Military's women's risk factors for and symptoms of genitourinary infections during deployment

Military Medicine, Jul 2003 by Lowe, Nancy K, Ryan-Wenger, Nancy A

Symptoms of vaginitis and urinary tract infections are miserable, distracting, and significantly affect women's quality of life. Among civilian women, these symptoms account for 10.5 million office visits per year. To examine the scope of the problem for military women during deployment situations, surveys were sent to randomly selected Army and Navy units. Of 841 women who completed the anonymous survey and had been deployed, vaginal infections were experienced by 30.1% and urinary tract infections by 18.4% of them during deployment. Vaginal symptoms were consistent with symptoms associated with the three most common vaginal infections (candida, bacterial, and trichomonas vaginitis). A variety of risk factors, both behavioral and situational, significantly differentiated women with and without infections. Urinary tract infections and vaginal infections are common during deployment situations where resources for self-care and appropriate primary health care for women are scarce or unavailable. One solution is a self-diagnosis and treatment kit for deployed military women.

Introduction

Approximately 347,000 women serve in more than 95% of all occupational areas of the Air Force, Army, Navy, and Marines1-4 and regularly deploy with their units to field settings, developing countries, and sea duty for war, peacekeeping, or humanitarian operations. During deployment, optimal health and functioning of all soldiers is critical to unit safety and success of the mission. Austere environments are often characterized by extreme temperatures, primitive sanitary conditions, and limited hygiene and laundry facilities, which are likely to increase military women's risk for development of genitourinary conditions such as vaginitis and urinary tract infection (UTI). Increased risk is compounded by inadequate management of these conditions due to unavailable or unacceptable health care resources for women.5

In the civilian environment, vulvovaginal pain, itching, burning, and vaginal discharge are the most common symptoms reported by women, resulting in 3.35 million office visits per year.6 Symptoms of lower UTI account for another 7 million office visits.7 If left untreated, symptoms from vaginitis and cystitis can significantly interfere with women's quality of life, comfort, and concentration.8.9 An Institute of Medicine report identified important topics for research on the health of military women, including management of common gynecological problems in the field.10 The purpose of this study was to describe the frequency with which military women experience risk factors for and symptoms of genitourinary infections when deployed to austere environments.

Literature Review

Genitourinary Infection.

The vagina is a dynamic ecological environment normally inhabited by at least 16 Gram-positive and -negative bacteria, yeast, and Mycoplasma organisms. Normal protective mechanisms include acidophilic lactobacilli that produce lactate and hydrogen peroxide to maintain the normal vaginal pH at 3.8 to 4.4 and suppress the overgrowth of normal flora.11-13 Basal and laminai layers of the vagina contain mast cells, lymphocytes, and immune globulins that protect against infection. The three most common vaginal infections are bacterial vaginosis (BV, 40%-50%), trichomonas vaginalis (TV, 15%-20%), and candidiasis vaginitis (20%-25%).14 Similarities and distinguishing symptoms among these three conditions are shown in Table I.

Risk factors for vaginal infection can be categorized as alterations in immune status, factors that alter the normal flora, factors that increase the vaginal pH, foreign bodies in the vagina, damage to the vaginal mucosa, and a history of previous vaginal infection.11,13,15-17 Immune status may be compromised , by systemic disease such as diabetes mellitus or HIV, estrogen changes due to pregnancy or oral contraceptives, and changes in the hypothalamic-pituitary-adrenal axis from chronic stress or steroid use.11,14 Broad-spectrum antibiotics enhance the overgrowth of candida organisms by inhibiting the growth of vaginal lactobacilli as well as other protective organisms.18 Douching, menstruation, multiple sexual partners, and frequent coitus favor a more alkaline vaginal pH in which BV and TV are more likely to develop.11,13 Damage to the vaginal mucosa can occur with frequent, vigorous coitus or douching and chronic use of tampons or other vaginal devices or agents.16 In a recent review, Sobel et al.14 identified regular sexual activity, frequent oral-genital contact, use of oral contraceptives, coitus with the use of a diaphragm and spermicide, use of the vaginal contraceptive sponge, use of intrauterine devices, and antibiotics as risk factors for candidiasis. Less consistent relationships between the development of candidiasis and other behavioral factors such as douching, feminine hygiene products, spermicides, and dietary excesses or deficiencies have been found. Similarly, restrictive clothing and nylon underwear are theoretically implicated in the development of vaginitis, but these factors are rarely documented.16