BACKGROUND: Syndromic management is widely used to treat symptomatic sexually transmitted infections in settings without aetiologic diagnostics. However, underlying aetiologies and consequent treatment suitability are uncertain without regular assessment. This systematic review estimated the distribution, trends, and determinants of aetiologies for vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa (SSA).
RESULTS: We searched Embase, MEDLINE, Global Health, Web of Science, and grey literature from inception until December 20, 2023, for observational studies reporting aetiologic diagnoses among symptomatic populations in SSA. We adjusted observations for diagnostic test performance, used generalised linear mixed-effects meta-regressions to generate estimates, and critically appraised studies using an adapted Joanna Briggs Institute checklist. Of 4,418 identified records, 206 reports were included from 190 studies in 32 countries conducted between 1969 and 2022. In 2015, estimated primary aetiologies for vaginal discharge were candidiasis (69.4% [95% confidence interval (CI): 44.3% to 86.6%], n = 50), bacterial vaginosis (50.0% [95% CI: 32.3% to 67.8%], n = 39), chlamydia (16.2% [95% CI: 8.6% to 28.5%], n = 50), and trichomoniasis (12.9% [95% CI: 7.7% to 20.7%], n = 80); for urethral discharge were gonorrhoea (77.1% [95% CI: 68.1% to 84.1%], n = 68) and chlamydia (21.9% [95% CI: 15.4% to 30.3%], n = 48); and for genital ulcer were herpes simplex virus type 2 (HSV-2) (48.3% [95% CI: 32.9% to 64.1%], n = 47) and syphilis (9.3% [95% CI: 6.4% to 13.4%], n = 117). Temporal variation was substantial, particularly for genital ulcer where HSV-2 replaced chancroid as the primary cause. Aetiologic distributions for each symptom were largely the same across regions and population strata, despite HIV status and age being significantly associated with several infection diagnoses. Limitations of the review include the absence of studies in 16 of 48 SSA countries, substantial heterogeneity in study observations, and impeded assessment of this variability due to incomplete or inconsistent reporting across studies.
CONCLUSIONS: In our study, syndrome aetiologies in SSA aligned with World Health Organization guidelines without strong evidence of geographic or demographic variation, supporting broad guideline applicability. Temporal changes underscore the importance of regular aetiologic re-assessment for effective syndromic management.
UNASSIGNED: CRD42022348045.

This paper reviews recent data and concepts on metritis, purulent vaginal discharge (PVD), and endometritis in dairy cows and the ways in which these diseases affect reproductive performance. Metritis is characterized by fetid discharge from the uterus, with or without fever. Purulent vaginal discharge describes exudate that is >50% pus that may be attributable to uterine infection or cervicitis. Endometritis is inflammation of the uterus diagnosed by endometrial cytology with a proportion of neutrophils (typically ≥5%) that is associated with impaired fertility. Metritis and PVD are associated with uterine bacterial dysbiosis: changes in the microbiota to lesser diversity and greater abundance of pathogens, especially Gram-negative anaerobic bacteria, and Trueperella pyogenes in the case of PVD. Metritis is justifiably treated with approved antibiotics but criteria for more selective treatment without loss of performance are emerging. Purulent vaginal discharge is not synonymous with clinical endometritis, and greater precision in terminology is warranted. PVD is likely under-diagnosed and represents an opportunity for improved management in many herds. Endometritis seems in many cases to reflect persistent, dysregulated inflammation, for which the inciting cause is unclear. Postpartum uterine infection and inflammation have harmful effects on oocytes, embryo development, and the endometrium for at least three months, even if the disease is apparently resolved. Emerging concepts of the resolution and regulation of inflammation are promising for the improvement of prevention and therapy of endometritis.

Vaginal foreign body (VFB) can be a routine presentation to a pediatric unit, especially with associated vaginal discharge. Although it can be rare, this case series highlights that child sexual abuse (CSA) should not be ignored as a possibility when such a presentation is investigated. In the first case, an 11-year-old school girl presented with vaginal discharge and urinary symptoms, which was revealed to be due to a vesico-vaginal fistula secondary to an intra-vaginal foreign body, which was a plastic cap. Further investigation revealed that she had undergone vaginal penetration since the age of 6 years by two older male relatives. However, she was unaware how a plastic object came in to being inside her vagina. In the second case, a polythene bag was retrieved from the vagina of a 15 and a half year-old, pubertal female with an intellectually disability who presented with a 3-4-month history of vaginal discharge. Further investigation revealed that she had been vaginally penetrated on multiple occasions by her elder brother, who used polythene bags instead of condoms. Such a bag had been retained in her vagina leading to the vaginal discharge. VFB with or without genito-urinary symptoms is a red flag to identify sexual abuse among children, especially with intellectual disabilities. Although literature reports a wide variety of vaginal foreign bodies, there had been no reports of polythene bags used in place of condoms which were retrieved from a vagina of a CSA victim.

Although puerperal metritis (PM) is a common infectious disease in dairy cattle, there are currently discrepancies between clinical case definitions within and between available peer-reviewed literature and on-farms practices. The inconsistent use of PM criteria across studies and on-farms practices can result in disparities related to recommendations for treating cows, affecting judicious use of antimicrobials. The objective of this study was to systematically review the peer-reviewed literature for clinical signs used for case definition of PM. The criteria used included local (e.g., vaginal discharge) and systemic clinical signs of infection (e.g., fever, drop in milk). The Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews protocols were used to screen commonly used databases. Following this protocol, one reviewer screened title and abstract for eligibility (n = 2,096), followed by full-text screening of selected articles (n = 396) by 2 reviewers to confirm eligible articles (n = 174). The most frequently cited reference article (37.5%) for the definition of PM was published in 2006, followed by articles published between 1998 and 2009 (13%). In 40.2% of articles, no reference was provided for definition of PM; vaginal discharge was described in terms of color, odor, and viscosity when related to the PM definition. Terms used for description of vaginal discharge color were red-brown (61.4%), red (5.1%), brown (8.6%), chocolate (4%), white (1.7%), yellow (0.5%), pink (5.7%), or gray (0.5%); vaginal discharge color was not reported in 24.1% articles. The vaginal discharge odor was described as fetid (75.8%), putrid (5.1%), foul (10.3%), or other (5.7%; e.g., abnormal, malodorous, odoriferous); odor was not mentioned in 7.4% of articles. The vaginal discharge viscosity was described as watery (74.1%), purulent (27%), mucopurulent (8.6%), thin (4%), serous (2.8%), or abnormal (2.3%) and was not mentioned in 11.5% of articles. Fever was included in 59.7% of articles as a criterion for PM diagnosis. The most used rectal temperature threshold was ≥39.5°C (56.8%), followed by ≥39.2°C (2.8%). Approaches used for vaginal discharge evaluation included rectal palpation (37.3%), intravaginal exploration with a gloved hand (18.4%), Metricheck (9.8%), or speculum (5.7%); and in 28.7% of articles, diagnostic tools used were not mentioned. Many of the color and odor vaginal discharge descriptions observed in the literature, used synonymous words to describe the same vaginal discharge sample, highlighting a lack of terminology consensus that could result in disagreements, especially due to the subjective character of these clinical evaluations of vaginal discharge color and odor. Although select consensus articles are available, it is common for studies to disregard a reference when defining PM cases. Furthermore, our findings highlight the need for a robust and clear consensus on criteria and terminology used to diagnose PM.

The aim of this paper is to describe the distinctive ultrasound findings of a case of vaginal bleeding caused by the presence of a foreign body. We present the case of an infant who consulted for vaginal bleeding and foul-smelling discharge. The ultrasound revealed signs of vaginal distension due to heterogeneous-hematic contents and parietal thickening. At Doppler examination, a striking finding of increased vascularization limited to the upper two-thirds of the vaginal wall was found, which was initially interpreted as a sign of local inflammation suggesting the presence of an underlying foreign body. At direct vaginoscopic examination remains of toilet paper in the vaginal fundus were found. The presence of a foreign body in the vagina is an uncommon cause of discharge and vaginal bleeding in pediatrics, therefore, this etiology should be kept in mind when the adequate clinical context arises. Doppler ultrasound represents a first-line complementary method when this entity is suspected.

Trichomonas vaginalis is a flagellate human parasite responsible for the most common non-viral sexually transmitted infection (STI) in the world. We aim to estimate the prevalence and basic characteristics of T. vaginalis infection in the Turkish population from 2002 to 2020. Six international and two national electronic databases were searched using keywords of \"Trichomonas vaginalis\" and \"Turkey\" both in English and Turkish languages. Searching motors for the present study included the following: Google Scholar, PubMed, Scopus, Mendeley, Science Direct, Proquest, Web of Science, YOKtez, and TRDizin. This review includes cross-sectional studies estimating the prevalence of T. vaginalis infection in the Turkish general population. If it meets the criteria for inclusion, the full-text article was obtained and reviewed. The basic characteristics of each paper were extracted and listed. Overall, 65 articles were found about T. vaginalis infection in the general Turkish population in this period. Overall, the mean prevalence of infection was found to be 5.94%, 2.87% in men, and 6.17% in women. The maximum prevalence rates were 42.4% in bar girls, 28.3% in patients with gynecological complaints, 28% in patients applied to gynecology clinics, and 15.37% in patients with vaginal discharge. Among the regions, the highest rate of infection was in the Black Sea (8.76%) and Eastern Anatolia (8.12%). In most of the studies, DM and culture methods were applied together, and the specificity of the culture method was found to be higher. Although the superiority of culture over DM is obvious, both methods can give false negativity. T. vaginalis is still an important health problem among the Turkish population. The prevalence varies depending on the socioeconomic structure of the region, the lifestyle of the person, the method used in the study, the size of the population, and the clinical condition of patients.

The concept of vaginal dysbiosis was for long considered synonymous with bacterial vaginosis (BV), which is characterized by a homogenous non-inflammatory vaginal discharge. The inflammatory variant of vaginal dysbiosis, called aerobic vaginitis (AV), has remained unknown to a large part of the global dermatology and venereology community, gynaecologists and reproductive tract infection specialists with consequential under diagnosis. AV significantly differs from BV, in clinical presentation, diagnostic criteria and management. The deleterious impact of untreated AV on pregnancy merits discussion. Understanding AV is also crucial for better comprehension of desquamative inflammatory vaginitis (DIV), the most severe form of the same entity. We review the condition\'s epidemiology, risk factors and suspected aetiology, symptoms and signs, and the latest evidence-backed approach to diagnosis and treatment. The ideal diagnostic approach and treatment for AV/DIV are yet to be established. The currently recommended diagnostic approach for AV/DIV merits an overhaul by incorporating changes to render it feasible for resource-constraint countries. The diagnostic criteria lack a uniform applicability in different physiological groups of women and cannot be used in postpartum or postmenopausal states at the same cut-off levels. Similarly, treatment guidelines merit a relook, and customization, given the equivocality of options suggested by different investigators.

Cervical cancer is the commonest gynaecological cancer in developing countries. It is a major cause of cancer related deaths among women in our subregion.
To determine the incidence, mode of presentation, associated risk factors and management of histologically confirmed carcinoma of the cervix at the Nnamdi Azikiwe University Teaching Hospital, Nnewi.
This was a retrospective study of all the cases of histologically confirmed carcinoma of the cervix at the Nnamdi Azikwe University Teaching Hospital, Nnewi, between first of August 2009 and 31st July 2014. Data collected was analysed with SPSS version 20.0 software and presented in tables and charts.
Sixty two patients with histological confirmation of cervical cancer were managed in the hospital over a five year period. Forty five of these patients with adequate information in their folders constitute the study group. There was an incidence of 9.2% of all gynaecological admissions. The highest incidence(31.2%) was found in age group 50-59 years.
The incidence of cervical cancer is very high in our environment. Majority of the presentations were at the advanced stage of the disease.

Syndromic management of sexually transmissible infections is commonly used in resource-poor settings for the management of common STIs; abnormal vaginal discharge (AVD) flowcharts are used to identify and treat cervical infection including Neisseria gonorrhoea and Chlamydia trachomatis. A systematic review and meta-analysis was undertaken to measure the diagnostic test performance of AVD flowcharts, including both World Health Organization (WHO)- and locally-adapted AVD flowcharts.
A systematic search of multiple electronic databases was conducted to locate eligible studies published between 1991 and 2014. Flowcharts were categorised into one of 14 types based on: 1) use of WHO guidelines or locally-adapted versions; 2) use of risk assessment, clinical examination or both; and 3) symptomatic entry. Summary diagnostic performance measures calculated included summary sensitivity, summary specificity and diagnostic odds ratio.
Thirty-six studies, including data on 99 flowcharts, were included in the review. Summary sensitivity estimates for WHO flowcharts ranged from 41.2 to 43.6%, and for locally adapted flowcharts from 39.5 to 74.8%. Locally adapted flowcharts performed slightly better than the WHO flowcharts. A difference in performance was not observed between use of risk assessment or clinical examination. The AVD flowchart performed slightly better when it was not restricted to symptomatic women only.
There was considerable variation in the performance of the AVD flowchart but overall it was a poor diagnostic tool regardless of whether risk assessment or clinical examination was included, or whether the flowchart was WHO or locally developed. Many women were treated unnecessarily and many women with cervical infection were not detected. We caution against their continued use for management of cervical infection.

BACKGROUND: This review aimed to synthesize and analyze the diagnostic accuracy and the likelihood of providing correct treatment of the syndromic approach Vaginal Discharge Flowchart in managing cervical infections caused by Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT), and vaginal infections caused by Trichomonas vaginalis (TV) and Bacterial vaginosis (BV) and Candida albicans. This review will inform updating the WHO 2003 guidelines on Vaginal Discharge syndromic case management.
METHODS: A systematic review was conducted on published studies from 01-01-2000 to 30-03-2015 in multiple databases. Studies evaluating the diagnostic accuracy and validation of the WHO Vaginal Discharge Flowchart were included. Validation parameters including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) and the 95% confidence intervals for the different types of the flowchart were taken as outcomes, re-calculated, and analysed using a fixed model meta-analysis for data pooling. The level of agreement between the index and reference test were determined by the Cohen\'s Kappa co-efficiency test. Each individual study was assessed on quality using the QUADAS-2 tool.
RESULTS: The search yielded 2,845 studies of which 16 met the eligibility criteria for final analysis. The diagnostic performance to identify cervical infections was low and resulted in a high proportion of over and missed treatment. The four flowcharts had a sensitivity between 27.37% in history and risk assessment and 90.13% with microscopy, with the inverse in specificity rates. The treatment performances between the flowcharts were inconsistent. The same applies to the use of vaginal discharge flowchart for treating vaginal infections. For vaginal infections the vaginal discharge flowchart had a good performance in flowchart 3 with 91.68% of sensitivity; 99.97% specificity; 99.93% PPV and 0.02% who missed their treatment and 8.32% of women who were over treated by the vaginal discharge flowchart.
CONCLUSIONS: The vaginal discharge flowchart should focus on management of vaginal infection. It could be used as an intermediate approach for cervical infections for sex workers until a point of care test is available in resource poor settings.