I read Ison and Hay’s paper concerning validation of grading of
vaginal smears with great interest but am concerned there was no mention
of earlier work which closely resembles their new grading system.[1]
The
examination of stained specimens of vaginal secretions for diagnosis,
research and classification of vaginal pathology has a long and sometimes
confusing history. Medline searches date from...
I read Ison and Hay’s paper concerning validation of grading of
vaginal smears with great interest but am concerned there was no mention
of earlier work which closely resembles their new grading system.[1]
The
examination of stained specimens of vaginal secretions for diagnosis,
research and classification of vaginal pathology has a long and sometimes
confusing history. Medline searches date from 1966 and authors can easily
overlook archived papers, many of which may remain relevant today. In 1914
Curtis described the vaginal flora in health and disease publishing
photomicrographs of stained vaginal specimens from healthy women and from
those with leucorrhoea. He noted that “the more patients deviate from the
absolute normal, with only Döderlein bacilli, i.e, the greater the
tendency to discharge formation and the more purulent its nature , the
more nearly do the bacteriological findings resemble in character the
picture presented by pathological cases.” [2,3] Curtis also cited even
earlier work by Döderlein (1882), Menge & Krönig (1897) and Wegelius
(1909) all of whom contributed to our understanding of the vaginal
bacterial flora.[2] In 1921 Schröder classified the vaginal flora into
three grades of cleanliness, (Reinheitsgrade).
Grade 1: Döderleins bacillionly,
Grade II Döderleins bacilli and other organisms, Grade III organisms
other than Döderleins bacilli, cited by Rakoff, Feo and Goldstein, 1944.[4,5]
In 1939 Liston and Liston, though not referencing Schröder’s earlier
work, introduced a modification of his classification as follows. “Type I,
a pure Döderlein flora’, Type II, Döderlein bacilli with an admixture of
Gram positive bacilli of diptheroid type,with perhaps one or two Gram-negative organisms only. Type III, many different kinds of organisms,
chiefly Gram-negative , generally small cocco-bacilli but including a few
Gram positive bacilli and cocci, comma bacilli (probably an early
reference to Mobiluncus species) leptothrix and spirochaetes.” [6]
Several
later publications concerning vaginal bacteriology also either adopt
and/or refer to Schröder’s original classification. These include Hite,
Hesseltine and Goldstein (1947), Weaver , Scott and Williams( 1950) , Lang
(1955) , Hunter and Long (1958), Burch ,Rees and Kayhoe (1958) and
Davidson and Layton (1968).[7-12] It is interesting that several early publications
note the relationship between increasing vaginal pH and increasing grade
of vaginal flora leading the way to Amsel’s diagnostic criteria for non-
specific vaginitis in 1983.[5,9,13,14]
It is of particular interest that in 1942 Hesseltine, Wolters and
Campbell classified the bacterial flora of the vagina as follows: “type I
reveals only vaginal bacilli present; type II, a mixture of vaginal
bacilli and other bacteria; type III, other bacteria without vaginal
bacilli; and type IV, a single type of some abnormal bacteria.” 15 This
is very similar to Hay and Ison’s new criteria “grade 0 epithelial cells
with no bacteria seen; grade I(normal flora), lactobacillus morphotype
only; grade II (intermediate flora), reduced lactobacillus morphotype with
mixed bacterial morphotypes; gradeIII (BV), mixed bacterial morphotypes
with few or absent lactobacillus morphotypes; grade IV epithelial cells
covered with Gram positive cocci only”.[1] The absence of any bacteria (Hay/Ison grade 0) can be considered normal if a woman has recently used
oral or topical (vaginal) antibacterial agents whilst the presence of
epithelial cells covered with Gram positive cocci (Hay/Ison grade IV)
begs the question of how one should classify a Gram stain in which
planktonic Gram positive bacteria only are observed.
How also should we grade the microscopic findings of gonococcal vaginitis, which, although
more common in prepubertal females, may also occur in adult women? [16]
Hesseltine and colleagues’ grading system (which was in practice a
modification of Schröder’s ) may therefore have distinct advantages. My
personal preference for describing the microbiology of the vagina by Gram
stain is to use Schröder’s original grading for bacteria with a fourth
category, “Other-specify” or, better still, “None of the above-specify”.
The fourth category should describe simply what is seen e.g. “no
bacteria”, “scanty/un-evaluable slide”, “Gram negative diplococci with
polymorphonuclear leucocytes”, “spores/mycelia” etc, etc. The majority of
specimens will reveal a vaginal flora that can be readily ascribed to one
of Schröder’s grades but the fourth category permits a pragmatic solution
for describing smears which cannot be so designated.
Finally, having read many old papers on vaginal infection gleaned by
laboriously hand searching the archival section of the library at St
Thomas’s hospital, London, in the 1970s and 80s, I find it difficult to
admit to having ever had a truly original thought on the subject. I feel
therefore that we should give due credit to Schröder’s work when naming
any “new” classification system of vaginal bacteriology, I wish also to
apologise to any now long dead researcher whose work I have overlooked.
References
(1) Ison CA, Hay PE. Validation of a simplified grading of Gram
stained vaginal smears for use in genitourinary medicine clinics. Sex
Transm Infect 2002; 78,6:413-16
(2) Curtis AH. Etiology and Bacteriology of Leucorrhoea. Surg Gynecol
Obstet 1914;18:299-306.
(3) Döderlein A. Uber Scheidensekrete und Scheidenkeime.
Verhandl.deutsch. Gesellsch. Gynak 1892 ;4:35
(4) Schröder R. Zur Pathogenese und Klinik des vaginalen Fluors .
Zentralbl. Gynak 1921;45:1350
(5) Rakoff AE, Feo LG, Goldstein L. The biological characteristics of
the normal vagina. Am J Obstet Gynecol 1944; 47:467-94.
(6) Liston WG, Liston WA. A study of Trichomonas Vaginitis in
Hospital Practice in Edinburgh. J Obstet Gynecol 1939; 22:474-94.
(7) Hite KE, Hesseltine HC, Goldstein L. A study of the bacterial
flora of the normal and pathologic vagina and uterus. Am J Obstet Gynecol
1947;53:233-40
(8) Weaver JD, Scott S, Williams OB. The bacterial flora found in non-
specific vaginal discharge. Am J Obstet & Gynecol 1950;60:880-84.
(9) Lang WR. Vaginal Acidity and pH. A Review. Obstet and Gynecol
Surv 1955;10:546-60.
(10) Hunter A, Long KR. A study of the microbiological flora of the
vagina. Am J Obstet Gynecol 1958; 75:865-71.
(11) Burch TA, Rees CW, Kayhoe DE. Laboratory and clinical studies on
vaginal trichomoniasis. Am J Obstet Gynecol 1958;76: 658-65.
(12) Davidson AJL, Layton KB. Vaginitis and Haemophilus vaginalis .
Med J Aust 1968;1:757-60.
(13) Cruickshank R,Sharman H. The biology of the vagina in the human
subject. Part II The Bacterial flora and secretion of the vagina in
relation to glycogen in the vaginal epithelium. J Obstet & Gynaec Brit
Emp 1934;41:208-226.
(14) Amsel R, Totten PA, Spiegel CA, et al. Non-specific Vaginitis.
Diagnostic Criteria and Microbial and Epidemiologic Associations. Am J Med
1983;74: 14-22.
(15) Hesseltine HC, Wolters SL,Campbell A. Experimental Human Vaginal
Trichomoniasis. J Infect Dis 1942;71:127-30 .
(16) Blackwell A L . Penicillinase producing Neisseria gonorrhoeae
associated with severe vulvo-vaginitis in a post menopausal woman. Genito-
Urin Med 1993; 69:482-83.
This has been an interesting study of releasing information about the
reason for encouraging partner notification. I wonder whether it is
possible to have some information about what happened in practice.
Presumably, there were some male patients, who had non-gonococcal
urethritis diagnosed on their first visit, and, at that time, it was not
known whether Chlamydia trachomatis was the cause....
This has been an interesting study of releasing information about the
reason for encouraging partner notification. I wonder whether it is
possible to have some information about what happened in practice.
Presumably, there were some male patients, who had non-gonococcal
urethritis diagnosed on their first visit, and, at that time, it was not
known whether Chlamydia trachomatis was the cause. Was partner
notification encouraged and were contact slips issued then and, if so,
what information did they carry about the patient's diagnosis? If such
patients re-attended when the C. trachomatis result was known to be
positive, were revised contact slips issued?
Dear Editor
I read Ison and Hay’s paper concerning validation of grading of vaginal smears with great interest but am concerned there was no mention of earlier work which closely resembles their new grading system.[1]
The examination of stained specimens of vaginal secretions for diagnosis, research and classification of vaginal pathology has a long and sometimes confusing history. Medline searches date from...
Dear Editor
This has been an interesting study of releasing information about the reason for encouraging partner notification. I wonder whether it is possible to have some information about what happened in practice. Presumably, there were some male patients, who had non-gonococcal urethritis diagnosed on their first visit, and, at that time, it was not known whether Chlamydia trachomatis was the cause....
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