Incidence of gonorrhoea in leucorrhoea cases.
The role of Neisseria gonorrhoea in obstetrics and gynaecologic infections is becoming increasingly evident. Hence, the present project was undertaken to assess the prevalence of gonococcal infection in cases of Leucorrhoea in the gynaecological outpatient department of our public hospital.
All patients with Leucorrhoea attending the gynaecological outpatient service of the K.E.M. Hospital were screened for this purpose from November, 1981 to August, 1982. Patients with normal urogenital tract and no evidence of Leucorrhoea were excluded from the study. Detailed history about their obstetric status, menstrual periods and other associated complaints was recorded. History, of exposure to venereal disease in the patient and/or in her husband was asked for. Any treatment taken in the past, especially for venereal diseases, was enquired into.
The study involved the detection of gonococcal infection from the cervical and urethral swabs of the patients, together with urethral swabs from their husbands. Blood samples from the patients and their husbands were collected for V.D.R.L. test. Similarly, urine samples from them were collected in sterile test tubes and directly inoculated into MacConkey's medium. The centrifuged urinary sediments were studied by Gram-stained smears and by inoculation on the Thayer-Martin medium. The samples were also processed for the detection of aerobes, Trichomonads and Candida.
Urethral and cervical swabs were collected from the patients with the swab sticks dipped in glucose broth. These were immediately stabbed into Stuart's medium which was used as a transport medium. In the husbands, the urethral swabs were obtained after prostatic massage, and were studied by primary smears and culture on Thayer-Martin medium,,, which was incubated at 36°C at a pH of 7.2 to 7.6 with a carbon dioxide concentration of 5-10%. The colonies were examined after 24 hours (48 hours in case of doubt). Gonococcal colonies were seen as small, round, soft and translucent colonies with a fine granular surface.
The diagnosis of gonorrhoea was based on a Gram-stained, direct smear, confirmed by detection of specific colonies on the Thayer-Martin medium and by the oxidase test for which the plates were flooded with the oxidase reagent (tetra methyl para-aminophylline diamine dihydrochloride). With this test the neisserian colonies turned purple with the dye; colonies which do not, show the colour change are not neisserian.
A total of 2514 patients were examined; of these, 125 cases (5.12%) were found to have some evidence of leucorrhoea. In 19 of these 125 cases, cultures and/or smears were positive for gonococci, giving an overall prevalence of 0.7 %.
[Table - 1] shows the age distribution of patients with and without gonococcal infection. The patients with gonorrhoea were older than those without it. The difference is statistically significant.
One hundred and fourteen patients were married and parous. Eight patients suffered from primary and 4 from secondary infertility. Associated symptoms were burning micturition in 6, backache in 35 and dyspareunia in 10 cases.
[Table - 2] shows the results of the investigations.
Husbands of 20 women refused to participate in this study. Of the 19 smear positive women, 8 had their husbands' urethral smears positive. Of the remaining 11 smear-positive females, 3 were single and in the rest 8, the husbands did not report for examination.
Of the total 125 leucorrhoea cases, 13 had their cultures positive for Candida, and 3 showed presence of Trichomonas on wet preparation of the vaginal secretion. Among the aerobes, Staph. aureus, Streptococcus viridans and Diphtheroids were the predominant isolates.
None of the patients with associated infertility was positive for gonococcal infection. Similarly, none of the 6 cases with associated burning micturition was found to have gonorrhoea either on smear or culture. Not a single case in the entire series volunteered a history of exposure to venereal disease and all denied such a history on deliberate enquiry.
Gonorrhoea is transmitted in most instances by sexual acts,, though other modes of transmission are known. The risk of transmission from an infected male to an exposed female is said to be 80-90%. It is the most commonly reported venereal disease in gynaecological patients in U.S.A., Great Britain and Scandanavian countries, with an estimated prevalence of 2.5 million., American Health Association reported an incidence of 4% in gynaecological patients. National Surveys in the United States have indicated that the prevalence varies from 1-2% in women seeking care from private practitioners to approximately 5% in those seeking health care at hospital based gynaecological clinics. In the present series, the incidence of gonorrhoea in gynaecological outpatients was found to be 0.7%. The approximate number of new cases notified each year throughout the world is around 150 million cases of gonorrhoea and 50 million cases of syphilis. These figures grossly underestimate the real incidence of gonorrhoea, as patients treated privately are usually not notified, and many others, especially those who are asymptomatic (most of them females), are not diagnosed and hence not notified.
In the present series, none of the six patients with burning micturition was found to have gonococci either on smear or culture. Similarly, none of the patients with infertility was positive for gonococci. The extent to which the infection may be detected by an individual physician depends upon the age and sexual habits of the population surveyed. This is so because promiscuity clearly plays a major role in the acquisition of the disease. It also depends upon how attuned the physician is to the diagnosis, since the disease is often asymptomatic, especially in females. Not a single patient in our series gave a history of exposure to venereal disease even on deliberate questioning. Diagnostic techniques at the physicians hands are also important since the causative organism is fastidious. Diagnosis of gonorrhoea is made on a direct smear or culture and by sugar fermentation test. Gonococci ferment glucose and maltose but not sucrose.,
Gonococci being difficult to grow, smear positivity may not always be confirmed by a positive culture. Sometimes, contaminants grow profusely and make the isolation more difficult. In the present series, only 9 women were culture positive in contrast to 19 who were smear positive for gonococci.
A routine culture for gonorrhoea at the time of annual pap smear must be included in the screening procedure for sexually active women, especially those with multiple partners. This may yield a high rate of detection in specific groups. The benefits obtained would justify the extra cost.
Although positive culture is the most reliable test of diagnosis of gonorrhoea, the serological technique is being increasingly used for this purpose.
We are thankful to the Dean, Seth G.S. Medical College for permitting us to carry out the studies. We are grateful to the Research Society, K.E.M. Hospital for financial help.