Chlamydia

Chlamydia trachomatis is an infection which commonly co-exists with gonorrhoea. It is a very common cause of urethritis (also known as non-gonococcal urethritis or NGU). Like gonorrhoea, chlamydia can ascend in the male urethra to cause prostatitis and epididymitis.

In women, the infection can be a cause of discharge, but more importantly may spread via the cervical canal to be a cause of PID (see below). If the baby develops the infection during passage through the birth canal, conjunctivitis and pneumonia can result.

Chlamydia infections are treated with a different class of antibiotics to gonorrhoea. Oxytetracycline or doxycycline are most commonly prescribed, to be taken by mouth for 1-2 weeks. Ideally, sexual contacts should be traced and treated also.

In Chinese medicine chlamydia infection, like gonorrhoea, is a manifestation of Damp - Heat in the Lower Jiao.

Gardnerella infection (bacterial vaginosis or BV)

Gardnerella infection is another example of an overgrowth of "healthy" organisms. Gardnerella vaginalis is a bacterium which is found to comprise up to 30% of the normal population of bacteria in a healthy vagina. In overgrowth, this bacterium causes the discharge to become more watery, and to have a characteristic fishy smell. This condition has been termed bacterial vaginosis (BV). There is usually no discomfort in BV. It has recently been reported that pregnant women with BV are more likely to go into premature labour. This has led to a debate over whether women with BV should be treated early in labour with antibiotics.

Treatment of BV is with a single dose of the antibiotic metronidazole (Flagyl®).

Genital Herpes

Genital Warts

Genital warts are the result of infection by certain strains of the human papilloma virus (HPV). The genital wart strains are different from those strains of HPV which cause bodily warts (which occur most commonly on the hands and knees). The virus causes a benign growth of epithelial tissue which develops into cauliflower-shaped bumps on the vulva, vagina, cervix and penis, and also around the anus. The genital wart, like the bodily wart, is painless, and, especially in women, may not be noticed by the patient. Sometimes the patient complains of itching or burning from the area of the warts.

HPV infection is very common; up to 30% of sexually active adults have evidence of current or past infection. The infection is important because a particular strain of HPV is known to induce pre-cancerous changes in cervical cells (see Lesson 5.2g). For this reason, a woman with warts should have annual cervical smear tests, so that any pre-cancerous changes can be followed up.

Warts can be treated by repeated application of a drug called podophyllin. This "burns" the wart away. Larger warts can be burned off by means of a laser or heat probe. Recurrence of the warts is common after both these treatments.

In Chinese medicine the genital wart is a manifestation of Damp and Phlegm.

Gonorrhoea

Gonorrhoea is caused by infection with the bacterium known as Neisseria gonorrhoeae (gonococcus). In women the initial infection initially presents with urinary symptoms and a vaginal discharge. There is a risk of transmitting this infection to the baby during labour, in which case a severe form of conjunctivitis can result. In men there may also be urinary symptoms, and a slight pus-like discharge from the urethra. This condition is called urethritis. Urethritis may be caused by a number of organisms in addition to the gonococcus.

In many of these initial infections, particularly in women, symptoms may be so mild as to be ignored. This means that there is high risk of transmission of the infection at this stage.

The real problems of gonorrhoea come if the infection spreads. In women, the next site of infection is the cervical canal and thence the lining of the uterus. This can lead to the chronic condition known as pelvic inflammatory disease (PID). PID will be discussed in more detail presently.

In men the gonococcus can spread to cause a chronic infection of the prostate, epididymis and the testes. Occasionally the infection can enter the blood stream. A feverish illness develops, characterised by painful joints and a widespread rash. This form of gonorrhoea is more common in women.

Gonorrhoea is treated by means of antibiotics. A single dose of amoxycillin or spectinomycin is all that may be necessary in uncomplicated cases. Long courses of these antibiotics may be required to treat chronic infections. Ideally, sexual contacts should be traced and treated also.

In Chinese medicine gonorrhoea would appear to represent Damp Heat in the Lower Jiao. It can manifest as Wind-Heat on the exterior (rashes and fever) and Wind-Damp (arthritis) in severe cases.

Pelvic inflammatory disease (PID)

PID is the term given to the syndrome which arises as a result of chronic infection of the uterus, fallopian tubes and ovaries. (the female internal genital organs). It is believed that over half of these infections are caused by chlamydia, and up to 30% by the gonococcus.

However, there are a number of less common organisms which may also cause PID. Commonly PID develops without any preceding symptoms. The risk of PID is reduced by use of barrier methods of contraception, and the contraceptive pill, but the risk is increased in users of the "coil"

The most common symptoms of an acute infection include severe abdominal tenderness and pain (with deep dyspareunia), and high fever. In a severe infection pus may collect in a fallopian tube, leading to a severe illness akin to appendicitis. Infection may also spread to the space surround the ovaries.

In its more chronic form, PID may lead to a long-standing feeling of being unwell, and pelvic discomfort, particularly on intercourse. There may be menorrhagia or secondary dysmenorrhoea. Internally, the genital organs may become stuck together (with "adhesions") and scarred.

A serious consequence of acute and chronic PID is infertility, as the scarring and adhesions may prevent ovulation or implantation of the fertilised ovum. Another severe consequence is that there is an increased incidence of ectopic pregnancy in women who have had PID

These long term effects of untreated PID are becoming increasingly common as unprotected sex, particularly amongst teenagers, is increasingly prevalent.

PID is treated with antibiotics, and these may be given intravenously in severe acute infections. Surgery may be necessary in cases in which pus has accumulated. However, as many cases are chronic, the diagnosis may not be made until permanent damage to the internal genital organs has occurred.

In Chinese medicine PID might correspond to one or more of Damp, Heat or Qi and Blood Stagnation in the Uterus.

Syphillis

Syphilis is caused by infection with the bacterium Treponema pallidum. Probably because of access to adequate antibiotic therapy, it is now a very rare condition in the U.K, although it is still common in developing countries.

Infection with syphilis has three stages. The primary stage is called a chancre. This is a thickened lump which forms in the genital area within 2-12 weeks of sexual contact with an infected person. The skin on top of the chancre breaks down, but is often painless. It is this stage which is highly infectious, but like genital warts. It is often unnoticed by the patient. After healing of the chancre there may be a delay of some weeks before appearance of secondary syphilis. In most people there is a flu-like illness, with swollen lymph nodes, a characteristic skin rash, and the development of warty genital lumps. In some cases there might be more severe inflammation of a deep organ such as hepatitis or meningitis.

Secondary syphilis will abate after 3-12 weeks if untreated, but then can recur due to persistence of the organism, in a more severe form as tertiary syphilis. In this stage the infection can cause large ulcerating lumps, called gummas, in a wide range of tissues.

The heart and blood vessels can be affected, and a form of dementia (neurosyphilis) may develop. The condition termed general paralysis of the insane, once familiar in Victorian asylums, was a result of the combined features of untreated syphilis. These later stages of syphilis are now very rare in developed countries because the earlier stages respond well to penicillin treatment.

In Chinese medicine the formation of warty lumps in all three stages of syphilis suggest that Damp/Phlegm is a prominent feature. The recurrence of the condition in a flu-like secondary form suggests that Latent Heat has been present from the primary infection.

Trichomonas infection

Trichomonas vaginalis is a bacterium which comprises up to 7% of the healthy bacterial population in the vagina. Trichomonas "infection" is another form of bacterial overgrowth which may also be sexually transmitted. It causes a moderate to profuse discharge which can cause intense itching in the woman. If severe, the discharge can have a green and frothy appearance.

Treatment of trichomonas involves a week's course of metronidazole. The male partner may be advised also to take this antibiotic to prevent re-infection of his partner.

In Chinese medicine vaginal discharge (leucorrhoea) represents Damp in the Lower Jiao. Itching redness, a coloured or smelly discharge all suggest Damp-Heat, whereas white, watery discharges are more suggestive of Damp-Cold. An underlying deficiency of Spleen Qi is likely.

Vaginal Discharge

Vaginal discharge is a common complaint, but may be physiological, rather than the result of an infection. Physiological discharge is odourless, does not cause itch and varies in quantity throughout the cycle. Nevertheless, it may be profuse and a source of embarrassment or discomfort. Benign changes of the cervix called cervical erosions and fleshy cervical polyps may be physical causes of excessive physiological discharge. Both these problems can be treated fairly simply by an out-patient procedure which involves a colposcopy.

A serious cause of vaginal discharge is vaginal, cervical or uterine cancer. In these cases the discharge is more likely to be of recent onset, varying in a way which is not related to the menstrual cycle, and may be smelly or blood stained. A discharge fitting this description should always be taken seriously, but particularly so in postmenopausal women in whom these cancers are more common.

Candida (yeast) infection or thrush: Thrush is the most common infectious cause of vaginal discharge. As yeasts form about 5% of the "healthy" organisms in the vagina, a candida "infection" usually represents an overgrowth of these yeasts rather than a new infection. Candida infection in women is usually internally arising, but also can be sexually transmitted. In contrast, sexual transmission is a common cause of genital candida infection in men.

Thrush develops very readily in some people, who may suffer from recurrent bouts. In susceptible people, a bout may be triggered by sexual intercourse, tight clothing, over-washing, use of a different soap or a course of antibiotics. However, serious causes, including immuno-deficiency and diabetes mellitus, must be excluded in people who suffer from recurrent thrush.

An alternative view is that recurrent thrush is associated with the candida syndrome, in which overgrowth of candida is believed to cause a wide range of physical and emotional symptoms. The candida syndrome is not recognised by conventional practitioners. Genital thrush causes itchy plaques of white discharge which may overlie red inflamed areas of epithelium. The itch can be intensely irritating, particularly in women, and may cause difficult urination.

Conventional treatment of thrush is with antifungal medication. In a mild case, application of a cream containing clotrimazole (Canesten® or Canesten HC®), may be sufficient to alleviate the symptoms. In more severe cases, this drug can be treated by mean of a course of vaginal tablet (called pessaries). Recurrent thrush may be treated with oral anti-fungal medication. Fluconazole (Diflucan®) is the most commonly prescribed preparation. Some women rely on recurrent treatments with these anti-fungal medications to keep their symptoms at bay.