Trends in Parasitology
Volume 28, Issue 2, February 2012, Pages 58-65
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Review
A review of female genital schistosomiasis

https://doi.org/10.1016/j.pt.2011.10.008Get rights and content

In a review of the studies on genital schistosomiasis, the cervix, the Fallopian tubes, and the vagina are the most common gynaecological sites to harbour Schistosoma haematobium. Lesions are caused by host responses to dead or viable schistosomiasis eggs and may render women with genital schistosomiasis susceptible to HIV. The typical genital changes, such as sandy patches and pathological blood vessels may make women susceptible to super-infection, cause contact bleeding, decreased fertility, abortions, discharge and bleeding. Further research is needed to find simple, low-tech diagnostic methods, treatment for chronic lesions, and to explore the preventive effects of mass drug administration on symptoms, sandy patches, HPV and the HIV epidemic.

Section snippets

Domestic necessity and recreation

In recreational, domestic and professional freshwater contact, people in endemic areas may acquire schistosomiasis (Bilharzia). There are several types of schistosomiasis which are associated with infection by Schistosoma haematobium, Schistosoma mansoni and the other types of schistosomes, and these have similar transmission cycles but different predilection sites and egg morphologies (Figure 1, Box 1). S. haematobium was originally termed urinary schistosomiasis, reflecting key symptoms such

Distribution of schistosome eggs in the genital tract

Many case reports indicate that S. mansoni and S. japonicum may affect the genital tract [7]. However, only two community-based studies have explored this via biopsy of the uterine cervix 8, 9. Both studies were carried out in low-endemic areas, and further investigations are required. Blood vessel anastomoses between the pelvic organs are probably responsible for ‘spill-over’ of eggs into the genital tract, and the cervix has been suggested to be the predilection site for trapped eggs (Figure 2

Histology of genital schistosomiasis

The tissue around both viable and dead S. haematobium eggs has increased vascularity and a high density of macrophages, lymphocytes, foreign body giant cells, eosinophils, neutrophils, plasma cells, Langerhans cells, fibroblasts, and multinucleate histiocytes 24, 25. Even calcified eggs may induce the influx of immune cells and blood vessel proliferation, local bleeding and edema [26]. The exact natural history of the local immune reactions to S. haematobium eggs in different phases is not

The mucosal remains of childhood infection

Female genital schistosomiasis (FGS) has been defined as having sandy patches and/or microscopically proven S. haematobium eggs in genital tissue (Figure 4). The largest clinical studies in adult women living in endemic areas have found that the prevalences of women with sandy patches, contact bleeding, or eggs in genital tissue seem to be fairly constant in adulthood 27, 28.

Mucosal and stromal lesion severities do not follow the same characteristic decline with age as urinary egg excretion 27,

Symptoms, suffering and chronicity in adult women

All community-based studies on FGS to date have been performed in pre-menopausal adults aged 15–49 years 27, 28, 36, 38, 49. Women with genital sandy patches have significantly more genital itch and perceive their discharge as abnormal [34]. Genital schistosomiasis is associated with stress incontinence and increased frequency of urination. There are case reports of severe acute disease such as ascites with ovarian schistosomiasis, ectopic pregnancy, and heavy egg infestation of the uterus in

Manifestations of genital schistosomiasis in the young

Because intravaginal inspection is usually not performed before the onset of sexual activity, the normal and pathologic characteristics of the prepubertal tissue have not been studied. Furthermore, adolescents are often too shy to come for gynecological investigations during the first few years after sexual debut. Case reports on girls below the age of 15 are therefore most commonly from the vulval regions 10, 13, 17, 50. A vaginal polyp was found in a 3 year old [18], a 4 × 4 cm ‘raised,

Traveling women and genital schistosomiasis

Travelers, defined as coming from non-endemic areas, are often exposed for a limited time. Unfortunately schistosomiasis, and in particular genital schistosomiasis, has been neglected in travelers despite increasingly common travel activities such as rafting and other forms of so-termed eco-tourism 53, 54. Eighteen percent of asymptomatic travelers to Africa, exposed to infested freshwater and subsequently screened at the Hospital for Tropical Diseases in London over the period 1993–1997, were

Genital schistosomiasis and the susceptibility to HIV

Public health interventions against the HIV epidemic have been implemented based on the evidence that sexually transmitted genital ulcers, Chlamydia, and gonorrhea may increase the susceptibility of women to HIV infection [58]. Currently, the syndromic management of STDs, based on concepts of etiology, has been a central strategy for HIV prevention in developing countries. In a given area, the impact of different STDs upon HIV transmission depends upon the relative frequencies of the different

A dangerous liaison: genital schistosomiasis and HIV

Dually infected women and men, with schistosomiasis and HIV, may pose an additional risk of HIV transmission to their partners [38]. Increased HIV levels have been demonstrated in genital ulcers compared to neighboring normal tissue in the same women; this may also hold true for schistosomal lesions 38, 60. Genital HIV RNA excretion increases in the presence of reproductive tract diseases in women and men alike [65]. Similarly, S. haematobium infection has been hypothesized to cause increased

Diagnosis of genital S. haematobium

An FGS consensus meeting held in Copenhagen in October 2010 considered clinical and laboratory results from several African studies (http://www.ivs.life.ku.dk/English/Sections/SPHD/Research/Research Projects/VIBE Project Female Genital Schistosomiasis.aspx). The meeting concluded that, in patients from S. haematobium endemic areas, one of three clinical findings, by visual inspection, may serve as an adequate diagnosis for genital schistosomiasis (Figure 4). The lesions are aceto-negative (i)

Treatment

In the urinary tract, the effect of praziquantel has largely been determined by resolution of lesions detectable by ultrasound scan and decreased egg excretion in urine [71]. Praziquantel kills the egg-laying worms; however, lesions may remain and develop around eggs already deposited in the tissues 32, 33. Once egg deposition has induced lesions in the genital tract, egg excretion and lesion development are two independent processes, with praziquantel affecting the former almost immediately,

Public health implications of genital schistosomiasis in girls and women

Of all parasitic infections, schistosomiasis is second only to malaria in terms of public health impact and has been estimated to affect at least 200 million people – equivalent to one in 30 people being affected worldwide [5]. Urogenital schistosomiasis is endemic in 53 countries in Africa and the Middle East [79]. The control groups in all studies to date are women who had been exposed to the same water sources 28, 32, 36. The differences between exposed and unexposed groups are therefore

Clinical action

Depending on the local panorama of diseases in a community and individual risk factors, S. haematobium may be the most likely cause of genital morbidity 27, 38. However, in S. haematobium endemic areas women currently receive neither correct advice nor treatment for the majority of their lower reproductive tract symptoms and findings. Based on the current knowledge of FGS, the information provided to adult women must be sober. The treatment kills the worm, but may have no effect on the lesions

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