细菌性阴道病临床诊断、混合感染及其与支原体关系的探讨
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摘要
细菌性阴道病(bacterial vaginosis，BV)是妇产科常见阴道感染性疾病之一，主要发生于育龄期妇女，感染率在15％～50％，虽然1周的治愈率为80％～90％，但在3个月内复发率有15％～30％，易引起各种妇产科并发症，严重影响女性生殖健康。寻找更客观的诊断方法，认识BV混合感染的特征以及发病机制，对其正确诊治，降低并发症具有重要意义。
本研究将分三个部分探讨BV的诊断、BV混合感染的临床特征以及BV与支原体(解脲脲原体、生殖支原体)的关系。
第一部分细菌性阴道病的诊断
目的：评价Amsel临床诊断方法中每项指标的诊断价值；以Nugent法为金标准，评价Amsel、BVBlue、BV速蓝三种检测方法诊断BV的敏感性、特异性；以Nugent法为金标准，评价BVBlue+pH、BVBlue+胺试验和BVBlue+线索细胞组合是否会提高诊断的敏感性、特异性。
方法：随机抽取2008年7月至12月在天津医科大学总医院普通妇科门诊以Nugent法或Amsel法诊断为确诊为BV的患者100例，同时取健康查体无阴道炎者100例作为对照。
结果：以灵敏度、特异度、ROC曲线下面积评价Amsel中的四项指标，线索细胞最佳，其次为胺试验。Nugent、Amsel、BVBlue、BV速蓝四种检测方法互相比较，诊断BV的Kappa值均大于0．7；以Nugent法为金标准，三种检测方法的灵敏度、特异度、ROC曲线下面积分别为，Amsel：96％、99％、0．975，BVBlue：87％、99％、0．929，BV速蓝：81％、98％、0．894。以Nugent法为金标准，BVBlue与Amsel中任一项指标组合的灵敏度、特异度、ROC曲线下面积分别为，BVBlue+pH：71％、100％、0．854，BVBlue+胺试验：73％、100％、0．864，BVBlue+线索细胞：83％、100％、0．914。结果提示：除Amsel、Nugent外，BVBlue、BV速蓝是诊断BV的客观诊断方法，但与Amsel中的任一项指标组合，特异性升高，但敏感性有下降趋势。
第二部分细菌性阴道病混合感染临床特征目的：探讨BV及其混合感染的临床特征，为BV及其混合感染的临床诊断提供帮助。
方法：2008年4月～2008年12月，天津医科大学总医院妇科普通门诊就诊病人22789人，随机抽取以外阴不适、白带异常、分泌物有异味等阴道炎症状600例，其中有完整资料记录者516例为研究对象。
结果：516例患者中，BV318例，占61．63％，其中混合感染94例，占29．56%。在94例混合感染中，以VVC多见，占58．51％；其次为AV，占21．28％；TV占19．15％。BV患者常见症状为白带有异味，其次为白带增多，一般不伴有白带性状改变、外阴瘙痒等症状；阴道pH值通常＞4．5，清洁度主要为Ⅰ°～Ⅱ°；BV混合感染症状体征不典型，阴道pH值多数＞4．5，清洁度主要为Ⅲ°～Ⅳ°。该结果提示：BV的混合感染比较多见，在诊断下生殖道感染时，应同时作几种阴道感染的检查。
第三部分支原体感染与细菌性阴道病的相关性研究
目的：应用real-time PCR方法对BV患者和健康对照者中解脲脲原体(Ureaplasma urealyticum，Uu)及生殖支原体(mycoplasma genitalium，Mg)DNA进行定量，同时对Uu进行分群定量检测，评估Uu、Mg的细菌定量是否参与BV的发病机制，旨在为临床诊治BV打下基础。
方法：于2008年7月至12月在天津医科大学总医院普通妇科门诊，随机抽取以阴道炎症状就诊，Nugent法确诊为BV者44例，同时取无阴道炎的健康查体者88例作为对照组。提取阴道分泌物细菌基因组DNA，real-time PCR方法检测阴道分泌物中Uu、Mg的DNA。
结果：BV组妇女中Uu的检出率为65．9％，对照组妇女中Uu的检出率为50．0％，两组比较差异无统计学意义(p=0．083)；而对Uu分群检测发现，BV组妇女中T960生物群的检出率为22．7％，对照组妇女中T960生物群的检出率仅为9．1％，两组比较差异有统计学意义(p=0．031)。Mg在BV患者中的检出率为4．5％(2／44)，在健康对照组也为4．5％(4／84)，经统计学分析无明显差异，两组中Mg DNA的定量值也均＜1．00×10~6copy／g，基本都位于10~3～10~5之间，进一步证实了Mg与BV无关。该研究结果提示：Uu中T960生物群可能与BV的发病有关。
结论
1．Amsel、Nugent、BVBlue、BV速蓝四种检测方法均为诊断BV的方法。除Amsel、Nugent外，BVBlue及BV速蓝也是诊断BV敏感性及特异性较高的方法。
2．细菌性阴道病是最常见的下生殖道感染，易合并其它病原体感染，尤以合并VVC、AV及TV多见。在BV诊断中，注意有无合并其它阴道感染，并在诊断其它阴道感染时，注意是否有合并BV。
3．Uu与BV无相关性，Uu的parvo生物群与BV亦无相关性，但Uu的T960生物群与BV存在相关性，是可能的致病菌群，而parvo生物群可能是定植菌群。Mg与BV无相关性。
Bacterial vaginosis is one of the most common vaginal infections in women ofreproductive age,the infection rate of 15% to 50%,cure rates of 80～90% atlweek,but recurrence rates of 15～C30% within 3 months.BV easily causes a variety ofobstetric and gynecologic complications,and has a serious impact on women'sreproductive health.The study on the clinical diagnosis and pathogenesis of BV isparticularly important.
This study will explore diagnosis and the clinical features of BV and its mixedinfection,and explore mycoplasma (Ureaplasma urealyticum,Mycoplasmagenitalium) whether to participate in the pathogenesis of BV.
SectionⅠ.The diagnosis of bacterial vaginosis
Objective:To evaluate the sensitivity and specificity of each indicator in the Amselmethod;the Nugent method as the gold standard,to evaluate sensitivity and specificity of theAmsel,BVBlue,and BVsualn on BV;the Nugent method as gold standard method,toevaluate whether BVBlue,BVBlue+pH,BVBlue+amine test,and BVBlue+clue cells willimprove the diagnostic sensitivity and specificity.
Methods:100 cases who were diagnosed with BV were randomly selected fromJuly 2008 to December 2008 in gynecologic outpatient clinic in the General Hospitalof Tianjin Medical University General.At the same time 100 non-vaginitis womenwere selected as control group.
Result:The most reliable indicator of Amsel was the presence of clue cells,with a highsensitivity and specificity,followed by amine test.The kappa coefficient of the four detectionmethods(the Nugent method,the Amsel method,BVBlue,and BVSualn) was more than0.7.The Nugent method as the gold standard,the sensitivity and specificity of three detectionmethods respectively,Amsel:96%,99%,0.975;BVBlue:87%,99%,0.929;BV-speed blue:81%,98%,0.894.The Nugent method as the gold standard,the combination of BVBlue and any indicator of the Amsel respectively,BVBlue+pH:71%,100%,0.854;BVBlue+amine test:73%,100%,0.864;BVBlue+clue cells:83%,100%,0.914.The results suggest that BVBlue andBVSulan are both objective diagnostic methods on BV besides Amsel and Nugent.
SectionⅡ.Clinical features of bacterial vaginosis mixed infections
Objective:To explore clinical features of BV and its mixed infection,and providehelp for the clinical diagnosis of BV and its mixed infection.
Methods:516 outpatients with vaginitis symptoms from April 2008 to December2008 in general gynecology in the General Hospital of Tianjin Medical Universitywere investigated randomly.Their infective ratio of bacterial vaginosis(BV),vulvovaginal eandidiasis(VVC),trichomonal vaginitis(TV),and aerobic vaginitis(AV)were analyzed by vaginal secretion examination.
Result:BV was found in 61.63% of the women studied and was the commonestinfection diagnosed.BV mixed vaginal infections were diagnosed in 29.56%.VVC,TV,and AV infections were easily mixed with BV infection.Common symptoms inpatients with BV were foul smell,followed by leucorrhea increase,and generally notaccompanied by changes in leucorrhea character,genital itching and other symptoms.Vaginal pH value was usually more than 4.5.Vaginal cleanliness was mainlyⅠ°～Ⅱ°.symptoms and signs of BV mixed infections was atypical.Vaginal pH valuewas usuallymore than 4.5.Vaginal cleanliness was mainlyⅢ°～Ⅳ°.The resultssuggest that BV mixed infections were the most common vaginal infections,and weshould detect several common vaginal infections in the diagnosis of reproductive tractinfections.
SectionⅢ.Study on the correlation between Mycoplasma infection andbacterial vaginosis
Objective:Real-time PCR method quantitatively detect Uu and Mg DNA inpatients with BV and healthy controls,and at the same time quantitatively detect UuParvum biovar and Uu Urealyticum biovar.To determine whether Uu,Mg involved inthe pathogenesis of BV,and provide help to clinical diagnosis and treatment of BV.
Methods:44 patients were diagnosed as BV by Nugent method,and at the sametime 88 cases as healthy control group.To extract vaginal secretions bacterial genomeDNA,real-time PCR methods was used to detect Uu,Mg DNA of vaginal secretions.
Result:Uu was present in (65.9%) of 44 women with BV compared with (50.0%)of 88 women without BV(p=0.083);T960 was detected in (22.7%) of 44 women incomparison with (9.1%) of 88 women without BV(p=0.031).Mg was detected in 2(4.5%)of 44 with BV in comparison with 4(4.5%)of 88 women without BV(p=1.000).The study results suggest that T960 may be associated with the pathogenesis of BV.
Conclusions
1.Amsel,Nugent,BVBlue and BVSulan are diagnostic methods on BV.In additionto the Amsel and the Nugent,BVBlue and BVSulan are both Sensitive andSpecific on BV.
2.Bacterial vaginosis is the most common vaginal infections,and easily mixed withother pathogens,especially with VVC,AV or TV.In the diagnosis of BV,to payattention to whether BV was mixed with other vaginal infections;and in thediagnosis of other vaginal infections,to pay attention to whether other vaginalinfections was mixed with BV.
3.There was no correlation between Uu and BV,as well as Uu parvo biovar,but UuT960 biovar was associated with BV.People infected with Uu parvo biovar maybe normal carriers.Uu T960 biovar may lead to infection by itself or cooperatedwith other pathogeny.There was no correlation between Mg and BV.
本研究将分三个部分探讨BV的诊断、BV混合感染的临床特征以及BV与支原体(解脲脲原体、生殖支原体)的关系。
第一部分细菌性阴道病的诊断
目的：评价Amsel临床诊断方法中每项指标的诊断价值；以Nugent法为金标准，评价Amsel、BVBlue、BV速蓝三种检测方法诊断BV的敏感性、特异性；以Nugent法为金标准，评价BVBlue+pH、BVBlue+胺试验和BVBlue+线索细胞组合是否会提高诊断的敏感性、特异性。
方法：随机抽取2008年7月至12月在天津医科大学总医院普通妇科门诊以Nugent法或Amsel法诊断为确诊为BV的患者100例，同时取健康查体无阴道炎者100例作为对照。
结果：以灵敏度、特异度、ROC曲线下面积评价Amsel中的四项指标，线索细胞最佳，其次为胺试验。Nugent、Amsel、BVBlue、BV速蓝四种检测方法互相比较，诊断BV的Kappa值均大于0．7；以Nugent法为金标准，三种检测方法的灵敏度、特异度、ROC曲线下面积分别为，Amsel：96％、99％、0．975，BVBlue：87％、99％、0．929，BV速蓝：81％、98％、0．894。以Nugent法为金标准，BVBlue与Amsel中任一项指标组合的灵敏度、特异度、ROC曲线下面积分别为，BVBlue+pH：71％、100％、0．854，BVBlue+胺试验：73％、100％、0．864，BVBlue+线索细胞：83％、100％、0．914。结果提示：除Amsel、Nugent外，BVBlue、BV速蓝是诊断BV的客观诊断方法，但与Amsel中的任一项指标组合，特异性升高，但敏感性有下降趋势。
第二部分细菌性阴道病混合感染临床特征目的：探讨BV及其混合感染的临床特征，为BV及其混合感染的临床诊断提供帮助。
方法：2008年4月～2008年12月，天津医科大学总医院妇科普通门诊就诊病人22789人，随机抽取以外阴不适、白带异常、分泌物有异味等阴道炎症状600例，其中有完整资料记录者516例为研究对象。
结果：516例患者中，BV318例，占61．63％，其中混合感染94例，占29．56%。在94例混合感染中，以VVC多见，占58．51％；其次为AV，占21．28％；TV占19．15％。BV患者常见症状为白带有异味，其次为白带增多，一般不伴有白带性状改变、外阴瘙痒等症状；阴道pH值通常＞4．5，清洁度主要为Ⅰ°～Ⅱ°；BV混合感染症状体征不典型，阴道pH值多数＞4．5，清洁度主要为Ⅲ°～Ⅳ°。该结果提示：BV的混合感染比较多见，在诊断下生殖道感染时，应同时作几种阴道感染的检查。
第三部分支原体感染与细菌性阴道病的相关性研究
目的：应用real-time PCR方法对BV患者和健康对照者中解脲脲原体(Ureaplasma urealyticum，Uu)及生殖支原体(mycoplasma genitalium，Mg)DNA进行定量，同时对Uu进行分群定量检测，评估Uu、Mg的细菌定量是否参与BV的发病机制，旨在为临床诊治BV打下基础。
方法：于2008年7月至12月在天津医科大学总医院普通妇科门诊，随机抽取以阴道炎症状就诊，Nugent法确诊为BV者44例，同时取无阴道炎的健康查体者88例作为对照组。提取阴道分泌物细菌基因组DNA，real-time PCR方法检测阴道分泌物中Uu、Mg的DNA。
结果：BV组妇女中Uu的检出率为65．9％，对照组妇女中Uu的检出率为50．0％，两组比较差异无统计学意义(p=0．083)；而对Uu分群检测发现，BV组妇女中T960生物群的检出率为22．7％，对照组妇女中T960生物群的检出率仅为9．1％，两组比较差异有统计学意义(p=0．031)。Mg在BV患者中的检出率为4．5％(2／44)，在健康对照组也为4．5％(4／84)，经统计学分析无明显差异，两组中Mg DNA的定量值也均＜1．00×10~6copy／g，基本都位于10~3～10~5之间，进一步证实了Mg与BV无关。该研究结果提示：Uu中T960生物群可能与BV的发病有关。
结论
1．Amsel、Nugent、BVBlue、BV速蓝四种检测方法均为诊断BV的方法。除Amsel、Nugent外，BVBlue及BV速蓝也是诊断BV敏感性及特异性较高的方法。
2．细菌性阴道病是最常见的下生殖道感染，易合并其它病原体感染，尤以合并VVC、AV及TV多见。在BV诊断中，注意有无合并其它阴道感染，并在诊断其它阴道感染时，注意是否有合并BV。
3．Uu与BV无相关性，Uu的parvo生物群与BV亦无相关性，但Uu的T960生物群与BV存在相关性，是可能的致病菌群，而parvo生物群可能是定植菌群。Mg与BV无相关性。
Bacterial vaginosis is one of the most common vaginal infections in women ofreproductive age,the infection rate of 15% to 50%,cure rates of 80～90% atlweek,but recurrence rates of 15～C30% within 3 months.BV easily causes a variety ofobstetric and gynecologic complications,and has a serious impact on women'sreproductive health.The study on the clinical diagnosis and pathogenesis of BV isparticularly important.
This study will explore diagnosis and the clinical features of BV and its mixedinfection,and explore mycoplasma (Ureaplasma urealyticum,Mycoplasmagenitalium) whether to participate in the pathogenesis of BV.
SectionⅠ.The diagnosis of bacterial vaginosis
Objective:To evaluate the sensitivity and specificity of each indicator in the Amselmethod;the Nugent method as the gold standard,to evaluate sensitivity and specificity of theAmsel,BVBlue,and BVsualn on BV;the Nugent method as gold standard method,toevaluate whether BVBlue,BVBlue+pH,BVBlue+amine test,and BVBlue+clue cells willimprove the diagnostic sensitivity and specificity.
Methods:100 cases who were diagnosed with BV were randomly selected fromJuly 2008 to December 2008 in gynecologic outpatient clinic in the General Hospitalof Tianjin Medical University General.At the same time 100 non-vaginitis womenwere selected as control group.
Result:The most reliable indicator of Amsel was the presence of clue cells,with a highsensitivity and specificity,followed by amine test.The kappa coefficient of the four detectionmethods(the Nugent method,the Amsel method,BVBlue,and BVSualn) was more than0.7.The Nugent method as the gold standard,the sensitivity and specificity of three detectionmethods respectively,Amsel:96%,99%,0.975;BVBlue:87%,99%,0.929;BV-speed blue:81%,98%,0.894.The Nugent method as the gold standard,the combination of BVBlue and any indicator of the Amsel respectively,BVBlue+pH:71%,100%,0.854;BVBlue+amine test:73%,100%,0.864;BVBlue+clue cells:83%,100%,0.914.The results suggest that BVBlue andBVSulan are both objective diagnostic methods on BV besides Amsel and Nugent.
SectionⅡ.Clinical features of bacterial vaginosis mixed infections
Objective:To explore clinical features of BV and its mixed infection,and providehelp for the clinical diagnosis of BV and its mixed infection.
Methods:516 outpatients with vaginitis symptoms from April 2008 to December2008 in general gynecology in the General Hospital of Tianjin Medical Universitywere investigated randomly.Their infective ratio of bacterial vaginosis(BV),vulvovaginal eandidiasis(VVC),trichomonal vaginitis(TV),and aerobic vaginitis(AV)were analyzed by vaginal secretion examination.
Result:BV was found in 61.63% of the women studied and was the commonestinfection diagnosed.BV mixed vaginal infections were diagnosed in 29.56%.VVC,TV,and AV infections were easily mixed with BV infection.Common symptoms inpatients with BV were foul smell,followed by leucorrhea increase,and generally notaccompanied by changes in leucorrhea character,genital itching and other symptoms.Vaginal pH value was usually more than 4.5.Vaginal cleanliness was mainlyⅠ°～Ⅱ°.symptoms and signs of BV mixed infections was atypical.Vaginal pH valuewas usuallymore than 4.5.Vaginal cleanliness was mainlyⅢ°～Ⅳ°.The resultssuggest that BV mixed infections were the most common vaginal infections,and weshould detect several common vaginal infections in the diagnosis of reproductive tractinfections.
SectionⅢ.Study on the correlation between Mycoplasma infection andbacterial vaginosis
Objective:Real-time PCR method quantitatively detect Uu and Mg DNA inpatients with BV and healthy controls,and at the same time quantitatively detect UuParvum biovar and Uu Urealyticum biovar.To determine whether Uu,Mg involved inthe pathogenesis of BV,and provide help to clinical diagnosis and treatment of BV.
Methods:44 patients were diagnosed as BV by Nugent method,and at the sametime 88 cases as healthy control group.To extract vaginal secretions bacterial genomeDNA,real-time PCR methods was used to detect Uu,Mg DNA of vaginal secretions.
Result:Uu was present in (65.9%) of 44 women with BV compared with (50.0%)of 88 women without BV(p=0.083);T960 was detected in (22.7%) of 44 women incomparison with (9.1%) of 88 women without BV(p=0.031).Mg was detected in 2(4.5%)of 44 with BV in comparison with 4(4.5%)of 88 women without BV(p=1.000).The study results suggest that T960 may be associated with the pathogenesis of BV.
Conclusions
1.Amsel,Nugent,BVBlue and BVSulan are diagnostic methods on BV.In additionto the Amsel and the Nugent,BVBlue and BVSulan are both Sensitive andSpecific on BV.
2.Bacterial vaginosis is the most common vaginal infections,and easily mixed withother pathogens,especially with VVC,AV or TV.In the diagnosis of BV,to payattention to whether BV was mixed with other vaginal infections;and in thediagnosis of other vaginal infections,to pay attention to whether other vaginalinfections was mixed with BV.
3.There was no correlation between Uu and BV,as well as Uu parvo biovar,but UuT960 biovar was associated with BV.People infected with Uu parvo biovar maybe normal carriers.Uu T960 biovar may lead to infection by itself or cooperatedwith other pathogeny.There was no correlation between Mg and BV.
引文
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