Occurrence and Clinical Characteristics of Vaginitis among Women of Reproductive Age in Lagos, Nigeria

Background: Vaginitis is an important public health problem globally. It is associated with gynaecological and obstetric complications. Vulvovaginal candidiasis, bacterial vaginosis and trichomoniasis are mainly responsible for vaginitis. The aim of this study is to determine the occurrence, clinical characteristics and associated risk factors of vulvovaginal candidiasis and bacterial vaginosis among women of reproductive age attending Primary Health Care centres in Lagos Nigeria. cross-sectional 258 Structured The results were analysed with descriptive statistics, chi-square and simple logistic regression. Results: Out of the 210 (81.4%) of the women with one or more vaginal infections, 105 (50.0%), 26 (12.4%) had bacterial vaginosis, and vulvovaginal candidiasis respectively while 78 (37.1%) had both vulvovaginal candidiasis and bacterial vaginosis. Only 1 (0.5%) participant had trichomoniasis and bacterial vaginosis. History of abortion and age below 25 years were associated with vulvovaginal candidiasis while pregnancy, history of miscarriage, age at first sexual activity and discharge were associated with bacterial vaginosis. Itching was associated with both vulvovaginal candidiasis and bacterial vaginosis. Conclusion: This study revealed vulvovaginal candidiasis and bacterial vaginosis as important cause of genital complaints among reproductive age women in Lagos. Health education, robust diagnosis and early treatment are needed in order to reduce the associated risk factors, disease burden and complications.


Introduction
Vaginitis is a global public health challenge among women of reproductive age.
It is estimated that more than one million sexually transmitted infections (STIs) are acquired every day and there are 374 million new infections with one of four STIs: Chlamydia, gonorrhea, syphilis and trichomoniasis [1]. Vaginitis contributes to gynaecological morbidity and maternal mortality [2]. Some vaginal infections present with few or no symptoms but many have abnormal vaginal discharge, itching, burning sensation, irritation, and discomfort as common complaints [3]. Though there are many pathogenic agents observed in the vaginal microflora, candidiasis, bacterial vaginosis and trichomoniasis are responsible for majority of vaginal infections in women of reproductive age [4] [5].
It is estimated to be the second most common cause of vaginitis after bacterial vaginosis [7]. Approximately 75% of all women experience at least one episode of VVC during their lives [8]. Candida albicans is the most frequent specie that causes VVC though other species like C. glabrata, C. dubliniensis, C. kefyr, C. pintolopesii, C. guilliermondii have been reported [9] [10]. Risk factors associated with VVC are sexual activity, recent antibiotic use, pregnancy and immunosuppression from such conditions as poorly controlled HIV infection or diabetes [11]. VVC is common in pregnancy and is associated with a significantly increased likelihood of low birth babies [12].
Bacterial vaginosis is a dysbiosis that results in reduction of vaginal lactobacilli leading to growth of anaerobic organisms like Gardnerella vaginalis, Prevotella spp, Mycoplasma hominis, Mobiluncus spp. [6] [13]. Although bacterial vaginosis is often sexually enhanced, it is not a sexually transmitted infection [13]. It is the most common cause of abnormal vaginal discharge in women of reproductive age [3] [4]. Up to half of the women with BV are asymptomatic [14] but for those that are symptomatic, the symptoms cause a lot of distress and impact their quality of life and relationships [15].
Trichomoniasis is caused by a parasitic protozoan, Trichomonas vaginalis,  [16]. It is the most common non-viral sexually transmitted infection in the world [16]. It is estimated that 156 million people are infected worldwide yearly [1]. Although the main clinical manifestation of trichomoniasis is vaginitis, urethritis and prostatitis, the symptoms of the disease in women are yellowish-green frothy discharge, dysuria and the strawberry cervix which is recognized by punctuates haemorrhagic lesions [17].
Vaginal infections are associated with gynaecological morbidity and maternal mortality. They can cause pelvic inflammatory disease, tubal infertility, ectopic pregnancy, reproductive dysfunction and adverse birth outcomes such as premature rupture of membranes, premature labour, low birth weight, neonatal morbidity and mortality, post abortion or poor hysterectomy infection and enhanced predisposition to neoplastic transformation in cervical tissues. They also increase the risk of HIV and herpes simplex virus acquisition and transmission [16].

Sample Collection and Processing
High vaginal swab (HVS) was collected using sterile disposable speculum and two swab sticks. One HVS sample was used for Gram stain, saline wet mount for

Data Analysis
Data entry and analysis were done using Statistical Package for Social Sciences version 26. The variables of the study participants were described using frequencies, percentages and charts. Chi square and simple logistic regression were used to compare the vaginal infections with sociodemographic and clinical profile variables. A value of P ≤ 0.05 was considered statistically significant.

Result
A total of 258 women with genital complaints were recruited for the study. Only
The study showed that 49.2% of the pregnant women had VVC. Some studies
Mucci et al. [39] and Sangre et al. [40] reported 24.8% and 22.7% from Argentina and Burkina Faso respectively. However, Akinbami et al. [41] reported a higher prevalence of 60% in Ogbomosho South West Nigeria. These observed differences may be as a result of diet, hygiene and sexual practices.
History of abortion and miscarriage was associated with VVC (P = 0.031) and bacterial vaginosis (P = 0.034) respectively. In a study by Konadu et al. [25], VVC and bacterial vaginosis were not associated with history of spontaneous abortion.
The study showed that bacterial vaginosis was the commonest cause of vaginal infection followed by VVC. This is consistent with findings from Tanzania, Yemen, South western Nigeria, Birgunj Nepal, Sudan [3] [7] [24] [27] [42]. Studies from Ethiopia, India, Brazil, observed that VVC was the commonest cause of vaginal infection [4] [5] [6]. The differences may be as a result of variations in method, study population, hygiene practices and educational status. In this study, 50.0% of the women had bacterial vaginosis only. This is higher than 27.2% reported among reproductive aged women seeking Primary Health Care in Yemen [7]. Bonneton et al. [43] also reported a lower prevalence of 18.6% in Senegal. Different studies in Nigeria have reported lower prevalence of bacterial vaginosis, 16.6% [20], 27% [21], 38% [23]. However, Udenze et al. [44] reported 74% while Enitan et al. [19] reported 65% and 85% prevalence by Nugent's criteria and culture respectively in Ilara, Ogun state Nigeria. The observed variations in prevalence may be due to differences in study populations and techniques used for the test.
The prevalence of T. vaginalis (0.5%) is in agreement with reports from Sudan [42] but in contrast with the studies in Nepal where there was no positive case [27]. Higher prevalence of trichomoniasis have been reported in Kanchipuram India (4.0%) [45], Kogi state Nigeria (5.1%) [18] and Ibadan south western Nigeria (1.5%) [46]. T. vaginalis was found only in 31 -35 years age group. Idakwo et al. [18] reported higher prevalence in age groups of 21 -30 and 31 -40 years while Tine et al. [47] reported 31 -45 years age group. Studies from Egypt [48], Iran [49] reported that women in age group 25 -45 years are at higher risk of T. vaginalis infection. There was no co-infection between VVC and T. vaginalis. This is in agreement with report by Idakwo et al. [18]. However, Mascarenhas et al. [6], Pondei et al. [34] reported co-infections by Candida species and T. vaginalis. Differences may be due to variations in methodology, level of awareness and poor personal hygiene. The low T. vaginalis prevalence could be as a result of the wet mount method used in detection. Studies by Adjei et al. [50], Squire et al. [51], showed that direct wet-mount microscopy has low sensitivity in detecting T. vaginalis.
The commonest symptom for patients with bacterial vaginosis was vaginal discharge (95.3%). Majigo et al. [3] and Enitan et al. [19] reported vaginal discharge as the commonest symptom. There was a significant association between discharge and bacterial vaginosis (P < 0.001). This finding agrees with previous  [52] in Nepal and Garba et al. [53] in North Central Nigeria. Itching was also statistically significant in patients with bacterial vaginosis (<0.001) but study by Ranjit et al. [52] registered no significant relationship between itching and bacterial vaginosis. However, itching was the commonest symptom in VVC patients (61.9%) [P = 0.035]. Hedayati et al. [10], Karmastaji et al. [54] reported erythema with itching in VVC patients as the commonest symptoms. Abdul-Aziz et al. [7] reported significant relationship between vaginal itching and VVC among reproductive aged women in Yemen though Habibipour [55] did not find any significant correlation. In this investigation, pregnancy was associated with bacterial vaginosis but study by Apalata et al. [56] reported no significant association.
The study has some limitations. Detection of T. vaginalis by wet mount may have reduced the actual prevalence. Other causes of abnormal discharge were not detected in the study. Some diseases that make VVC to thrive were not taken into consideration.

Conclusion
Findings from this study reveal high burden of bacterial vaginosis and vulvovaginal candidiasis among reproductive age women with history of abortion and miscarriage as potential risk factors. There is need for strategy that will improve reproductive health education especially among women of age 25 years and below.