metronidazole in either dose was a useful treatment of non-specific vaginitis.

328 samples of vaginal discharges in adult fertile women, aged between 16 and 48, were examined in this trial. After excluding 95 women (39 were affected by vaginal Trichomoniasis, 55 whose discharge presented yeasts and 1 affected by gonococcal infection), the authors divided the remaining 233 cases into subjects affected or not affected by nonspecific vaginitis (NSV) only using a Gram-stained smear. In the 83 patients affected by NSV, the authors isolated Gardnerella vaginalis in the 90.4% of the cases. After statistically correlating the different parameters described in literature as associated to NSV (pH, KOH-test, Clue Cells, isolation of G. vaginalis, symptoms), the authors concluded that: a) Gram-stained smear may be used as a simple microscopical test for diagnosis, in most of the cases, NSV; b) in most of the cases of NSV are implicated more organisms (essentially G. vaginalis and anaerobic organisms); c) G. vaginalis can be considered as a marker of these infections.

A proctocol to be administered by nurses for the management of dysuria, frequent urination, and vaginal discharge was validated. In a randomized, controlled trial, 146 women were seen by both nurse and physician and then assigned to either the nurse-proctocol treatment plan or the physician treatment plan. The clinical data collected by the nurse showed no important differences from the physicians' data. The protocol recommended that 89 percent of the patients be sent home without seeing the physician. The physicians agreed with the protocol-recommended disposition in all but two cases. All patients with complications were appropriately referred to the physician. In follow-up, more than 95 percent of both groups reported symptomatic improvement, and repeat urine cultures were negative. We conclude that the protocol can be accurately administered, makes sound recommendations, is safe, and efficiently saves physician time.

Sera from 200 pregnant women, with symptoms suggestive of vaginitis and harbouring yeast in the vagina, were examined for precipitating antibodies to three antigens of C. albicans, using a gel double diffusion test. A high overall incidence of precipitin-positive sera (47.5%) was found compared with an incidence of 18% in the unselected pregnant population previously studied (Stanley, Hurley, and Carroll 1972). Using the clinicopathological criteria of Carroll, Hurley, and Stanley (1973), a final aetiological diagnosis of C. albicans mycosis was reached in 75 cases and precipitins were demonstrated in 64%. Forty-eight women harbouring C. albicans responded favourably to a single course of antifungal treatment, and probably had mycotic vaginitis. The incidence of precipitins in this group was 42%. C. albicans was isolated from a further 55 of 62 patients, in whom the incidence of precipitins was 32%.;Booking' sera were investigated from 50 of the 200 women studied. Sixty-four per cent of women had symptoms of vaginitis at booking and 32% were precipitin positive. Twenty-eight per cent had precipitins on both occasions, and a further 24% acquired candida precipitins during pregnancy. None of the seven newborn with oral or skin thrush had precipitins to C. albicans.The results indicate that the detection of precipitating antibodies to C. albicans, particularly to all three of the antigens described in this paper, would be a useful additional criterion in the diagnosis of candida vaginitis, particularly if the vaginitis were persistent, recurrent, or unresponsive to therapy. The sensitivity of the test system used was 64%, and its specificity 87%; as such, the test is valid and may be reasonably useful as a screening procedure.

The term bacterial vaginosis is used to reflect the complex alterations of vaginal microorganisms and connotes the presence of a malodorous discharge without apparent inflammation. The normal vaginal flora is reviewed in order to better understand this syndrome. This article also discusses the frequency, clinical symptoms, diagnosis, and treatment of this condition.

Nonspecific vaginitis causes diagnostic as well as therapeutic difficulties in gynecological private practice. In a study in 63 patients with "nonspecific" vaginitis, clinical parameters were related to the bacteriological isolation of G. vaginalis in order to try to find criteria which can help to make a correct diagnosis of "nonspecific vaginitis". These patients were treated with three different regimens of metronidazole, either 2000 mg as a single dose, or two single doses of 2000 mg each taken the first and the third day, or 400 mg 2 times daily for 7 days. Patients with Candida or Trichomonas infections were excluded. Partners were treated at the same time, with the same regimen as the patient. The patients were controlled 14 and 28 days after the beginning of the treatment. The preliminary results showed that all regimens give good clinical effect, but the treatment with 2000 mg given as a single dose the first and the third days seems to lead to fewer failures.

We describe the preparation and usage of positive and negative quality control standards for the proline aminopeptidase assay of vaginal secretions as an indicator of bacterial vaginosis.

A principal cause of desquamative vaginitis is erosive lichen planus. We report five cases to illustrate the classic oral and vaginal findings, describe the histology, and relate the therapeutic response of the disease. Early recognition of the disorder and prompt use of corticosteroids and vaginal dilators may prevent the common sequelae of adhesion formation and vaginal stenosis.

A clinical and quantitative microbiological study was performed on 32 women with fishy odour of the vaginal fluid. This odour could be intensified by the addition of one drop of 10% potassium hydroxide. Clue cells were found to be present in all cases. Gardnerella vaginalis was isolated from the vaginal fluid in 97%, and large quantities of mixed anaerobes in 100% of the patients. The therapy with metronidazole, 400 mg twice daily for 5 days, was successful in 22 out of 24 patients. After therapy the fishy odour and the clue cells were no longer detectable. G. vaginalis and anaerobes could only be isolated sporadically and in small quantities. The isolation rate of Lactobacillus species increased from 3% to 86% within one week.

Almost 30 years ago Gardner & Dukes introduced the term Haemophilus vaginalis vaginitis. Most authors agree that this disease entity is characterized by a malodorous, homogeneous, greyish-white discharge, displaying clue cells in the wet-mount preparation. The diagnosis can be made in the office, the microscope being the most important diagnostic tool. There still seems to be some controversy regarding cause and clinical manifestations of the condition. A lack of uniformity in case definition and laboratory methods is probably responsible. The use of the term non-specific vaginitis should be discouraged, the condition being a specific entity not accompanied by vaginitis. A new term, 'clue cell-positive discharge' (CCPD), is proposed.