Dear Editor

In 1997, Professor Adler’s stark assessment of the deterioration of sexual health of the UK [1] laid the blame for it on presumably highly influential (though unnamed) groups attempting "to withhold information on the basis of a particular agenda of family values and morality.[2] At least his 2003 editorial,[2] charting more recent decline on every parameter examined, does not repeat this former unreferenced and, in my view unsupportable, scape-goating. This time, he appears to blame the government for not making sexual health "an NHS or political priority".

Whilst I agree they have not and the currently allocated financial resources are totally inadequate, it is the political correctness of sexual-health policy-makers that is the main barrier to improving the sexual health of the nation. It is widely accepted that up to 80% of unplanned pregnancies are due to contraceptive (mainly condom) failure,[3] yet condoms still continue to be promoted as a "the solution" the very problem they contribute so heavily towards.[4,5]

Condoms, when used consistently and correctly, do provide reasonable protection against HIV and gonorrhoea.[6] However, they are rarely consistently and correctly used [7] and even when they are, there is no evidence that any protection they may provide against the majority of sexually transmissible agents is anywhere near as good at that for HIV;[6,8] in the case of HPV it is possibly none at all. [6,9]

Adler indicates that reversing adverse trends in sexual behaviour is a key priority in controlling STI escalation. Increased condom use alone is "not enough to offset the increase in sexual partners". He also suggests the increase in sexual intercourse among under-17s as a major contributor to poor sexual health. If delaying the age of first coitus is therefore so important, why is there seemingly complete denial in the Department of Health about the effectiveness of abstinence education?[10] Both unplanned pregnancy and STI rates have been reduced in appropriate abstinence-based programmes, not only in the USA [11,12] but also in Zambia [13] and Uganda.[14]

In spite of such evidence for their effectiveness, abstinence programmes are labelled in the UK as being unworkable.[15] Instead we continue to base our programmes for reducing unplanned pregnancy on condoms, the failure of which is implicated in 80% of them. More recently the emphasis has switched to the emergency pill, but the unrestricted use of this from pharmacies will only further the increase in STIs.[16] Until such short-sighted policies change, we will indeed sadly "witness failure upon further failure" in sexual health in the UK. However, Professor Adler has not told us the real reasons why.

References

(1) Adler M. Sexual health- a Health of the Nation failure. BMJ 1997;314:1743-1747.

(2) Adler M Sexual health – health of the nation. Sex Trans Infec 2003;79:85-7.

(3) Pearson VAH, Owen MR, Phillips DR, Pereira Gray DJ, Marshall MN. Pregnant teenagers’ knowledge and use of emergency contraception. BMJ 1995; 310:1644

(4) Richens J, Imrie J, Copas A Condoms and seat belts: the parallels and the lessons Lancet 2000 355 400-3

(5) Doughty S Charity to hand out free condoms to 11-yr olds Daily Mail 28.3.2003 http://www.likeitis.org.uk/welcome_to_like_it_is.html

(6) http://www.niaid.nih.gov/dmid/stds/condomreport.pdf

(7) de Visser RO Smith AM When always isn’t enough; implications of the late application of condoms for the validity and reliability of self- reported condom use. AIDS Care 200012:221-4.

(8) Mann J, Stine C, Vessey J The role of disease-specific infectivity and number of disease exposures on long-term effectiveness of the latex condom. Sex Trans Dis 2002;29:344-9.

(9) Manhart LE, Koutsky LA. Do condoms prevent genital HPV infection, external genital warts or cervical neoplasia? A meta-analysis. Sex Trans Dis 2002;29:725-35.

(10) CMO’s Update 35 DoH Jan 2003: http://www.doh.gov.uk/cmo/cmo_35.htm#10

(11) Doniger AS, Adams E, Riley JS, Utter CA, Impact evaluation of the "Not Me, Not Now”' abstinence-oriented, adolescent pregnancy prevention communications program, Monroe County, New York. J Health Communication 2001;6:45-60. http:// www.notmenotnow.org/research/NMNNimpactevaluation.pdf

(12) Mohn JK, Tingle LR, Finger R An analysis of the causes of the decline in non-marital birth and pregnancy rates for teens from 1991 to 1995. Adolesc and Fam Health 2003;3:39-47.

(13) Martin K Zambia’s HEART programme evaluation shows youth respond positively to AIDS prevention plan promoting abstinence. John Hopkins University Centre for Communications Programmes 2002. http://www.jhuccp.org/pressroom/2002/07-11.shtml

(14) Hogle J, Green EC, Nantulya R, Stoneburner J et al. Whatever Happened in Uganda? Declining HIV prevalence, behaviours change and the national response USAID-Washington and The Synergy Project TvT Associates Washington D.C. 2002 http://www.usaid.gov/pop_health/aids/Countries/africa/uganda_report.pd

(15) Swann C, Bowe K, McCormick G, Kosmin M Teenage pregnancy and parenthood; a review of reviews. Health Development Agency 2003.

(16) Stammers T. Emergency contraception from pharmacists misses opportunity. BMJ 2001;322:1245.

Michael Adler’s editorial on sexual health - health of the nation - makes pessimistic reading. While it is apparent that the rate of STIs and unwanted pregnancy has increased in the UK over the last 10 years, he fails to mention what has happened to sexual dysfunction (SD) over that period of time. The National Strategy for Sexual Health and HIV document mentions SD a number of times [1]. SD is indeed part of sexual health.

Problems in sexual functioning such as erectile dysfunction (ED),premature ejaculation, low sexual desire in women and vulvadynia affect a third of men and well over a third of women in the UK [2]. Fifty per cent of patients so effected would want treatment for their problem [2]. Management of ED significantly improves both the quality of life and its concomitant mental illness [3][4]. Although the absolute cost of ED treatments has risen three fold between 1997 and 2000 in the UK, the cost per patient fell significantly [5]. Much of the cost effectiveness in the treatment of ED is related to very effective pharmaceutical agents such as sildenafil [4]. However, female sexual dysfunction (FSD), which is largely managed at present by sex therapy and cognitive behaviour therapy, appears to be similarly cost effective [6].

It is my impression that a decade ago most GU medicine clinics did not offer treatment for SD. A study in 1997 [7] and again in 2000 [8] suggested that over 80% of GU clinics supported the notion of treatment of SD and that over 40% actually carried out SD management.

Treating SD, apart from its direct effects on restoring sexual functioning, quality of life and reversing depression, may indeed have positive spin offs in decreasing STI acquisition in men ( e.g. condom use is only effective on an erect penis) and women with low sexual desire [9].

SD management in GU medicine clinics in the UK, I believe, is still treated as a Cinderella subject by central government and local purchasers, in spite of the surrogate and indirect evidence of its success over the past 10 years. Furthermore, there is no specific funding for it. Its mention in the National Strategy for Sexual Health document might be perceived as mere lip service to placate the few champions who voice their opinions on behalf of the literally vast numbers of patients with SD who suffer in embarrassed silence.

I believe central government should look carefully at this neglected success story and encourage it to continue by means of adequate education of medical students and junior doctors in the SD field as well as proper financial support.

References

(1) Department of Health. The National Strategy for Sexual Health and HIV. DoH, London, 2001.

(2) Dunn KM, Croft PR, Hackett GI. Sexual problems: a study of the prevalence and need for health care in the general population. Fam Pract 1998;15:519-524

(3) Guest JF, Das Gupta R. Health related quality of life in a UK based poulation of men with erectile dysfunction. Pharmacoeconomics2002;20): 109-117

(4) Guiliano F, Pena BM, Mishra A, Smith MD. Efficacy results and quality of life measures in men receiving sildenafil citrate for the treatment of erectile dysfunction. Qual Life Res2002;(11)359-369

(5) Wilson EC, McKeen ES, Scuffham PA et al. The cost to the United Kingdom Health Service of managing erectile dysfunction: the impact of sildenafil and prescribing restrictions. Pharmacoeconomics, 2002;(20):879-889

(6) Goldmeier D, Malik F, Green J, Phillips R. Cost effectiveness of sexual dysfunction – the female picture, Int J Impotence Res,in press.

(7) Keane FE, Carter P, Goldmeier D, Harris JR The provision of psychosexual services by genitourinary medicine physicians in the United Kingdom, Int J STD AIDS, 1997;(8):402-404

(8) Kell P, The provision of sexual dysfunction services by genitourinary medicine physicians in the UK 1999, Int J STD AIDS, 2001;(12):395-397

(9) Goldmeier D, Female low desire and sexually transmitted diseases,STI 2001;(77):293-294

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 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.

Dear Editor

We were interested in the case report, "Perianal Crohns Disease masquerading as perianal warts"[1] (August) In which the authors highlight the diagnostic difficulty with other anogenital conditions such as perianal warts. Plus the initial lack of obvious bowel symptoms considered to be the hallmark of Crohns disease.

We too have recently seen a similar case, but in an older women aged 43 who presented with a vulvitis of several months duration, the main symptoms being pruritis vulvae and superficial dyspareunia. There was absolutely no gastrointestinal symptoms or systemic upset and past general health was good. Initial clinical examination revealed diffuse erythema and swelling of the Labia Majora, and some perineal fissuring was also noted.

All routine STI screening tests were negative, and a provisional diagnosis of Vulval Dermatitis was made. With agreement of the patient a therapeutic trial of Hydrocortisone 1 % was tried but with no effect. A vulval biopsy was therefore carried out which revealed histological features consistent with Crohns disease,i.e. non-caseating granuloma,giant cells and chronic inflammatory infiltrate. A colonoscopy was reported as normal and the patient remains asymptomatic.

This case, in common with the reported case[1], reminds us that Crohns disease can present initially as a common clinical condition to GU Clinics, such as warts or vulvitis. The diagnosis rests primarily on biopsy of the lesion,this is especially so in cases of "metastatic disease"[2] either preceeding bowel involvement by years,[3] or exclusive involvement of genital tract only.[2] Is it possible that Crohns disease of the genital tract is an underdiagnosed condition?

Benjamin Goorney

References

(1) Garg M, Kawsar M, Forster GE, and Medows NJ. Perianal Crohn’s disease masquerading as perianal warts. Sex Transm Infect 2002;78:302-303.

(2) Urbanek M, Neill SM, Mckee PH. Vulval Crohns disease: difficulties in diagnosis. Clinical and Experimental Dermatology 1996;21:211-214.

(3) Bruce L, Donaldson, MD. Crohns disease: its gynecologic aspect. Am J Obstet Gynecol 1978;131:196-202