“TOILET DISEASE”: The facts and the myths

Background

What a number of people term “Toilet disease” is not actually contracted from the toilet, but other sources. The actual term is Vaginitis, which simply means inflammation of the vagina and is the commonest gynaecological condition that affects women of child-bearing age and menopausal women. The commonest causes are practices that disturb the composition of the normal flora, sexual activities and poor hygiene. If one is to go by the observation of Claude Bernard, which is that “the terrain is more important than the pathogen – get the terrain right and the pathogen loses its grip”, it will be right to conclude that disturbance of the normal flora is the commonest cause of vaginitis. The toilet is not the problem; rather it is the activities and practices of the user of the toilet.
Certain types of bacteria (normal flora) are present in the vagina and they help to maintain the vaginal environment. The normal flora is maintained by a complex and intricate balance of certain microbes, usually Lactobacilli, Yeast and Corynebacteria. The presence of this normal flora prevents the growth of the deleterious microbes that cause vaginitis, moreover, vaginitis is not always caused by infection. A normal healthy vagina secretes mucoid discharges daily and such discharges are usually milky or clear and not malodorous. A change in the quantity, smell and colour of discharges usually suggest vaginitis.

Causes and symptoms
The fallacious cause people usually attribute to vaginitis is the toilet. Studies have shown that the toilet is not the problem, rather the users of the toilet. Furthermore, the main cause of vaginitis is the things that alter the composition of the normal flora. A number of factors can disturb the composition of the vaginal flora, including the following:
Age
Sexual activity (or abuse) and sexually transmitted diseases
Hormonal status
Hygiene and feminine hygiene products
contraceptives
Immunologic status
Underlying skin diseases
The normal pH of a menstruating vagina is 3.8-4.2. This pH range usually inhibits the growth of pathogenic organisms. Disturbance of the normal vaginal pH can alter the vaginal flora, leading to overgrowth of pathogens. The depletion of vaginal lactobacilli appears to be the primary factor in the changes leading to bacterial vaginosis. Inability to establish a healthy vaginal microflora dominated by lactobacilli is associated with recurrent vaginitis.
Majority of the cases of vaginitis are attributable to three (3) causes: bacterial infection (bacterial vaginosis), fungal infection (vaginal candidiasis) and Trichomonal vaginalis infection (trichomoniasis).

Bacterial vaginosis
Bacterial vaginosis is the most common cause of vaginitis, accounting a half of cases. pH of the vagina is usually 5.0-6.0. Bacterial vaginosis is asymptomatic in up to 50% of women. If a discharge is present, it is typically thin, homogeneous, malodorous (fish-smelling), and grayish white or yellowish white in color. Vaginal pain or vulvar irritation is uncommon but pruritus may occur.
Bacterial vaginosis can be caused by Streptococcal species (including group A streptococci), Escherichia coli, and Shigella sonnei. A Shigella infection may result in a bloody vaginal discharge without symptoms of diarrhea. Streptococcal infection may present with itching or painful defecation. Purulent discharge may develop insidiously.
A form of bacterial vaginosis called vulvovaginitis can affect prepubertal children; however, it has several causes that are not veneral. If discharge suggests STD, sexual abuse should be considered. Symptoms of vulvovaginitis in prepubertal girls generally include localized pain, dysuria, pruritus, erythema, and purulent discharge.
Bacterial vaginosis can be caused by Streptococcal species (including group A streptococci), Escherichia coli, and Shigella sonnei. A Shigella infection may result in a bloody vaginal discharge without symptoms of diarrhea. Streptococcal infection may present with itching or painful defecation. Purulent discharge may develop insidiously.
Risk factors include pregnancy, intrauterine device (IUD) use, and frequent douching.

Vaginal candidiasis
Vaginal candidiasis is the second most common cause of vaginitis, responsible for a quarter of cases. pH of the vagina is usually less than 4.5
Candidiasis is a fungal infection common in women of childbearing age. Pruritus is the most common symptom and often begin just before menses. This is accompanied by a thick, odorless and white vaginal discharge. Usually, associated vulvar candidiasis is present, commonly with vulvar burning, dyspareunia, and vulvar dysuria (a burning sensation arising when urine comes into contact with vulvar skin). If candidal vulvovaginitis is considered (a rare condition in healthy prepubertal girls), recent antibiotic use, immunosuppression, possible diabetes mellitus, family history of mucocutaneous candidiasis and underlying skin disease should be considered. Candidiasis is usually not contracted from a sexual partner. About three quarter of all women have at least a episode of candidiasis in their lifetime. Recurrent episodes may indicate underlying immunodeficiency or diabetes.
Risk factors include oral contraceptive use or hormone replacement therapy, IUD use, young age at first intercourse, increased frequency of intercourse, receptive cunnilingus, diabetes mellitus, HIV or other immunocompromised states, long-term antibiotic use, and pregnancy.

Trichomoniasis
Trichomonal vaginalis infection, the third most common cause of vaginitis, is caused by trichomonads and account for a fifth of cases. pH of the vaginal is usually 5.0-7.0. Trichomonads are transmitted sexually and can be identified in as many as 80% of male partners of infected women. Trichomoniasis is associated with risk factors for other STDs.
Trichomonal vaginalis infection is the most common non-viral STD in the world. Many patients (20-50%) are asymptomatic. If discharge is present, it is usually copious and frothy and can be white, gray, yellow, or green (the yellow and green colors are due to the presence of white blood cells). Local pain and irritation are common. Dysuria, pruritus, and post-coital bleeding due to cervicitis are other possible symptoms. Symptoms often peak just after menses.
Trichomoniasis is rare in prepubertal children. Sexual abuse should be suspected if symptoms are present. Symptoms include a copious frothy discharge, local pain, irritation, and, occasionally, pruritus.
Risk factors include tobacco use, unprotected intercourse with multiple sexual partners, and the use of an IUD.
Non-infectious vaginitis is usually due to allergic reaction or irritation. Allergic reactions or irritation can also be due to mechanical irritation (presence of foreign bodies in the vagina e.g. IUD) or chemical irritation to recent bubble baths, washing hair with shampoo while bathing, douching, use of feminine hygiene sprays, colored or scented toilet papers, panty liners, antiseptics etc.
Another common cause is due to estrogen deficiency. This type is called atrophic vaginitis. Hormone replacement therapy is indicated for this type of vaginitis.

Prevention
1. Common preventable causes of candidal vaginitis or bacterial vaginosis include damp or tight-fitting clothing, scented detergents and soaps, feminine sprays, and poor hygiene.
2. Clothing especially pants should not be damp and tight fitted. Cotton pants are preferable to nylon pants because they absorbed moisture and thereby prevent dampness around the genital area. Washed pants should be thoroughly rinsed with water and sun dried.
3. The use of scented detergent and soaps should be avoided as they disturb the normal flora of the vaginal. The use of feminine sprays, antiseptics lotion and douching also has similar effects as the use of detergent, soaps and other chemical irritatants and mechanical irritants to the vaginal. Avoid use of the materials and practices mentioned in this paragraph.
4. Poor personal hygiene and toilet techniques are one of the contributory factors to candida vaginitis and bacterial vaginosis. Cleaning the vagina with antiseptics and ‘over cleaning’ with water in a bid to keep proper personal hygiene should be avoided as this practice kill the beneficial microbes (normal flora) in the vagina. More so, proper wiping technique ‘i.e wiping from front to back’ after using the toilet should be upheld as this prevent the introduction of faecal matter into the vaginal. Faecal matter is laden with microorganisms that are pathogenic to the vaginal. In addition, women that require water to clean up after defecation due to socio-religious practices should do so after wiping with tissue paper. The vaginal area should be air-dried / towel-dried or underwear should be changed when women are involved in practices that keep the vaginal area moist e.g. swimming, exercise or cleaning vaginal area with water.
5. Safe sex practices and sexually transmitted disease counseling can help prevent infection and re-infection of Trichomonal vaginalis. Unsafe sexual practices like having unprotected sexual intercourse with multiple partners should be avoided.
6. Proper treatment and management of other co-morbidities like HIV, diabetes mellitus and other immunopressive conditions.
7. Avoid unnecessary use of antibiotics for a long period of time.
8. Both partners should be treated if one of the partners present with symptoms of trichomoniasis.

Therapeutic Approach
The goals of pharmacotherapy in vaginitis are to reduce morbidity, prevent complications, and eradicate the infection. Treatment of vaginitis varies by cause and is directed at the relevant pathogen. Drugs used for infectious vaginitis may be applied topically or may require oral or rarely parenteral administration. People that have sexual partners who present with infectious vaginitis (especially trichomoniasis) may need to subject their partners to treatment. For non-infectious vaginitis, sources of irritants should be stopped or remove and may require vaginal anti-itch creams. Atrophic vaginitis may require estrogen replacement.
In the developing and underdeveloped world where state of the art health care facilities are not available and proper means and sources of testing are not adequate, an empirical treatment of all the relevant pathogens is usually the practice. Moreover, if there is no improvement, despite symptomatic or over-the-counter treatment, seek expert (gynaecologist) workup of possible STDs and other infectious causes of vulvovaginitis.
The pharmacologic therapies are:
Bacterial vaginosis: Antibacterial agents like metronidazole, tinidazole, secnidazole and clindamycin are recommended. Metronidazole and clindamycin are available as intravaginal tablet (pessary), ovule and cream and oral tablet. Metronidazole is safe in pregnancy, in order words pregnant women with bacterial vaginosis can take it. Clindamycin on the hand is only safe in the first trimester. However, metronidazole should not be taken with alcohol as it interacts with alcohol. Sexual partners of women diagnosed with bacterial vaginosis do not need to be treated.
Vaginal candidiasis: Anti fungal agents like Nystatin , Clotrimazole, Miconazole,Tioconazole and Fluconazole. All but Fluconazole are available as intravaginal tablet/cream/ovule. Fluconazole , on the other hand is available as oral tablets or capsules. Although Clotrimazole vaginal cream may be acceptable in pregnant women, Nystatin is the most preferred agent in pregnant women. Women should have it in mind that oil-based intravaginal agents (cream/suppositories) might cause failure of latex condoms and suppositories should be kept in cool place preferably refrigerator. Women that lack refrigerator in their homes should drop a suppository in cold water 5 to 10 minutes prior to use (insertion into vaginal). Sexual partners of women diagnosed with vaginal candidiasis do not need routine treatment.
Trichomoniasis: treatment is usually with Metronidazole or Tinidazole orally in a single dose. However, if the oral single dose of metronidazole is not adequate, a 5 to 7-day course might be required. Metronidazole is safe in pregnancy, but lactating women might need to stop breastfeeding for 24 hours. Lactating women placed on Tinidazole should interrupt breastfeeding for 3 days after the last dose. Sexual partners of women diagnosed with trichomoniasis should be treated concomitantly and sexual intercourse should be avoided until both partners become asympthomatic.
For more information on the most appropriate medicine and dose for your condition, consult your doctor/pharmacist.

How important is the terrain?

Louis Pasteur personified the pathogen theory of disease; nevertheless, he was reported to have said “Bernard is right; the pathogen is nothing; the terrain is everything” in his deathbed. In other words, if our focus is directed towards killing the pathogen alone, we will always fail. The terrain should be seen holistically because the terrain in the concept of vaginitis could be localize (to the vagina), individualize and socialized (public health).
For the individual’s terrain to be optimum, dietary nutrition and immune system should also be optimum. As part of the effort to get the terrain right, some vaginal suppositories now contain lactobacillus spores which help to restore the presence of this beneficial microbe in the vagina. Patient education and public health promotion are ways of getting the social terrain right.
In conclusion, it is not ‘toilet disease’ rather it is known as vaginitis and getting the terrain right is the key to stopping vaginitis.

Written by Sikiru Amoo, a ⇒Pharmacist and Biochemist.
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