The prevalence of urethral infections amongst asymptomatic young men in Hat Yai, southern Thailand.

The aim of this study was to survey sexual behaviour and estimate the prevalence of urethral infections amongst male vocational college students. A cross-sectional survey was performed among 479 young men attending 2 vocational colleges in Hat Yai, southern Thailand. Polymerase chain reaction (PCR) tests of first-void urine (FVU) samples were used to detect infection with Chlamydia trachomatis, Neisseria gonorrhoeae, Ureaplasma urealyticum, Mycoplasma genitalium and Mycoplasma hominis. Girlfriends were the usual sexual partners for 89% of men with only 11% regularly patronizing sex workers. Condom usage was low. The prevalence of any urethral infection was 15.9% with: C. trachomatis 4%, N. gonorrhoeae 0.2%, U. urealyticum 10.9%, M. genitalium 2.3% and M. hominis 1.3%. Infection with more than one organism was found in 2% of men. While the prevalence of infection with chlamydia or gonorrhoea was relatively low, the prevalence of 'any urethral infection' was moderately high and suggests that unprotected sexual intercourse is commonly occurring. As girlfriends were the most usual sexual partners, they must be at significant risk of pelvic infection. There is a need for programmes targeting this group of people.

Can a two-glass urine test or leucocyte esterase test of first-void urine improve syndromic management of male urethritis in southern Thailand?

The goal of this study was to determine whether a urine two-glass test or a leucocyte esterase (LE) test of first-void urine (FVU) improve the sensitivity or specificity of the World Health Organization (WHO) algorithm for the syndromic management of men with urethritis in southern Thailand. A secondary aim was to determine whether infection with Trichomonas vaginalis was sufficiently common to include treatment for it in a syndromic management protocol. One hundred and twenty-nine men with symptoms of urethritis seen at 2 STD clinics in Songkla Province, Thailand were enrolled. Symptoms and signs of each man were recorded and a urethral swab collected for microscopy and culture for Neisseria gonorrhoeae. A two-glass urine test and an LE test of an FVU specimen were performed. The FVU was tested by polymerase chain reaction (PCR) for N. gonorrhoeae, Chlamydia trachomatis and T. vaginalis. Dysuria was a symptom in 78% of men. A urethral discharge was a symptom in 68% but was evident on examination in 95% of the men. The prevalences of infection were 32.6% for N. gonorrhoeae, 23.3% for C. trachomatis, 1.6% for T. vaginalis and 51.9% for any infection. The sensitivities and specificities of urethral discharge on examination, two-glass test and LE test of FVU as indicators of infection with either or both of N. gonorrhoeae or C. trachomatis were 97% and 8%; 57% and 83%; and 59% and 78% respectively. Combinations of urethral discharge on examination and one of the other indicators were more specific but much less sensitive than the presence of discharge alone. Culture for N. gonorrhoeae was found to be only 43% sensitive compared with an expanded gold standard involving a PCR test. Our analysis demonstrates that neither the two-glass test nor the LE test of FVU were useful in improving on the WHO algorithm for management of men with urethritis. T. vaginalis was not common enough to include in a first-line syndromic management protocol for male urethritis. We recommend that, in southern Thailand, men with symptoms of urethritis in whom a urethral discharge is present on examination be offered immediate treatment for both N. gonorrhoeae and C. trachomatis as per the WHO algorithm.

Effect of the levonorgestrel-releasing intrauterine system on uterine myomas in a renal transplant patient.

The levonorgestrel-releasing intrauterine system (LNG-IUS) has been used in the treatment of both idiopathic menorrhagia and adenomyosis. An electronic search of the on-line medical literature revealed no reports of its use for menorrhagia secondary to uterine myomas. Presented here is the successful treatment of uterine myomas with menorrhagia in a woman with a renal transplant. There was a significant reduction in menorrhagia, dysmenorrhea, and uterine and myoma size with the use of the LNG-IUS. We believe that this system provides an alternative to conventional hysterectomy and gonadotrophin-releasing hormonal analog medical treatment for uterine myomas, with a possibly inhibitory effect on myoma growth.

PIP: This case report focuses on the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) on uterine myomas in a renal transplant patient. The successful treatment of uterine myomas with menorrhagia in a 43-year-old woman with a renal transplant is presented. Preinsertion, the uterine cavity was not distorted and it measured 12 cm. The LNG-IUS was inserted without difficulty. On follow-up, 3 months later, improvement was observed. Her cycles were regular with heavy flow only on the first 2 days. The uterus was 10 weeks¿ size on pelvic examination and her hemoglobin was 9.5 g/dl. One year after the initial insertion, she was asymptomatic with normal menstrual flow. The uterus was 6-8 weeks' size on pelvic examination and the uterine cavity was 6 cm. The largest intramural fibroid measured 10-15 mm. Hemoglobin was 10.8 g/dl without any hematinics. There was a significant reduction in menorrhagia, dysmenorrhea, and uterine and myoma size with the use of the LNG-IUS. Thus, the system provides an alternative to conventional hysterectomy and gonadotrophin-releasing hormonal analog medical treatment for uterine myomas, with a possibly inhibitory effect on myoma growth.

Trichomonas vaginalis as a cause of urethritis in Malawian men.

BACKGROUND AND OBJECTIVES: Trichomonas vaginalis is one of the most common sexually transmitted infections. In Malawi, rates of trichomoniasis in women are high. The prevalence of T. vaginalis infection in men is expected to be high but has not previously been documented. GOALS: We sought to determine the prevalence of trichomoniasis in Malawian men with and without urethritis, to evaluate a polymerase chain reaction detection assay for T. vaginalis in urethral swabs and to examine the effect of T. vaginalis infection on excretion of human immunodeficiency virus (HIV) in semen. STUDY DESIGN: Men presenting at the Sexually Transmitted Diseases (STD) and Dermatology Clinics in Malawi were enrolled in a cross-sectional study. We compared a polymerase chain reaction-based test for T. vaginalis detection with wet-mount microscopy and culture of urethral swabs. HIV serology was determined by enzyme-linked immunosorbent assay (ELISA), and HIV-1 RNA concentrations in semen were measured by quantitative nucleic acid sequence-based analysis. RESULTS: T. vaginalis was detected in 51 of 293 men. The estimated prevalence among symptomatic men was 20.8% and among asymptomatic men, 12.2%. Polymerase chain reaction performed with a sensitivity of 0.82 (95% CI: 0.66-0.92) and specificity of 0.95 (95% CI: 0.91-0.97) compared to wet-mount microscopy and culture. There was no difference in the rate of HIV seropositivity in men with and without T. vaginalis infection. However, in men with symptomatic urethritis, the median HIV RNA concentration in seminal plasma from men with T. vaginalis was significantly higher that in seminal plasma from HIV-positive men without trichomonas.

PIP: This study was conducted to determine the prevalence of trichomoniasis in Malawian men, to evaluate a polymerase chain reaction (PCR) detection assay for T. vaginalis in urethral swab samples, and to examine the effect of T. vaginalis infection on HIV excretion in the semen. There were 206 men with symptomatic urethritis in STD clinic and 127 asymptomatic men in the Dermatology Clinic who were enrolled from January to March 1996. Results, according to a wet-mount microscopy and urethral swabs culture combination, showed that, of 293 men, only 38 (13%) men were positive for T. vaginalis. The estimated prevalence among symptomatic and asymptomatic cases was 15.7% and 8.7%, respectively. The PCR yielded a sensitivity of 0.82 (95% CI: 0.66-0.92) and specificity of 0.95 (95% CI: 0.91-0.97); these were compared to the wet-mount microscopy and culture combination. Overall HIV seroprevalence of men was 51%, because gonococcal urethritis was shown to significantly increase seminal HIV RNA levels. The median HIV RNA concentration in seminal plasma from men with symptomatic urethritis plus T. vaginalis infection was significantly higher than in seminal plasma from HIV-positive men with symptomatic urethritis only. Since this study has several important limitations, a randomized clinical trial would be useful for determining whether urethritis cure rates can be significantly improved.

Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection.

BACKGROUND: A decrease in risk of urinary-tract infection is one of the most commonly given reasons for circumcision of newborn boys. Previous studies have reported rates of UTI to be 10-20 times higher in uncircumcised than in circumcised boys. This population-based cohort study followed neonates in Ontario, Canada, prospectively to study the relation between circumcision and subsequent UTI risk. METHODS: Eligible boys were born to residents of Ontario between April 1, 1993, and March 31, 1994. We used hospital discharge data to follow up boys until March 31, 1996. FINDINGS: Of 69,100 eligible boys, 30,105 (43.6%) were circumcised and 38,995 (56.4%) uncircumcised. 888 boys circumcised after the first month of life were excluded. 29,217 uncircumcised boys were matched to the remaining circumcised boys by date of birth. The 1-year probabilities of hospital admission for UTI were 1.88 per 1000 person-years of observation (83 cases up to end of follow-up) in the circumcised cohort and 7.02 per 1000 person-years (247 cases up to end of follow-up) in the uncircumcised cohort (p<0.0001). The estimated relative risk of admission for UTI by first-year follow-up indicated a significantly higher risk for uncircumcised boys than for circumcised boys (3.7 [2.8-4.9]). 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life. INTERPRETATION: Although our findings support the notion that circumcision may protect boys from UTI, the magnitude of this effect may be less than previously estimated.

PIP: A prospective population-based cohort study assessed the association between male circumcision and subsequent urinary tract infection (UTI) in children born in Ontario, Canada, in a 12-month period in 1993-94. Of the 69,100 eligible infants, 30,105 (43.6%) were circumcised in the first month of life. 29,217 uncircumcised boys were matched to circumcised boys by date of birth and followed for 24-36 months. Information on UTIs was extracted from the Canadian Institute for Health Information computerized database on hospital discharges. There were 83 UTI cases in the circumcised cohort (1.88/1000 person-years of observation) and 247 in the uncircumcised group (7.02/1000 person-years) (p 0.0001). The relative risk of UTI in uncircumcised compared to circumcised boys was 4.5 (95% CI, 2.4-8.4) in the first month of life and 3.7 (95% CI, 2.8-4.9) in the year after the procedure. Calculation of the attributable risk indicated 195 circumcisions would be necessary to prevent one admission for UTI in the first year of life. Previous studies have recorded UTI rates 10-20 times higher in uncircumcised than circumcised boys. These findings support the hypothesis that circumcision protects boys from UTI, but the magnitude of this effect may be less than previously estimated.

The use of two estrogen preparations (a combined contraceptive pill versus conjugated estrogen cream) intravaginally to treat urogenital symptoms in postmenopausal Thai women: a comparative study.

OBJECTIVE: To determine whether the combined contraceptive pill used intravaginally was as effective as the standard conjugated estrogen cream for the treatment of urogenital symptoms in postmenopausal Thai women. SUBJECTS AND METHODS: In a randomized clinical trial, 40 postmenopausal women with urogenital symptoms were randomly allocated to two treatment groups for 8 weeks. The first group (n = 20) received a combined contraceptive pill by the vaginal route, one tablet per week at bedtime for 8 weeks. Each tablet contained 250 microg levonorgestrel plus 30 microg ethinyl estradiol. The second group (n = 20) was given 1 gm of an intravaginal conjugated estrogen cream at bedtime, three times in the first week, twice in the second week, and then once a week for the next 6 weeks (1 gram of conjugated estrogen cream contained 0.625 mg conjugated equine estrogens). Subjects were questioned about their urogenital symptoms, and vaginal cytologic smears, vaginal bacterial cultures, and urine cultures were performed before treatment and after 2, 4, and 8 weeks of therapy. RESULTS: The vaginal pH and the proportion of the fecal type bacteria decreased in both groups, with no statistically significant difference between the groups. The karyopyknotic index and the maturation index were improved during treatment in both groups. An increase in the proportion of lactobacilli were recorded in both groups after therapy, with no significant difference between the two groups. No significant changes were observed in urinary bacteria. The therapy (combined contraceptive pill and estrogen cream) had a marked effect on urogenital symptoms (vaginal dryness, dyspareunia, urinary frequency, and urinary urgency), with impressive improvement comparably in both groups. CONCLUSIONS: A combined contraceptive tablet administered vaginally once a week can alleviate urogenital symptoms in Thai postmenopausal women as effectively as the vaginal estrogen cream. However, the pills are much less expensive and are easily obtained in developing countries.

PIP: A randomized clinical trial conducted in Bangkok, Thailand, investigated whether intravaginal use of a combined oral contraceptive (OC) is as effective for the treatment of urogenital symptoms in postmenopausal women as the standard regimen of conjugated estrogen cream. 40 postmenopausal women (mean age, 54 years) with urogenital symptoms related to estrogen deficiency were allocated to one of two treatment groups for 8 weeks. The first 20 women received one OC (250 mcg of levonorgestrel and 30 mcg of ethinyl estradiol) per week; the remaining 20 women were given estrogen cream (0.625 mg conjugated equine estrogens) at bedtime 3 times in the 1st week, twice in the 2nd week, and weekly for the last 6 weeks. Vaginal pH and the proportion of fecal-type bacteria decreased, the karyopyknotic and maturation indices improved, and the proportion of vaginal colonization with lactobacilli increased in both groups, with no significant differences between treatments. Also recorded in both groups were impressive improvements in vaginal dryness, dyspareunia, urinary frequency, and urinary urgency. No significant changes were observed in urinary bacteria. Combined OCs are less expensive than vaginal estrogen cream and more readily available in developing countries. Since they are as effective as the cream at alleviating urogenital symptoms in postmenopausal women, their use for this purpose merits consideration.

Schistosomiasis and the risk of bladder cancer in Alexandria, Egypt.

The relationship between history of schistosomiasis and bladder cancer risk was investigated using data from a case-control study conducted between January 1994 and July 1996 in Alexandria, Egypt. Cases were 190 subjects with incident, histologically confirmed invasive cancer of the bladder, and controls were 187 subjects admitted to hospital for acute, non-neoplastic, non-urinary tract conditions. Eighty-six cases (45%) vs 69 controls (37%) reported a history of urinary schistosomiasis. The corresponding multivariate odds ratio (OR) of bladder cancer -- after allowance for age, sex, education, smoking, other urinary infections and high-risk occupations -- was 1.72 (95% confidence interval (CI) 1.0-2.9). The ORs were 0.22 (95% CI 0.1-0.4) for intestinal schistosomiasis and 0.32 (95% CI 0.1-1.9) for schistosomiasis of other types. The OR for urinary schistosomiasis was higher in subjects who were younger at first diagnosis (OR of 3.3 for <15 years) and in those with a long time since first diagnosis (OR of 3.0 for > or = 35 years). The ORs were 15.8 for male ever-smokers with a history of urinary schistosomiasis, compared with never-smokers without such a history, and 3.2 for men ever-infected with urinary Schistosoma haematobium and ever-employed in high-risk occupations, compared with those never-infected and with no high-risk occupational history. This study confirms that clinical history of urinary schistosomiasis is significantly, but modestly, associated with increased bladder cancer risk, explaining some 16% of bladder cancer cases in this Egyptian population.

PIP: A case-control study conducted in Alexandria, Egypt, in 1994-96, investigated the association between a history of schistosomiasis and the risk of bladder cancer. Egypt's bladder cancer rate is the highest in the world. Enrolled were 190 adults with incident, histologically confirmed invasive cancer of the bladder and 187 controls admitted to the same hospitals for acute causes unrelated to neoplasms or the urinary tract. 86 cases (45%) and 69 controls (37%) reported a history of urinary schistosomiasis. After adjustment for age, sex, education, smoking, high-risk occupations, and other urinary infections, the odds ratio (OR) for bladder cancer risk was 1.72 (95% confidence interval (CI), 1.0-2.9). The ORs were 0.22 (95% CI, 0.1-0.4) for intestinal schistosomiasis and 0.32 (95% CI, 0.1-1.9) for other types of schistosomiasis. The risk for urinary schistosomiasis was higher in subjects under 15 years of age at first diagnosis (OR, 3.3), suggesting a duration-risk relationship. The ORs were 15.8 for male ever-smokers with a history of urinary schistosomiasis and 3.2 for men ever-infected with Schistosoma haematobium and ever-employed in a high-risk occupation. Other studies that have used eggs in urine or histologic samples, rather than self-reported clinical history of urinary schistosomiasis, have produced similar results. Based on the findings of this study, a clinical history of urinary schistosomiasis accounts for an estimated 16% of bladder cancer cases in this Egyptian population. Tobacco smoking is a far greater risk factor for bladder cancer in Egypt.

Serologic association of human herpesvirus eight with posttransplant Kaposi's sarcoma in Saudi Arabia.

BACKGROUND: This study investigates the association between human herpesvirus eight (HHV8) and Kaposi's sarcoma (KS), the most common cancer occurring in renal transplant recipients in Saudi Arabia. METHODS: A cross-sectional study of seroreactivity to HHV8 antigens in posttransplant KS patients from a tertiary care hospital in Riyadh, Saudi Arabia, and in control subjects without KS was conducted. Seroreactivity rates were determined using immunoblotting assays to detect antibodies to two lytic cycle HHV8 antigens: p40, an antigen found in infected cells, and sVCA, an HHV8-encoded small viral capsid antigen expressed in Escherichia coli. RESULTS: Antibodies to HHV8 p40 and sVCA were present in a significantly higher proportion of renal transplant patients with KS (13 of 14 patients) compared to renal transplant patients without KS (5 of 18; P<0.001) and compared to other control individuals (6 of 44; P<0.001). HHV8 seroreactivity was more common among patients with renal failure (28%) than among other control groups (7%). CONCLUSIONS: The serologic results provide evidence of a strong association between HHV8 and posttransplant KS in Saudi Arabia.

PIP: In Saudi Arabia, Kaposi's sarcoma occurs in 4.1% of renal transplant recipients and accounts for 70% of malignancies in this group. Human herpes virus 8 (HHV8) has been identified in the DNA of many of these patients. The association between HHV8 and Kaposi's sarcoma was investigated further in post-renal transplant Kaposi's sarcoma patients from a tertiary care hospital (King Faisal Specialist Hospital and Research Center) in Riyadh, Saudi Arabia (n = 14), and non-Kaposi's sarcoma controls with renal transplant (n = 18), chronic renal failure (n = 14), other cancers that did not affect renal function (n = 15), and healthy volunteers (n = 15). The median time from transplant to Kaposi's sarcoma was 13 months. A serum sample was assumed to have antibodies to HHV8 if antibody to either p40 or sVCA was detected. The prevalence of HHV8 seroreactivity was 13/14 (93%) in cases, 5/18 (28%) in renal transplants without Kaposi's sarcoma, and 11/62 (18%) in the aggregate control group. HHV8 seroreactivity was significantly more common (p 0.001) among transplant patients with Kaposi's sarcoma than those without this cancer (odds ratio, 33.80; 95% confidence interval, 2.96-904). These findings suggest an etiologic link between HHV8 and Kaposi's sarcoma presumably due to immunologic or cellular factors that influence host-virus interactions.

Frequent urination and Depo-Provera. Ask the experts.

PIP: This "Ask the Experts" column addresses two concerns related to use of Depo-Provera. The first question relates to the clinical significance of frequent urination. Two of the three experts assert that frequent urination in a Depo-Provera user is unlikely to be related to method use; urinary tract infection and diabetes are more probable causes. The third notes that hypoestrogenicity could be a factor and suggests examination of the vagina for atrophy, which could cause the tissue around the urethra to become atrophic. The second question addresses techniques for confirming menopause in Depo-Provera users. The experts concur that measurement of follicle-stimulating hormone in perimenopausal Depo-Provera users lacks predictive value. Recommended, instead, is continuation of Depo-Provera with supplemental estrogen until the woman is in her mid-50s. At that time, conventional hormone replacement therapy can be initiated.^ieng

[The urological complications of contraception using intrauterine coils]. / Urologicheskie oslozhneniia kontratseptsii vnutrimatochnymi spiraliami.

Being a foreign body, intrauterine coil causes decubitus and inflammation of the adjacent tissues. Long-term carriage of the coil may give rise to endometritis, myometritis, parametritis, salpingo-oophoritis, tubo-ovarian inflammatory infiltrates. These infiltrates invade retroperitoneal pelvic fat and may obstruct pelvic ureters. Ureteral obstruction may bring about ureterohydronephrosis, pyelonephritis and renal calculi. The coil may be also responsible for chronic pyelonephritis. The authors have treated 64 females aged 18-45 years with urological complications due to intrauterine coils which stayed from 6 months to 14 years. 34 of them presented with attack of acute pyelonephritis, 29 with renal colic and acute pyelonephritis, 26 with renal calculi. To arrest renal colic and attack of acute pyelonephritis ureteral catheterization and renal pelvis drain were performed in 31 patients. One patient has undergone ureterolithotomy. 8 patients rejected removal of the coil and had recurrent renal colics and acute pyelonephritis attacks. Removal of the coil arrested pyelonephritis and lithogenesis in the kidney. In one case of coil removal there was injury to the uterine cervix and urinary bladder eventuating in vesicovaginal fistula.

PIP: According to various authors the frequency of inflammatory complications associated with the use of IUDs ranges from 2% to 8%. Gynecological surgery on account of purulent, inflammatory disease of the adnexa uteri associated with IUD use (4-7%), damaging the urinary bladder and the ureters, is not uncommon. At the urological clinic of Stavropol, Russia, a total of 64 women who were in the 18-64 year age range, had urological complications, and had worn IUDs for 6 months to 14 years were observed. 34 of them presented with acute pyelonephritis attacks, 29 of them with renal colic and acute pyelonephritis, and 26 with renal calculi. In 22 women the acute pyelonephritis attacks were treated with antibiotics and uro-antiseptics. 19 of the 29 women who had renal colic and acute pyelonephritis underwent catheterization and drainage of the renal pelvis, and all of them passed fine kidney stones after the removal of their catheters. Urethral catheterization and drainage of the renal pelvis were performed in 31 patients in order to arrest renal colic and acute pyelonephritic attacks. The catheters stayed in for 2-3 days. For all these women removal of the IUD was recommended. 1 patient underwent ureterolithotomy. 8 patients rejected the removal of the IUD and had recurrent renal colics and acute pyelonephritis attacks. Removal of the IUD arrested pyelonephritis and lithogenesis in the kidneys. In 1 case of IUD removal injury to the uterine cervix and urinary bladder occurred, resulting in a vesicovaginal fistula. The report concludes with the case of a 44-year old patient who had worn a plastic IUD for 14 years.

Early-onset neonatal sepsis in Pakistan: a case control study of risk factors in a birth cohort.

We prospectively evaluated risk factors for early-onset neonatal (EON) sepsis in a case-control study among inborn patients at the Aga Khan University Medical Centre in Karachi between 1990-1993. A total of 38 cases with blood culture proven bacterial sepsis were identified within 72 hr of birth (prevalence 5.6 of 1000 live births) and matched with two consecutive gender matched births with no complications. The most common isolates were Staphylococcus aureus (18%), group B Streptococci (13%), and Klebsiella pneumoniae (13%). Univariate analysis of maternal risk factors revealed a significant association between maternal urinary tract infection (UTI) (odds ratio [OR]20, 95% confidence interval [CI]2.4-166.9), maternal pyrexia (P < 0.0001), vaginal discharge (P < 0.05), vaginal examinations during labor (P = 0.03), and EON sepsis. The infected newborns also had significantly lower apgar scores at birth (P < 0.0001) and a significantly greater number were intubated at birth (Fisher's exact test P = 0.04). Infected newborn infants were transferred out of the labor room earlier than noninfected controls and significantly fewer received exclusive breastfeeds (OR 0.33, 95% CI 0.1-0.8). Our data suggest the possibility that both vertical transmission from the mother as well as postnatal acquisition of infection from the environment may be of importance in the pathogenesis of EON sepsis in Karachi. Preventive measures should focus at recognition of high-risk infants, strict asepsis during labor, and early institution of exclusive breastfeeding.

Condom use and first-time urinary tract infection.

We evaluated the effects of condom use, lubricated condom use, and spermicide use on risk of acquiring first urinary tract infection in a case-control study of sexually active college women ages 18-39 years. Cases (N = 144) were women with first urinary tract infection that was confirmed by culture recruited at the student health service; controls (N = 286) were women without a history of urinary tract infection who were randomly sampled from all women enrolled at the university. Participants completed a self-administered questionnaire regarding type and frequency of condom use during the previous 2 weeks. Condoms and spermicides usually were used in combination with each other or oral contraceptives. After adjusting for frequency of vaginal intercourse, using unlubricated condoms compared with using no birth control method strongly increased the risk of first urinary tract infection (odds ratio = 29.1; 95% confidence interval = 3.1-1,335). Using a lubricated condom (with or without spermicide in the lubricant) or a spermicidal cream or gel with an unlubricated condom was associated with two- to eightfold risk of first urinary tract infection. Unlubricated condom use was strongly associated with risk of first urinary tract infection, but this effect was largely neutralized by using a spermicidal cream or gel with the unlubricated condom or by using a lubricated condom.

Azithromycin in the treatment of chlamydial cervicitis and eradication of Ureaplasma urealyticum in female lower genital tract.

From May 1995 to May 1996, thirty-six females with chlamydial cervicitis were enrolled at Bangrak Hospital's Venereal Disease Clinic in an open study to assess the efficacy and safety of a single, 1-gram oral dose of azithromycin. Thirty-five had positive C. trachomatis and one had a positive Gen-probe test. Twenty-two returned for their first and second follow-ups and 18 came back for their final follow-up (visit 4). Eradication rate was 100 per cent on all visits. Fourteen patients were excluded from the final analysis- three had dropped out from the beginning, ten had sexual intercourse without a condom and one had a positive Gen-probe test but negative C. trachomatis culture. U. urealyticum was isolated from the vaginal wall of 15 of the 36 cases and eradication rate was 0 per cent at visit 2 and visit 4. In conclusion, this study shows that a single, 1-gram oral dose of azithromycin is an effective and well-tolerated alternative therapy for chlamydial cervicitis.

Acute urinary retention secondary to urethral inflammation from a vaginal contraceptive suppository in a 17-year-old boy.

We report the case of a 17-year-old boy who developed acute urinary retention following unprotected intercourse. His partner employed for the first time a nonoxynol-9-based commercial vaginal contraceptive insert. During intercourse the patient felt severe burning pain in the urethra. He was subsequently unable to void. Flexible cystourethroscopy revealed gross mucosal erythema and inflammation in the distal urethra and navicular fossa. We discuss the clinical management and review relevant literature.

PIP: Reported is the case of a 17-year-old US boy who developed acute urinary retention due to severe urethral inflammation, secondary to absorbance of a nonoxynol-9-based contraceptive. He had a recent history of unprotected intercourse with his regular sex partner until she used, for the first time, a vaginal suppository containing nonoxynol-9. During intercourse on this occasion, the adolescent experienced severe burning pain in the urethra and was subsequently unable to void. He denied any prior history of urinary tract infection, sexually transmitted diseases, or urethral discharge prior to this episode. The only significant clinical findings at examination were an inflamed meatal mucosa and severe tenderness to palpation 2 cm proximal to the glans. Flexible cystourethroscopy revealed gross mucosal erythema and inflammation in the distal urethra and navicular fossa. A French Foley catheter was easily inserted into the bladder and 1000 cm of clear urine were drained. An indwelling catheter was kept in place for 48 hours until the patient voided successfully. This is the first reported case of severe urethritis and obstruction in a young male. In this case, urethral absorption of nonoxynol-9 caused a severe inflammatory reaction sufficient to obstruct the distal urethra. When evaluating young men with acute urinary retention, clinicians should inquire about recent use of contraceptive inserts.

Malignant hypertension in young women is related to previous hypertension in pregnancy, not oral contraception.

Previous studies have suggested that one-third of women of childbearing age who develop malignant phase hypertension (MHT) are likely to be taking oral contraceptives (OC). We surveyed 104 women with a history of MHT. None of the 65 aged > 45 years were taking OC or other sex hormones. Thirty-nine (mean age 34.9 years, SD 8.0) were aged 15-44 years at presentation: 22 Caucasian, 10 Black/Afro-Caribbean and seven Indo-Asian. Of these 39, 22 had a history of hypertension in pregnancy (group 1), and 17 did not (group 2). Three of group 1 also had a history of OC-induced hypertension. None were pregnant, but one was taking an OC at presentation with MHT. Blood pressures at presentation and follow-up, and mean serum urea and creatinine at presentation were similar between groups, as was median survival (96 vs. 47 months, Lee-Desu statistic 0.75, p = 0.38). There was a trend towards poorer renal function at follow-up in group 1 patients, with higher mean serum urea and creatinine levels. The causes of death were renal failure (5), stroke (4) and heart disease (2). The OC was not a common cause of MHT-amongst our sample of women of childbearing age, but a past history of hypertension in pregnancy was important. Such patients also had a longer duration of hypertension and poorer renal function at follow-up.

Ureteroperitoneal fistula secondary to tubal sterilization by laparoscopy.

PIP: In Spain, a 32-year-old woman presented at Motril Hospital in Granada with pain and a fever arising 3 days after undergoing laparoscopic tubal sterilization with electrocoagulation at a nearby hospital. She had tenderness on palpation in the left lower quadrant of the abdomen. Since no pathology was evident on ultrasonography but laboratory studies revealed leucocytosis, the physicians diagnosed pelvic inflammatory disease and treated her with clindamicin and gentamicin. She returned to Motril Hospital a month later with pain in the lower left quadrant of the abdomen and in the left costovertebral angle and a fever of 2 days' duration. The physical examination indicated peritonitis. The hemoglobin level was 100 g/l; the hematocrit was 32%; and she had leucocytosis. Free fluid in the pelvic peritoneum and mild ureterohydronephrosis were found by ultrasonography and confirmed by IVP. Retrograde pyelography indicated an ureteric fistula with contrast medium passing to the Douglas pouch. The clinicians could not pass a catheter via the affected ureteric segment. Laparotomy revealed uroperitoneum with a hole at the posterior parietal peritoneum through which urine passed. Surgeons dissected the area up to the ureteric injury, presumably caused by electrocoagulation during laparoscopy, anastomosed the ureter end-to-end, and placed a 6 F stent catheter in the ureter for 10 days. The IVP 2 months later was normal. As new laparoscopic procedures emerge, there will be new cases of ureteric injury. The first treatment choice is percutaneous nephrostomy. Surgery should be the treatment choice for cases of failure or when clinicians suspect other complications associated with the ureteric injury.^ieng

Genital ulcer disease among STD clinic attenders in Nairobi: association with HIV-1 and circumcision status.

In previous studies, genital ulcers in men have been found to be associated with increased risk of HIV-1 seroconversion. To further explore this association male patients attending a sexually transmitted disease (STD) clinic in Nairobi for either urethritis (controls, n = 276) or a genital ulcer (cases, n = 607) were compared with respect to sexual behaviour, presence of HIV-1 antibody and circumcision status. Patients were followed to study risk factors for incident genital ulcers and HIV-1 seroconversion. At entry, being married was associated with higher prevalence of HIV-1 (OR = 1.76) and genital ulcers (OR = 1.42). Lack of circumcision was associated with both HIV-1 infection (OR = 4.67) and the presence of a genital ulcer (OR = 2.23). Genital ulcers were also associated with HIV-1 infection (OR = 1.87) independent of circumcision status. On follow-up, HIV-1 seropositivity was associated with incident genital ulcers. It is argued that the association between genital ulcers and HIV-1 infection may be more complex than ulcers simply being a risk factor for HIV-1 infection, and that HIV-1 infection may either increase the risk of acquiring a genital ulcer, or HIV-1 infection and genital ulcers may have some unknown risk factor in common.

PIP: Male patients (mean age, 28 years) attending a sexually transmitted disease clinic in Nairobi, Kenya, for either urethritis (276 controls) or a genital ulcer (607 cases) were compared with respect to sexual behavior, presence of HIV-1 antibody, and circumcision status. Only 164 men were not circumcised. Circumcised men reported more life-time sex partners than uncircumcised men (19 vs. 10, p 0.01). Patients were followed up for 196 days to explore the risk factors for incident genital ulcers and HIV-1 seroconversion. On average, 2.66 follow-up visits per patient were recorded. 28 men seroconverted to HIV-1 during follow-up. 61% of the ulcer patients reported sex workers as the likely source of their infection, whereas 58% of the urethritis patients did so. Multiple logistic regression variables of marital status, age, and genital ulcer in the past were used to examine the relationship among these variables. Ulcer in the past was a significant predictor of a current ulcer (p 0.01) and higher age was significantly associated with HIV-1 seropositivity (p 0.01). At entry, being married was associated with higher prevalence of HIV-1 (odds ratio [OR] = 1.76) and genital ulcers (OR = 1.42). Lack of circumcision was associated with both HIV-1 infection (OR = 4.67) and the presence of a genital ulcer (OR = 2.3). 68 men acquired a new ulcer during follow-up. HIV-1 seropositivity at enrolment was significantly associated with genital ulcer reinfection (relative risk = 3.63 by Cox's regression). Genital ulcers were also associated with HIV-1 infection (OR = 1.87) independent of circumcision status. On follow-up, HIV-1 seropositivity was associated with incident genital ulcers. The association between genital ulcers and HIV-1 infection may be more complex than ulcers' simply being a risk factor for HIV-1 infection: either HIV-1 infection may increase the risk of acquiring a genital ulcer or HIV-1 infection and genital ulcers may have some unknown risk factor in common.

Association between use of spermicide-coated condoms and Escherichia coli urinary tract infection in young women.

Diaphragm/spermicide use increases the risk of urinary tract infection (UTI). To determine whether spermicide-coated condoms are also associated with an increased risk of UTI, the authors conducted a case-control study at a large health maintenance organization in Seattle, Washington. Cases were sexually active young women with acute UTI caused by Escherichia coli, identified from computerized laboratory files during 1990-1993. Age-matched controls were randomly selected from the enrollment files of the plan. Of 1,904 eligible women, 604 cases and 629 controls (65%) were interviewed. During the previous year, 40% of the cases and 31% of the controls had been exposed to any type of condom. The unadjusted odds ratio for UTI increased with frequency of condom exposure from 0.91 (95% confidence interval (CI) 0.65-1.28) for weekly or less during the previous month to 2.11 (95% CI 1.37-3.26) for more than once weekly. Exposure to spermicide-coated condoms conferred a higher risk of UTI, with odds ratios ranging from 1.09 (95% CI 0.58-2.05) for use weekly or less to 3.05 (95% CI 1.47-6.35) for use more than once weekly. In multivariate analyses, intercourse frequency (odds ratio (OR) = 1.14 per weekly episode), history of UTI (OR = 2.64), and frequency of spermicide-coated condom exposure (OR = 3.34 for more than once weekly and 5.65 for use more than twice weekly) were independent predictors of UTI. Spermicide-coated condoms were responsible for 42% of the UTIs among women who were exposed to these products.

PIP: A large population-based case-control study found that condoms coated with the spermicide nonoxynol-9 were responsible for 42% of urinary tract infections (UTIs) in women exposed to these products. 604 women 18-40 years old who presented to a health maintenance organization in Seattle, Washington, during 1990-93 with acute UTI caused By Escherichia coli served as cases; 629 age-matched controls were randomly selected from the health facility's files. In the preceding month, nonoxynol-coated condoms had been used by 35% of cases and 25% of controls. The unadjusted odds ratios for having an acute UTI among women who had used any type of condom in the previous month and previous year were 1.24 (95% confidence interval, 0.94-1.63) and 1.47 (1.16-1.85), respectively. The UTI risks for women who used the nonoxynol-9 coated condoms in the previous month and more than twice a week during the past year were 1.72 (1.08-2.75) and 2.39 (1.10-5.16), respectively. Independent predictors of UTI, identified through multivariate analyses, included intercourse frequency (odds ratio of 1.14 per weekly episode), past history of UTI (2.64), and frequency of coated condom exposure (3.34 for more than once weekly and 5.65 for use more than twice weekly). Among cases exposed to spermicide-coated condoms during the previous month, 41.9% of UTIs were due to coated condoms. The association confirmed in this study is supported by research indicating that nonoxynol-9 induces changes in the normal vaginal flora that facilitate colonization with coliform bacteria.

Urea kinetics in healthy young women: minimal effect of stage of menstrual cycle, contraceptive pill and protein intake.

Urea kinetics were measured using prime/intermittent oral doses of [15N15N]urea, on five separate protocols in thirteen normal young women. Each woman underwent either two or three study protocols. Measurements were made at day 12 and day 22 of the menstrual cycle, whilst consuming their habitual protein intake in seven women not taking the contraceptive pill and in six women taking the contraceptive pill. In three women taking the pill, and three not taking the pill, urea kinetics were measured whilst taking a diet in which the intake was restricted to 55 g protein/d. There was no difference in the rate of urea production, urea excretion or urea hydrolysis between the women taking the pill and those not taking the pill at day 22. In the women not taking the pill there was no difference in any measure between day 12 and day 22. In the women taking the pill there was a significant difference in the disposal of urea N to excretion or hydrolysis on day 12 compared with day 22, with a relative decrease in excretion and enhancement of hydrolysis at day 12 compared with day 22. On the restricted diet, an intake of 55 g protein/d represented 77% of the habitual intake and urea production, excretion and hydrolysis were reduced to about 84% of the rate found on the habitual intake. In paired studies the reduction in urea production was statistically significant, and there was a statistically significant linear relationship between urea production and either intake or the sum of intake plus hydrolysis. The within-individual variability for urea production was about 10%, for excretion 15% and for hydrolysis 44%. The between-individual variability for intake was about 17% on the habitual intake. The variability for production, excretion and hydrolysis (14, 13, 36%) was less in the women not taking the contraceptive pill than in those taking the pill 23, 32, 42% respectively). The variability was reduced on the controlled low intake of 55 g protein compared with the habitual intake. These results confirm the wide variability in aspects of urea kinetics between individuals. In women this variability is not, to any large extent, accounted for by changes associated with the menstrual cycle.

PIP: In England, nutritionists measured urea kinetics in 13 women aged 21-37 years who took prime/intermittent oral doses of [15N15N]urea under five separate conditions to identify the extent to which the stage of the menstrual cycle and the use of a low-dose estrogen oral contraceptive (OC) contribute to variability. The protocols included habitual diet alone and urea measurement on either day 12 or day 22 of the menstrual cycle, habitual diet and OC use with urea measurement on either day 12 or day 22, a diet of 55 g protein/day (around 77% of habitual intake) with no control over day of urea measurement, and a diet of 55 g protein/day and OC use with no control over day of urea measurement. The habitual diet had little effect on urea kinetics of the time of the menstrual cycle. OC use also had little effect, except it did decrease excretion (107 vs. 132 mg N/kg/day for non-use) and increase hydrolysis (97 vs. 62 mg N/kg/day) of urea at day 12 of the menstrual cycle. The 55 g/day protein intake decreased urea production, excretion, and hydrolysis (about 84% of habitual diet). It effected the least variation among individuals. For all protocols, the variation in plateau enrichment for urea was 11.8%. The within-individual variability stood at around 10% for urea production, 15% for excretion, and 44% for hydrolysis. For intake, the between-individual variability was around 17% on habitual intake. Nonusers exhibited less variability for production, excretion, and hydrolysis than OC users. In the paired studies, the reduction in urea production and the linear relationship between urea production and either intake or the sum of intake plus hydrolysis was statistically significant. These findings show that healthy young women have urea kinetics similar to those of men and that there is wide variability in urea kinetics between individuals.

Urinary schistosomiasis: options for control within endemic rural communities: a case study in south-west Nigeria.

A preliminary investigation was conducted into factors that may bring about control of morbidity due to endemic urinary schistosomiasis in rural communities. A Knowledge, Attitudes, Practices and Beliefs (KAPB) study was conducted among primary schoolchildren (those with more than four years elementary education) in Ogbagba village, Osun State, Nigeria, from October 1990 to December 1993, to ascertain their understanding of urinary schistosomiasis. The study further assessed the potential of subjective haematuria, i.e. asking children with haematuria in the recent past to so indicate, in detecting urinary schistosomiasis. It was established that subjective haematuria is both sensitive and specific for detecting urinary schistosomiasis in endemic communities. The study also established that subjective haematuria offers a valid, easy to recognize target for morbidity control in endemic situation. It is proposed that with appropriate health education; availability of safe, effective, easy-to-administer drugs, such as praziquantel, morbidity control of urinary schistosomiasis is feasible within the primary health care system with the lower cadre health worker or even a volunteer village health worker (VVHW) at the centre of the control effort.

PIP: During October 1990 to December 1993, in Ife-Central Local Government Area of Osun State, Nigeria, interviews with and physical and laboratory examinations of 106 grade 4-6 pupils aged 8-16 were conducted in Ogbagba village so the researchers could determine their knowledge, attitudes, practices, and beliefs about urinary schistosomiasis as well as the factors that offer opportunities for morbidity control of urinary schistosomiasis in an endemic area. There was no health facility in Ogbagba. 89.5% of the children had urinary schistosomiasis. 75.5% of all pupils knew the local name for urinary schistosomiasis. 66% had previously passed blood in their urine. 85.7% of these pupils believed hematuria was serious. 70.8% gave a positive history of current episode of hematuria. 62.7% of these pupils did not seek any treatment. Symptoms associated with past hematuria included abdominal pain, weakness, weight loss, and fever. 65.7% of all pupils did not know what causes urinary schistosomiasis. 67.1% believed that urinary schistosomiasis was acquired via some form of contact with water, especially swimming (57.1%). The leading types of water contact included washing clothes (95.3%), fetching water (94.3%), bathing (87.7%), and swimming (74.5%). 74.5% of all pupils urinated deliberately in the river. The sensitivity, specificity, predictive values, and efficiency of alternative methods of detecting urinary schistosomiasis revealed that subjective hematuria was comparable to gross/microscopic hematuria. These findings will be used to design information, education, and communication materials for a health education program on urinary schistosomiasis using the primary health control approach. The researchers propose that both subjective and gross hematuria be used as the basis for treating children aged 4-19 living in areas endemic for urinary schistosomiasis. Praziquantel should be used as the only drug for treating urinary schistosomiasis. Health education in the schools' curriculum and information, education, and communication developed by health authorities should promote better water contact practices. Teachers need to regularly ask their pupils about hematuria and encourage them to seek medical treatment.