Introduction
Schistosomiasis, also called Katayama fever or snail fever, is a parasitic disease caused by trematode worms (blood flukes). It is more prevalent in tropical and subtropical areas, especially economically poor communities and agricultural and fishing populations without adequate access to safe drinking water and proper sanitation. About five main species of blood flukes are known to cause two major forms of this disease, namely intestinal and urogenital schistosomiasis. Schistosomiasis transmission occurs when people infected with the disease contaminate freshwater sources with urine or feces containing the eggs of the parasite, which hatch in water. Chronic schistosomiasis can affect the ability to work or may even be life-threatening. The World Health Organization's (WHO) strategy for controlling schistosomiasis mainly focuses on reducing the disease through periodic and targeted large-scale treatment with Praziquantel in the affected and high-risk populations.
What Is Female Genital Schistosomiasis?
Female genital schistosomiasis (FGS) is a chronic gynecological disease caused by the waterborne parasite Schistosoma haematobium. It is a significant public health concern as it affects both the urinary and genital tracts of infected patients. FGS develops over a long period of time and is a consequence or manifestation of schistosomiasis when women or girls do not have proper access to treatment. Approximately 30 to 75 percent of girls and women suffering from urinary Schistosoma haematobium are estimated to develop FGS. It is one of the underreported and underdiagnosed conditions that can have serious implications on the reproductive health of women. The exact pathological manifestation of the parasite is unknown; however, it is understood that the adult worms migrate through the veins via blood-vessel anastomoses and reach the genital organs, where females produce eggs. It commonly affects the cervix, fallopian tubes, and uterus.
What Are the Symptoms of Female Genital Schistosomiasis?
Female genital schistosomiasis can be a recurrent infection and may occur throughout life following repeated exposures to infected water sources. After the parasite egg gets deposited in the female genital tissues, it causes chronic inflammation and triggers various symptoms such as:
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Nonspecific and persistent abdominal and pelvic pain.
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Vaginal itching.
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Increased vaginal discharge.
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Genital ulcers.
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Urinary incontinence (sudden and intense urge for urination).
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Contact bleeding or blood in the urine.
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Leucorrhea (thick, whitish-yellow or greenish vaginal discharge).
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Dyspareunia (pain during sexual intercourse).
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Abnormalities in the menstrual cycle.
What Are the Complications of Female Genital Schistosomiasis?
When left untreated, women suffering from female genital schistosomiasis can experience various complications such as:
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Premature birth.
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Low birth weight infants.
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Development of tumors.
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Swelling in the internal or external genital areas.
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Vaginal bleeding or spotting.
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Abortion or miscarriage.
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Ectopic pregnancy (fertilized egg attaches anywhere outside the uterus).
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Increased risk for human immunodeficiency virus (HIV) and human papillomavirus (HPV).
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Infertility (unable to conceive).
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It can result in inflammation, open sores, and bleeding, providing easy access for microorganisms to enter the body.
How Is Female Genital Schistosomiasis Diagnosed?
Diagnosis of FGS must be considered in females presenting with urogenital symptoms and living in countries endemic for schistosomiasis. Public health officials distribute a pocket atlas for reference and better knowledge of the condition for patients and healthcare workers. Female genital schistosomiasis can be diagnosed using different methods:
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Visual inspection is performed by a healthcare specialist using a good light source, a magnification lens, and by inserting a vaginal speculum. It can also be improved using a digital camera or a colposcope. The speculum is manipulated or rotated to visualize all the fornices and anterior and posterior vaginal walls. FGS exhibits characteristic lesions on the vaginal wall and cervix, rubbery yellowish papules, sandy patches, mucosal variations, contact bleeding, and abnormal blood vessels. However, current laboratory techniques are insufficient to confirm the diagnosis of FGS.
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FGS can also be diagnosed by detecting parasite eggs in urine samples or antigens or antibodies in the blood samples. Microscopy, polymerase chain reaction (PCR), and antibody tests may be performed, but these may not predict genital pathology. Serological and immunological examinations are useful for patients living in non-endemic or low-transmission areas. A biopsy can help confirm the diagnosis, but a Pap smear test may not be useful for diagnosing FGS.
How Is Female Genital Schistosomiasis Managed?
Female genital schistosomiasis is mainly treated by Praziquantel (PZQ), but variable multidisciplinary management, which includes invasive procedures, may be needed in many cases to avoid future complications. Praziquantel is the only medication available for schistosomiasis and is recommended at 40 mg/kg (milligram per kilogram). It is safe, effective, affordable, has minimal side effects, and has low resistance, making it suitable for use in most females and children. It is pivotal in preventing complications and minimizing lesions. According to the WHO, a single course of Praziquantel is the gold standard treatment for hepato-intestinal and urogenital schistosomiasis, especially for people living in endemic areas. Treatment is considered highly effective if started early in life and continued periodically throughout life. Reinfection may occur in some cases, but the severity will be lower, and the condition can be efficiently managed.
Mass drug administration (MDA) for preventive chemotherapy using Praziquantel has been practiced since 2001. Recently updated guidelines provide eligibility for individuals over two years and support more frequent therapies, including biannual MDA. To avoid complications, in various countries in sub-Saharan Africa, regular treatment with Praziquantel is followed outside school-based deworming programs. Education and creating awareness among people, including community healthcare workers and health practitioners, about schistosomiasis are essential, as females, particularly in endemic countries, are vulnerable to HIV.
Female genital schistosomiasis can be prevented by:
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Improving access to safe water resources.
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Conducting sanitation and hygiene programs and educating people.
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Creating awareness about sexual and reproductive health.
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Avoiding swimming, bathing, or drinking unsafe water.
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Training healthcare workers to improve the diagnosis and management of FGS.
Conclusion
Schistosomiasis is a parasitic infection caused by the genus Schistosoma. According to the WHO, schistosomiasis affects approximately 240 million people worldwide, with about 90 percent living in sub-Saharan Africa (SSA). Female genital schistosomiasis is a chronic manifestation of urogenital schistosomiasis that occurs when parasite eggs get deposited in the female genital tract. It exposes women to various complications such as infertility, sexually transmitted diseases, and poor reproductive or sexual health. It can often be misdiagnosed as a sexually transmitted infection (STI) in primary healthcare clinics as awareness and information on FGS is grossly insufficient. Recently, several control and preventive measures have been proposed by healthcare organizations. However, enhanced education, information dissemination, and a better understanding of the condition are necessary to prevent this condition successfully.
