By Dr Anuma Kalu Ulu
For full disclosure, I will start by stating that I shall be calling body parts freely no matter where they are located without recourse to the sanctimonious, a politically-correct nuance expected of a writer like me in Nigeria. Over here in USA, we call a spade a spade. This is because I have been rail-roadeded in the past by girls who reach me from Nigeria seeking for medical advice and who either by piety or bashfulness or a combination of both, euphemistically referred to their vaginas as something akin to their anuses, making me give them wrong treatment until I caught on with the programme. In this article, there will not be such ambivalence!
Toilet infection in Nigeria erroneously refers to a group of infections that manifests with itchy vaginal discharge and is medically called vaginitis in other climes. Vaginitis generally is inflammation of the vagina as may be caused by infections with Gardnerella vaginalis, staphylococcus, gonorrhea, streptococcus and chlamydia; Viruses like herpes; irritation from chemicals in douching, fungal infection (candidiasis) ; protozoal infection, e.g., Trichomonas vaginalis; tumours of the cervix or vagina; foreign bodies like tampons; or vulval atrophy in the elderly. It is the pervasively mistaken belief that it is contracted from sharing dirty toilets with infected persons as in schools and other public toilets and in the ‘villages’ that makes sufferers too shy to admit to it lest they be perceived as being dirty. As such, a lot of people suffer in silence or try outrageous remedies and the few that venture to seek medical advice from people like me, always tell me it is their phantom roommate or friend who has the infection, yet when I ask for colour, consistency and other details, they are quick to supply these graphically without recourse to the facade of a reported speech. My intention here is not to ridicule anybody but to teach you that it is okay to admit to having the infection, as the cause has nothing to do with being dirty, and it is even easily treatable. Here in the USA, a young female with these symptoms will come to my emergency room, tell me exactly what symptoms she has, and will be examined by me with speculum and all that, and a high vaginal swab will be taken to be examined in the lab as wet prep and result will be back within 10 minutes showing either of or a combination of 3 organisms, and pt will be treated appropriately. Try that in Nigeria, for a young girl sufferer to even come forward with such an admission, let alone be examined there, ‘akuko’!!
It may be seem like this is a female issue but guys should not stop reading here because we may not show symptoms but could act as storage depot to re-infect treated female partners who may have had unprotected sex with us prior to their treatment. A case can be made for treating male partners who have had unprotected sex with infected females the first time the woman is diagnosed but this is not strictly done, but in recurrent infections of the same female after treatment, then the male partner has to be treated too.
I shall concentrate on the main causes from the above causative agents which span 3 different classes of organisms viz bacteria especially Gardnerella vaginalis ( called bacterial vaginosis or BV), a protozoan called Trichomonas vaginalis which causes trichomoniasis and finally a fungus of the candida specie especially Candida albicans which causes candidiasis or yeast infection. In the USA, BV is the most common vaginitis but in Nigeria yeast is the most common so much so that most people do not know that there are other causes of toilet infection ( there I go too!) except candida. I shall take each of them separately.
BV is characterized by vaginal itching and frothy discharge although 50% may be asymptomatic and causes include new or multiple sexual partners, cigarette smoking and douching with resulting bacterial shift. Although sexual activity may play a role, women who have never had sexual intercourse can also be affected. Presence of clue cells in wet prep exam is diagnostic. It is treated with metronidazole ( flagyl) at 500mg by mouth 2x/day for 7days although it can also be treated with tinidazole or even clindamycin. Untreated cases can result in miscarriage or even premature birth in pregnant females. It is recommended to treat the male partner also to avoid re-infection from these asymptomatic males.
Trichomoniasis is characterized by itchy frothy yellowish-green vaginal discharge although 50% could be asymptomatic and it is definitely diagnosed on saline wet preps when multiple flagella of the protozoan are seen. It is treated with flagyl (metronidazole) 500mg by mouth 2x/day for 7days or just one dose of flagyl 2grams (2000mg) by mouth. Since about 60% of male partners of infected females carry the organism although asymptomatic, they also need to be treated as above to avoid
re-infection. Flagyl will need to be avoided in early pregnancy.
The poster child for toilet infections in Nigeria is candidiasis as caused chiefly by Candida albicans although other candida species have been implicated. It presents with itchy thick white curdy vaginal discharge and is made possible due to a distortion in the urogenital normal flora or a change in the immunity of the infected. Antibiotic therapy which destroys the normal bacteria flora, leaving the fungus to grow unopposed; and steroid therapy, which decreases white blood cell function thereby rendering the patient less immune, are the chief causes candidiasis, and not being dirty! It is also common during pregnancy because of increased estrogen levels and in diabetes mellitus, due to high blood sugar, since the fungus grows well on sugar. So candida lives normally in the urogenital and alimentary tracts because it thrives in warm moist areas but is held in check by commensal bacteria in these places. When a female takes antibiotics for anything else like pneumonia, etc, these antibiotics also kill the commensal bacteria thus leaving the fungus or candida unchecked, resulting in vaginal candidiasis. This is why in the USA, most girls on antibiotics for anything else are given 150mg of fluconazole once by mouth to prevent candidiasis. Those who are familiar with my practice in Nigeria know that I am big on this method of treatment too. It is also common in chronic diseases like kidney failure patients, diabetes mellitus, AIDS patients, patients who have received transplants, cancer patients especially those receiving chemotherapy as well as a host of other chronic diseases. Treatment is simple, just fluconazole (diflucan) 150mg by mouth once or in pregnant patients an insertion clotrimnazole vaginal preparations once nightly for 7days. A usually asymptomatic partner can also reinfect a treated female, so he will need to be treated too with the one time fluconazole.
In conclusion, toilet infection should not carry the stigma that it carries at present and sufferers should step forward to be treated. In places where no wet prep test is immediately available, a young female with itchy vaginal discharge should just cover all bases by taking 150mg of fluconazole together with 2000mg of flagyl (10 tabs of the 200mg or 5 tabs of the 400mg in Nigeria) all at once and this should take care of the above 3 causes. When i send down the flagyl from the USA, it is 8tabs of the 250mg or 4 tabs of the 500mg, since that is thee type we have here, so that those i have been treating do not get it mixed up.
I hope that we learn one or two things from the above.
