[Management of sexually transmitted diseases in primary care (II). Genital ulcers. Vulvovaginitis. Human papilloma virus]. / Manejo en atención primaria de las infecciones de transmisión sexual (II). Lesión ulcerada genital. Vulvovaginitis. Virus del papiloma humano.

In this paper we approach three clinical syndromes with different microbial agents that cause sexually transmitted diseases (STD) with a common condition: the symptomatology is in the genital area. Some of these microbial agents are transmitted strictly sexually, but not all. In this section we will discuss about vulvovaginitis, genital ulcers and human papilloma virus, three syndromes which have increased their incidence in recent years and primary care must know its management: diagnosis, correct treatment, controls, and study of sexual contacts. The optimal approach is as important as knowing how to recommend prevention of STD, contact study and screening for other infections that can be present at the same time although asymptomatically.

[TWO CASES OF ALLERGIC VULVOVAGINITIS DIAGNOSED BY DIRECT MICROSCOPIC URINE SEDIMENT EXAMINATION].

Cedar pollen is known as a typical allergen that causes various allergic symptoms in the nasal mucosa, conjunctiva, and skin. However, inflammation of the vulvar mucosa due to sensitization to cedar pollen is not well-known. We experienced two cases in which the detection of cedar pollen during microscopic urine sediment examination led to the diagnosis of allergic vulvovaginitis caused by cedar pollen. The cases involved a 4-year-old girl and a 10-year-old girl. In both cases, the patients presented with chief complaints of pruritis in the vulva and insomnia due to frequent urination during the season of cedar pollen dissemination. Both patients were afebrile. No inflammatory skin changes such as erythema, swelling, or non-purulent discharge from mucous membranes of the vulva were observed. Microscopic urine sediment examination revealed large amounts of shed cedar pollen. The patients' conditions improved after treatment with oral antihistamines and instruction to dry their underwear indoors. Follow-up blood tests revealed high levels of specific anti-IgE antibodies to cedar pollen, thus confirming a diagnosis of allergic vulvovaginitis due to cedar pollen. Cedar pollen can cause allergic vulvovaginitis. Microscopic urine sediment examination is useful, and when combined with specific IgE antibody testing, leads to an appropriate diagnosis. This disease should also be considered in patients with complaints of vulvar discomfort during the season of cedar pollen dissemination.

New Antifungals for Vulvovaginal Candidiasis: What Is Their Role?

New antifungals, ibrexafungerp and oteseconazole, are now available for treatment of vulvovaginal candidiasis. Both have novel antimicrobial and pharmacokinetic properties and advantages over fluconazole, although comparative trials have involved only placebo. In the absence of allergy, intolerance, and resistance, it is unclear whether these antifungals will replace fluconazole.

ß-Estradiol and progesterone enhance biofilm development and persister cell formation in monospecies and microcosms biofilms derived from vulvovaginal candidiasis.

The present study aimed to: (1) evaluate the influence of the steroid hormones (SH) on biofilm development; (2) investigate the formation of persister cells (PC) in biofilms; and (3) investigate the influence of SH on PC formation. Biofilms were derived from vulvovaginal candidiasis (VVC) samples and evaluated by three models: microcosm biofilms grown in Vaginal Fluid Simulator Medium (MiB-VFSM); monospecies biofilms grown in VFSM (MoB-VFSM) and RPMI media (MoB-RPMI). SH altered cell counting and biomass of biofilms grown in VSFM; MoB-RPMI were negatively affected by SH. SH stimulated the formation of PC in MiB-VFSM but not MoB-VFSM; MoB-RPMI showed a lower number of PC in the presence of SH. The results showed that SH altered the dynamics of biofilm formation and development, depending on the study model. The data suggest the influence of hormones on the physiology of Candida biofilms and reinforce the importance of PC in the pathogenesis of VVC.

Vaginal bleeding in children: A retrospective audit at a tertiary paediatric gynaecology service.

AIM: The aim of this study was to describe the clinical features and investigations of vaginal bleeding in prepubertal children. METHODS: We performed a retrospective case series of children under the age of 10 who presented with vaginal bleeding to our institution between 2018 and 2019. RESULTS: There were 32 cases identified during the timeframe, with a mean age of 5.5 years (standard deviation 3.2 years, range 5.5 days to 9.6 years). Vulvovaginitis was the most common diagnosis (n = 12, 37.5%), followed by precocious puberty (n = 5, 15.6%). Uncommon but serious causes were vaginal rhabdomyosarcoma (n = 1), and sexual abuse (one patient presenting with gonorrhoea and one with a non-accidental injury). Vaginoscopy was performed in nine patients (28.1%) for various reasons, and a vaginal foreign body was identified in two patients (6.3%). All the patients who had a serious cause of bleeding (neoplasm or sexual assault) or who required specific treatment (precocious puberty, lichen sclerosus, urethral prolapse) presented with red flags on history and/or examination: recurrent episodes of vaginal bleeding, heavy bleeding, associated general symptoms (poor feeding and growth), presence of thelarche, abdominal mass, associated profuse vaginal discharge and abnormal genital examination (skin changes, urethral prolapse or protruding mass from the vagina). CONCLUSIONS: A thorough history-taking and clinical examination aiming at identifying red flags may help to discriminate between benign causes of vaginal bleeding, where no further investigations are indicated, and alternative diagnoses with a poor outcome and/or requiring specific treatment and additional investigations.

Species identification, antifungal susceptibility patterns, and vitamin D3 level in women with vaginal candidiasis: a case-control study in Iran.

Vulvovaginal candidiasis (VVC) is a fungal infection that is a global issue of women's health due to its association with morbidity, infertility, and economic costs. This study aimed to compare the vitamin D3 levels between women with VVC to healthy controls and determine the species distribution and susceptibility pattern of isolates. Species identification was performed using sequencing of the ITS-rDNA regions and amplification of the HWP1 gene. Antifungal susceptibility testing was determined by the disk diffusion method. Moreover, serum vitamin D3 levels were measured using a commercial ELISA (enzyme-linked immunosorbent assay) kit. Our results indicated that vitamin D3 level in women with VVC was lower than those of healthy women (p-value < .001). Candida albicans complex (62.8 percent) was the most common species, and most species were susceptible to fluconazole, itraconazole, ketoconazole, and nystatin. In conclusion, our study revealed a potential link between vitamin D3 deficiency and VVC in women. Although our findings showed significantly lower vitamin D3 levels in women with VVC, further research is needed to establish a definitive causative relationship between vitamin D3 deficiency and VVC. Nonetheless, our study highlights the potential importance of maintaining adequate levels of vitamin D3 and the need for further exploration in this area.

Early treatment of vulvar synechiae in childhood - prevention of late complications.

Synechiae of the vulva occurs especially in girls in the so-called resting hormonal period with a minimal serum concentration of estrogens. If the external genitalia of the girl are not treated properly, the mucous membrane of the vaginal entrance is not regularly checked and mechanically removed, then the smegma of the opposite mucous membranes of the vulva can stick together. The place of the adhesion of epithelium in the vaginal introitus can be covered by a new epithelium and can create a firm adhesion, synechiae of the vulva, which is usually asymptomatic and is discovered incidentally during pediatric examination. Clinically significant vulvar synechiae can cause impaired bladder evacuation and recurrent lower urinary tract infections. Dissection of synechiae in the stage of conglutination or thin adhesion is performed manually on an outpatient basis, but extensive and firm adhesions must be divided surgically under general anesthesia. Local application of cream with estriol or betamethasone is also used for the therapy of synechiae of the vulva, but this treatment is more time-consuming compared to rapid manual separation and requires good compliance of the girls and their parents. The prevention of synechiae is based on the education of parents by pediatricians and gynecologists about the need for regular checks of the external genitalia and sufficient hygiene.

Efficacy of a Novel Rigenase® and Polyhexanide (Fitostimoline® Septagel) Hydrogel Device for the Treatment of Vulvovaginitis Symptoms: Cross-Sectional Analysis of a National Survey and Prospective Observational Study.

Background and Objectives: Signs and symptoms of vulvovaginitis, especially when recurrent, have a significant impact on a woman's quality of life. The aim of this study was to survey gynecologists about their habits regarding the treatments of the pathology and to evaluate the efficacy of a novel vaginal hydrogel composed of wheat extracts and polyhexanide aimed at reducing vulvovaginitis symptomatology. Materials and Methods: A cross-sectional analysis of a national survey using 155 Italian gynecologists and a prospective, open-label, observational study were carried out in 75 outpatient clinics across Italy. Pre- and postmenopausal women with suspicion of vulvovaginitis due to at least four of the following symptoms (leucoxanthorrhea, bad odor from genitalia, vulvovaginal dryness, petechiae, burning, and pruritus) while waiting for microbiological swab analysis were included and treated with one hydrogel application every 3 days for 1 week. Primary endpoint was the complete resolution of symptomatology. Results: The pre-study survey reported that, for most clinicians, local or oral treatment (65.7% and 82.8%, respectively) with antibiotics or antifungals is used very often. Therefore, we proceeded to carry out an observational study. Overall, 615 (362 of fertile age and 253 in postmenopause) women were included in this study. At the 28th follow-up examination, complete resolution of symptomatology was achieved in 578/615 (94.1%; p < 0.001) within 12.72 ± 6.55 and 13.22 ± 6.33 days for those of fertile age and in postmenopause, respectively (p = 0.342). All of the evaluated symptoms were significantly reduced after treatment (p = 0.001) without differences according to the patient's menopausal status. A slightly significant reduction in Gardnerella Vaginalis (p = 0.040) and Candida Albicans (p = 0.049) was found after treatment. No patient reported side effects, adverse reactions, or discontinued therapy. Conclusions: This pilot study showed that a hydrogel based on Rigenase® (wheat extract) and polyhexanide could be a promising treatment for the relief of vulvovaginitis symptoms. However, these results are limited by the absence of a control group. Additional comparative and randomized controlled trials between the hydrogel and other non-antibiotic devices as well as local antibiotic therapy should be performed to increase the validity of the findings.

First detection of mutated ERG11 gene in vulvovaginal Candida albicans isolates at Ouagadougou/Burkina Faso.

BACKGROUND: Vulvovaginal candidiasis is an important cause of morbidity among women due to Candida species. In the last decades, resistance to azoles, first-line antifungals has increased. One molecular mechanism of azole resistance by Candida involves mutations in the ERG11 gene encoding lanosterol 14-α-demethylase, the target enzyme. This study was conducted to identify the clinical Candida species associated in vulvovaginal candidiasis; to determine the rate of antifungal resistance among Candida albicans isolates and to determine mutated ERG11 gene at Saint Camille Hospital in Ouagadougou, Burkina Faso. METHODS: Antifungals susceptibility were performed using Kirby-Bauer disk diffusion method. ERG11 gene was detected using conventional PCR in C. albicans isolates resistant to at least one azole. RESULTS: Out of 262 clinical strains isolated, C. albicans accounted for 59.90%, followed by Candida glabrata 27.86%, Candida famata 7.25%, Candida tropicalis 3.05% and Saccharomyces cerevisiae 1.91%. Resistance rate of fluconazole to C. albicans was 59.54%. ERG11 gene was found in 9.79% of 92 C. albicans strains resistant to azoles. CONCLUSIONS: This detection of mutated ERG11 gene in C. albicans is the first in Burkina Faso and may be a cause of azole resistance in recurrent Candida vulvovaginitis.

Microbiological findings in prepubertal and pubertal girls with vulvovaginitis.

Vulvovaginitis is a common and challenging gynaecological problem in prepubertal and pubertal girls. Such an infection, owing to a wide range of aetiologies, if not responding to hygienic measures, needs further investigation through vaginal cultures, since treatment should be tailored accordingly. This study aimed to investigate the pathogens isolated in prepubertal and pubertal girls with signs and symptoms of vulvovaginitis. A total of 2314 symptomatic girls, 1094 prepubertal and 1220 pubertal, aged 2 to 16 years, were included. Vaginal samples were inoculated on specific culture plates followed by incubation in aerobic, anaerobic or CO2 atmosphere at 37 °C for 24 or 48 h, as appropriate. The identification of the isolated pathogens was carried out using Gram stain, conventional methods and the automated system VITEK 2 (BioMerieux, Marcy l'Etoile, France). Positive cultures were obtained from 587 (53.7%) of prepubertal girls and 926 (75.9%) of pubertal girls. A total of 613 and 984 pathogens were detected in prepubertal and pubertal subjects, respectively. Isolated bacteria included 40.1% and 22.8% Gram-positive cocci, 35.6% and 24.8% Gram-negative rods in the prepubertal and pubertal groups, respectively, with faecal pathogens being the most prevalent. Bacterial vaginosis was diagnosed in 22.8% of prepubertal and 37.9% of pubertal girls. Candida species were isolated mostly in the pubertal girls (14.5%). CONCLUSION: Culture results should be evaluated with caution in children with vulvovaginitis. In the prepubertal girls, the most common isolated pathogens were opportunistic bacteria of faecal origin while girls in late puberty were more susceptible to bacterial vaginosis and vulvovaginal candidiasis. WHAT IS KNOWN: • Vulvovaginitis is the most frequent and challenging reason for referral to paediatric and adolescent gynaecology services. • Microbiological examination can prove to be a significant tool to help diagnosis although results should be evaluated with caution in children. WHAT IS NEW: • Significantly more positive vaginal cultures and pathogens were recorded in symptomatic pubertal girls compared to prepubertal children. • The prevalence of bacterial vaginosis was increased in both prepubertal and pubertal girls with vulvovaginitis although significantly more in girls at puberty.

DETECTION OF CANDIDA SPP. THAT CAUSES VULVOVAGINITIS IN WOMEN THAT USE CONTRACEPTIVE METHODS.

OBJECTIVE: The aim: To determine the distribution of Candida spp. within different age groups and contraceptive methods in women with vulvovaginitis, as well as the susceptibility of Candida spp. to commonly used antifungals. PATIENTS AND METHODS: Materials and methods: High vaginal swabs were taken from 98 women aged 18 to 50 with vulvovaginitis who used contraceptives and attended the Women and Children Hospital in Al-Diwaniyah; after diagnosis of Candida species, the sensitivity of Candida spp. to some antifungals was studied. RESULTS: Results: The results showed (43/98) women (43.87%) used IUD, (15/98) women (15.30%) used birth control pills, (7/98) women (7.14%) used an injection of contraceptive, (5/98) women (5.10%) used contraceptive suppositories, and (28/98) women (28.57%) did not use any contraceptives. Candida spp. was found in (48/83) specimens (57.831%) from women who used contraceptives and only (11/28) specimens (39.285%) from women who did not use contraceptives. Only (59/98) vaginal specimens tested positive for vaginal candidiasis, (28/59) isolates (47.457%) for C. albicans, then (16/59) isolates for C. glabrata (27.118%), (9/59) isolates (15.254%) for C. tropicalis and (6/59) isolates (10.169%) for C. krusei. Nystatin was the best treatment for all Candida spp. under study, and the MIC was 6.25, and the MFC was 50 for all antifungals and Candida species under study. CONCLUSION: Conclusions: C. albicans was the most prevalent cause of vulvovaginal candidiasis, while C. glabrata was the most common non-albicans species in women aged 26 to 35; using an IUD was associated with an increased infection of vulvovaginal candidiasis, and nystatin was the most effective treatment.

Characteristics of the vaginal microbiomes in prepubertal girls with and without vulvovaginitis.

The present study focused on the characteristics of the vaginal microbiomes in prepubertal girls with and without vulvovaginitis. We collected 24 vaginal samples and 16 fecal samples from 10 girls aged 3-9 years with vulvovaginitis and 16 healthy girls of the same age. The samples were divided into three groups: fecal swabs from healthy controls (HF), vaginal swabs from healthy controls (HVS), and vaginal swabs from girls with vulvovaginitis (VVS). Sequencing of the V3-V4 region of the 16S rDNA gene was performed with the NovaSeq PE250 platform to reveal the vaginal microbial community structure in healthy prepubertal girls and vulvovaginitis-associated microbiota. The intestinal microbiomes of healthy children were also analyzed for comparison. This study revealed that the healthy vaginal tract in prepubertal girls was dominated by Prevotella, Porphyromonas, Ezakiella, and Peptoniphilus species, with a high diversity of microbiota. The vulvovaginitis-associated microbiota were dominated by Streptococcus, Prevotella, Haemophilus, and Granulicatella, with lower diversity than that in healthy girls. Furthermore, the compositions of the vaginal and intestinal microbiomes were completely different. ANOSIM, MRPP, Adonis, and AMOVA were used to analyze the beta diversity, and the results showed that there were significant differences in the microbial communities among the three groups. Lactobacillus deficiency and high bacterial diversity were characteristics of the vaginal microbiome in healthy prepubertal girls; this is inconsistent with that in reproductive-age women. The vulvovaginitis-associated vaginal microbiota differed dramatically from normal microbiota, and the main causative agents were not fecal in origin.

Vulvovaginal candidiasis and current perspectives: new risk factors and laboratory diagnosis by using MALDI TOF for identifying species in primary infection and recurrence.

Vulvovaginal candidiasis (VVC), considered the second cause of genital infection among women, has pathogenic mechanisms still to be elucidated and unknown risk factors. Prevalence studies with laboratory diagnosis (at first diagnosis and recurrence) are uncommon, especially using MALDI TOF, used in this clinical, epidemiological, and laboratory study for evaluating candidiasis, and identifying unknown risk factors. To obtain clinical and epidemiological data, patients were questioned, and there was material collection. Samples collected were identified by using phenotypic and presumptive methods and confirmed by MALDI TOF. This study analyzed 278 patients, divided into symptomatic (n = 173) and asymptomatic (n = 105) groups. Regarding the main candidiasis symptoms (discharge, itching, and burning), only 50.3% of patients described these concomitant symptoms, showing a positive predictive value of 67.8%. Regarding the risk factors investigated, there was a statistical correlation between candidiasis and dairy products, gut transit, contraceptive use, respiratory allergy, and panty liners, describing new risk factors related to intestinal and vaginal dysbiosis. After Candida species analysis and confirmation, the primary prevalence was 80.9% (Candida albicans), 15.2% (non-albicans), 1% (Rhodotorula mucilaginosa), and 1.9% (unidentified species). In recurrence, the prevalence was 66.7% (C. albicans) and 33.3% (non-albicans). The presence of symptoms has low positive predictive value for the diagnosis of candidiasis, even when considering the classic triad of symptoms. Laboratory identification of yeast species is essential for correct treatment, preventing the resistance to antifungals and the high recurrence. In addition, dairy products and bowel habits, both related to intestinal and vaginal dysbiosis, may be associated with VVC.

Bacterial agents in vulvovaginitis and vaginal discharge: a 10-year retrospective study in the Netherlands.

Vulvovaginitis is a common problem in the GP's practice. Causes are bacterial vaginosis (BV), Candida infection and sexually transmitted infections (STIs). Only if empirical treatment fails, a vaginal swab is sent in for culture and BV detection. However, without culture essential, bacterial pathogens may escape diagnosis. Many molecular BV assays have recently appeared on the marketplace, all quite differing in price and targets. However, for years, the Nugent score has been the gold standard for BV detection. We analysed retrospectively 10 years of microbiology results of vulvovaginal swabs, focusing on less frequently reported bacterial pathogens, and assessed the characteristics of BV diagnostics. Vulvovaginal swabs sent in between 2010 and 2020 from > 11,000 GP patients with vulvovaginitis associated symptoms, but negative STI tests, were analysed. First cultures and repeat cultures after at least 6 months were included in four age groups: < 12, 12-17, 18-51 and > 51 years. Candida species and BV were most frequently found, with the highest prevalence in premenopausal women. Haemophilus influenzae, beta-haemolytic streptococci, Streptococcus pneumoniae and Staphylococcus aureus were isolated in 5.6% of all cultures, with the highest percentages in children and postmenopausal women. If empirical treatment of vulvovaginitis fails, bacterial culture should be performed to detect all potentially pathogenic microorganisms to obtain a higher rate of successful diagnosis and treatment, avoiding unnecessary antimicrobial use and costs. For BV detection, molecular testing may seem attractive, but Nugent scoring still remains the low-cost gold standard. We recommend incorporating the above in the appropriate guidelines.

Clinical predictive value of the urine leukocyte esterase test positivity in childhood.

BACKGROUND: False negative or positive results may occur in the urine dipstick test for leukocyte esterase (LE), which is used to determine urinary tract infection (UTI). We aimed to investigate the clinical importance of the presence or absence of pyuria in urine sediment for diagnosing UTI in the presence of positive LE in dipstick analysis. METHODS: Patients admitted to the pediatric nephrology outpatient clinic with positive urine LE tests were divided into two groups: those without pyuria (Group 1) and those with pyuria (Group 2) in their urine sediment. Hospital files of the patients were evaluated retrospectively for demographic variables, lower or upper UTI symptoms, physical examination for phimosis and vulvovaginitis, urinalysis for LE and nitrite tests, urine sediment microscopy, urine culture, complete blood count and C-reactive protein. Both groups were compared for the significant growth of pathogenic bacteria in urine cultures along with clinical and laboratory parameters. RESULTS: Among 578 children giving samples for urinalysis, there were 287 cases with positive LE tests. Groups 1 and 2 included 123 and 164 cases, respectively. The proportion of girls was higher in Group 1 and vulvovaginitis rate was higher among the girls in Group 1. Girls with vulvovaginitis were mostly prepubertal. Upper UTI symptoms, significant pathogen growth rate, and elevated acute phase response were more common in Group 2. In addition, the phimosis rate was more common among the boys in Group 1 with false positive LE test. CONCLUSIONS: Children with positive LE tests without pyuria are mostly prepubertal girls and there is a high rate of vulvovaginitis in these girls. Unnecessary tests and treatments for UTI may be avoided with detailed history and physical examination in prepubertal girls who have a false positive LE test. We also found, for the first time, that a false positive LE test is significantly associated with phimosis in boys.

Star-Shaped Poly(furfuryl glycidyl ether)-Block-Poly(glyceryl glycerol ether) as an Efficient Agent for the Enhancement of Nifuratel Solubility and for the Formation of Injectable and Self-Healable Hydrogel Platforms for the Gynaecological Therapies.

In this paper, we present novel well-defined unimolecular micelles constructed a on poly(furfuryl glycidyl ether) core and highly hydrophilic poly(glyceryl glycerol ether) shell, PFGE-b-PGGE. The copolymer was synthesized via anionic ring-opening polymerization of furfuryl glycidyl ether and (1,2-isopropylidene glyceryl) glycidyl ether, respectively. MTT assay revealed that the copolymer is non-cytotoxic against human cervical cancer endothelial (HeLa) cells. The copolymer thanks to furan moieties in its core is capable of encapsulation of nifuratel, a hydrophobic nitrofuran derivative, which is a drug applied in the gynaecology therapies that shows a broad antimicroorganism spectrum. The study shows high loading capacity of the copolymer, i.e., 146 mg of nifuratel per 1 g of copolymer. The load unimolecular micelles were characterized using DLS and TEM microscopy and compared with the reference glyceryl glycerol ether homopolymer sample. The presence of numerous 1,2-diol moieties in the shell of PFGE-b-PGG macromolecules enabled the formation of reversible cross-links with 2-acrylamidephenylboronic acid-based polyacrylamide. The obtained hydrogels were both injectable and self-healable, which was confirmed with a rheological study.

Gynaecological infections in paediatric and adolescent gynaecology: a review of recommendations.

Inflammation within the genital organs in women is an important problem in gynaecology and venereology. Understanding the factors contributing to the inflammatory process and the role of defence mechanisms against their occurrence is important in terms of prevention and treatment. It is especially visible in paediatric gynaecology, where inflammatory diseases of the vulva, dermatoses, injuries and the effects of possible sexual harassment may overlap.

Convergent-Divergent Validity and Correlates of the Day-to-Day Impact of Vaginal Aging Domain Scales in the MsFLASH Vaginal Health Trial.

INTRODUCTION: Clinical research and management of postmenopausal vaginal symptoms have been limited by the lack of validated measures for assessing symptom impact. AIM: To evaluate convergent-divergent validity of the Day-to-Day Impact of Vaginal Aging (DIVA) questionnaire among postmenopausal women with moderate-to-severe vulvovaginal symptoms and identify demographic and clinical factors associated with greater symptom impact. METHODS: We examined baseline data from postmenopausal women with moderate-to-severe vulvovaginal itching, pain, irritation, dryness, or pain with intercourse in a randomized trial of vaginal estradiol, moisturizer, or placebo. In addition to completing the DIVA questionnaire, participants rated the severity of their most bothersome vulvovaginal symptom, underwent assessment of vaginal pH and epithelial cytology, and completed other self-report measures including the Female Sexual Function Index (FSFI), Female Sexual Distress Scale (FSDS), and Patient Health Questionnaire-8 for depression (PHQ-8). MAIN OUTCOME MEASURE: The main outcome measures were the unadjusted correlations and multivariable-adjusted associations with 4 DIVA domain scales designed to assess symptom impact on day-to-day activities, sexual functioning, emotional well-being, and body image/self-concept on a scale of 0 to 4. RESULTS: Among 301 women, we detected moderately strong correlations between the DIVA emotional well-being scale and PHQ-8 scores (Pearson correlation coefficient [r] = 0.39) and strong correlations between the DIVA sexual functioning scale and FSFI and FSDS scores (r > 0.50). No significant correlations were detected between any DIVA scales and vaginal pH or epithelial cytology. In adjusted linear-regression analyses, greater vulvovaginal symptom severity was associated with worse DIVA scores for emotional well-being, sexual functioning, and self-concept/body image (average 0.3- to 0.5-point higher DIVA score for each 1-point difference in vulvovaginal symptom severity). Depression symptoms were associated with worse DIVA scores for activities of daily living and emotional well-being (0.2- to 0.4-point higher DIVA score for each 5- point worsening of PHQ-8 score). Women reporting recent sexual activity had lower symptom impact on sexual functioning and self-concept/body image domains (-0.3- to -0.4-point lower DIVA score with weekly sexual activity). CLINICAL IMPLICATIONS: Findings suggest that the impact of postmenopausal vaginal symptoms on functioning and well-being is greater in women with co-morbid depression symptoms and less frequent sexual activity, independent of symptom severity. STRENGTHS & LIMITATIONS: Strengths include the multicenter sample and wide array of measures. Results may not generalize to women with mild symptoms. CONCLUSION: Our results support the construct validity of the DIVA questionnaire for clinical practice and research and indicate that depression and lower frequency of sexual activity are markers of greater impact of postmenopausal vaginal symptoms on multiple dimensions of functioning and quality of life. Hunter MM, Guthrie KA, Larson JC, et al. Convergent-Divergent Validity and Correlates of the Day-to-Day Impact of Vaginal Aging Domain Scales in the MsFLASH Vaginal Health Trial. J Sex Med 2020;17:117-125.

The use of 3 selected lactobacillary strains in vaginal probiotic gel for the treatment of acute Candida vaginitis: a proof-of-concept study.

In vitro studies suggest that certain probiotic bacterial strains have potential activity against opportunistic infections such as Candida. There are few in vivo trials using probiotics as a single treatment for acute Candida vulvovaginitis (CV). In this open-label, proof-of-concept study, selected Lactobacillus strains were tested in women with acute Candida vaginitis. Twenty women diagnosed with proven, symptomatic CV were instructed to administer a vaginal probiotic gel with L. plantarum YUN-V2.0, L. pentosus YUN-V1.0 and L. rhamnosus YUN-S1.0 for 10 consecutive days. Vaginal rinsing fluid, vaginal culture swab and vaginal smear for fresh wet-mount microscopy were collected before and 7, 14 and 28 days after start of treatment. On average, participating women were 39 years old and had an history of 5 vaginal infections of which 95% was CV. Nine women (45%) completed the study without the need of rescue medication. Women who needed rescue treatment experienced twice as much Candida infections in the past. A negative correlation was found between the clinical composite score and the time to use rescue medication (R2 = 0.127). Seventy-four per cent of participants found the study gel comfortable to use, and 42% of all women would use the tested gel again for this indication. Forty-five per cent of women were treated successfully for acute CV with a novel vaginal gel containing 3 selected Lactobacillus strains. Patients needing rescue treatment were suffering from more severe and long-standing disease. These results warrant for further testing of this new product, especially of its potential in cases with mild to moderate severity, as an adjuvant to antimycotics or as a preventive measure in women with recurrent vulvovaginal candidosis.

Prevalence and antifungal susceptibility of Candida albicans causing vaginal discharge among pregnant women in Lebanon.

BACKGROUND: Vaginal candidiasis is frequent in pregnant women and is associated with sepsis and adverse neonatal outcomes. This study determined the prevalence of candida species in symptomatic pregnant women and evaluated the antifungal susceptibility profile of the isolated Candida strains. It also aimed to explore whether Candida species predicts gestational complications and adverse neonatal outcomes. METHODS: A total of 258 pregnant women with vaginal discharge at 35 to 37 week of gestation participated in this study. Vaginal swabs from these patients were collected at various obstetrics and gynecology clinics in Lebanon for a period of 14 months. Candida isolates were identified at species level and antifungal susceptibility of Candida albicans to fluconazole (FCZ), amphotericin B (AMB), itraconazole (ICZ) and voriconazole (VCZ) was determined by the agar-based E-test method. RESULTS: Among 258 women tested, 100 (39%) were positive for Candida species. C. albicans, C. glabrata and C. krusei were isolated from 42, 41 and 17% of the women, respectively. C. albicans was significantly associated only with gestational diabetes while C. krusei or C. glabrata had significant positive associations with other gestational complications. The antifungal susceptibility tests of C. albicans isolates revealed 97.5, 90, 87.5 and 97.5% susceptibility to AMB, FCZ, ICZ and VCZ, respectively. CONCLUSION: The current study revealed high incidence of both C. albicans and non-C. albicans Candida strains causing vulvovaginitis among pregnant women in Beirut, Lebanon. Candida screening as antenatal follow up is advised to minimize the risk of adverse neonatal outcome or gestational complications.