INTRODUCTION

Sexually transmitted infections (STIs) are infections that are spread primarily through
person-to-person sexual contact.1 Reproductive tract infections (RTIs) is a broad term
that includes not only STIs but other infections of the reproductive tract also that are
not transmitted through sexual intercourse. In women, RTIs include infections of the
outer genitals, vagina, cervix, uterus, tubes, or ovaries.2 STIs/RTIs constitute a major
public health problem for both developing and developed countries. In general, STIs
are epidemics and present an enormous health and economic consequences.3 The
emergence of HIV infection has increased the importance of measures aimed at the
control of STIs.

Assessment of STIs/RTIs is of particular importance in women, as they tend to suffer

more in this regard. Women have poor access to information and education as a result
of lower priority given to their health and their lack of decision-making powers within
the family. Also, they usually have poor mobility, which inhibits access to
information and services. This is further accentuated among poverty-stricken
communities. Abstinence and condom use are usually not the options available to
women since social norms are, that women are not ‘supposed’ to be sexually
knowledgeable. This is compounded in respect of sex workers who are doubly
stigmatized and marginalised.4

The World Health Organization (WHO) definition of health states that “Health is a
state of complete physical, mental and social well being and not merely the absence of
disease or infirmity” clearly emphasizing on the importance of mental and social well
being of an individual.5 STIs/RTIs are known to have an adverse effect on the quality
of life because of their impact on physical, psychological and sexual health.6,7 Over
the past few decades there has been a decline in bacterial STIs and a rise in viral STIs
due to widespread use of antibiotics, use of barrier methods of contraception and
adoption of safer sexual behaviors due to risk perception of HIV (these prevent
bacterial STIs more efficiently than viral STIs).6 Viral STIs , because of their chronic
course , have a greater impact on the quality of life of patients.6 There have been
numerous studies supporting evidence of impaired quality of life in recurrent genital
herpes conducted in various countries.8.9 However data is scarce regarding quality of
life in other STIs/RTIs, especially in the Indian setting.6,7 Quality of life may be
particularly relevant in STIs/RTIs that are unlikely to cause large reductions in life
expectancy like genital herpes, anogenital Commented [mp1]: sentence incomplete

WHO (QUALITY OF LIFE) QOL – BREF Questionnaire is an instrument developed

by WHO for use across patient groups in different countries and cultures to analyze
the quality of life. It encompasses physical, psychological, social and environmental
domains.10 Understanding the psychological impact of STIs/RTIs will help
physicians to reduce the disabling consequences and prevent its transmission among
the population. Also, patient's emotional and sexual concerns can be addressed with Commented [mp2]: incomplete

Investigating sexual function is important in order to allow interventions to improve

the overall sexual function of the patient. Female Sexual Function Index (FSFI)
questionnaire is a brief questionnaire used to measure the sexual functioning in
women. It studies various domains of sexual functioning (desire, arousal, lubrication,
orgasm, satisfaction and pain).11 It has been used previously to assess the sexual
function in STIs/RTIs.12

It is an established fact that effective prevention and control of STIs/RTIs is the most
cost effective intervention to reverse the HIV epidemic progress.13 Here lies the role
of investigating sexual behavior, knowledge and awareness in the mass regarding
these infections, as only a well scrutinized scenario can help us formulate further
plans to tackle this situation effectively. Patterns of sexual behavior may or may not
be correlated with the STIs/RTIs and this information can be used to assess
interventions in order to improve the sexual health of the patients. High risk sexual
behavior is also associated with increased occurrence of STIs/RTIs. Analyzing the
prevalence of high risk sexual behavior will give us a greater insight about the patient
profile visiting our setup. Knowledge and awareness regarding Commented [mp3]: formatting

STIs/RTIs, especially amongst women has been consistently found to be low in the
developing countries as compared to developed countries due to many reasons such as
ours being a male dominated society, low education levels (especially amongst
women, stigmatization of these infections and lack of resources to provide
information at a community level.
Review of literature
studies have also provided some evidence that the psychological impact of an STI
diagnosis may be greater in women than in men.12The origin of these differences is
presently unclear but may be caused by factors such as concerns about sexual
infectivity and reproductive health. Further research would be required to explore
these issues more fully and to address the differential nature of perceptions of the
diagnosis in men and women. The recurrent nature of genital warts and the potential
for a single episode to persist for several months, or even years, means that even a
small difference in HRQoL caused by genital warts could have a considerable impact
on the loss of quality-adjusted life- years. 3
Commented [mp4]: should start with quality of life in
sti/rti in general, then using bref, followed by quality of
life in specific conditions.
Similar pattern to be followed for FSF, general, using FSFI
and then in specific conditions
lastly discuss studies about awareness, knowledge,
sexual behaviour, myths and others as included in
semistructured questionnaire
Commented [mp5]: Is it part of review?

Genital warts
Genital warts (GW) are caused by infection with certain types of human
papillomavirus virus (HPV) and are one of the most prevalent sexually transmitted
infections in the world 45 [1,2]. The disease affects mainly adolescents and young
adults, who are more sexually active and therefore susceptible to primary HPV
infection after the onset of sexual activity 4[1].

Although information on the prevalence of genital warts is scarce, it is estimated to be

approximately 1% among the sexually active populations in some high- income
countries. Data also suggest that the cumulative lifetime risk of GW can reach around
10%467 [1,3,4]. In addition, several epidemiological studies show that the prevalence
of genital warts seems to be increasing 7[4]. A greater distress in women with external
GW lesions is aligned with previous observations where the psychological im- pact of
a sexually transmitted disease diagnosis (regard- less of which one) seems to be
greater in women than in men 8

It has been estimated that at least 25% of cases recur within 3 months and episodes
can vary from weeks to occasionally years in duration. 9 Woodhall et al. in their study
on quality of life in patients with genital warts revealed that when patients were asked
whether genital warts affected their quality of life, almost half of the cases answered
‘‘significantly’’ or ‘‘very significantly’’.2 it is known about the experience of genital
warts, in that most of the associated morbidity is thought to be psychological.
1011121314The relationship between STI diagnosis and psychological impact may not be
straightforward, as previous studies of patients attending sexual health clinics have
shown high levels of psychological morbidity among those with and without an active
diagnosis. in addition, among persons with a history of ano- genital warts in
Vancouver, measurements of quality of life were significantly lower than age-
matched, population norms.15In a descriptive study of persons with HPV, most survey
respondents reported experiencing depression, isolation, or shame, as well as impacts
on sexual behavior. 16

Data indicate that patients with GW suffer anxiety, ex- perience shame and carry the
stigma of having a ven- ereal disease. All of these disease sequelae affect sexual and
love lives as well as health-related quality of life 41171819[15-18], though there are little
empirical data on how psychological distress related to GW impacts quality of life
2021[19,20].

Vaginal Discharge

Recurrent vulvovaginal candidosis (RVVC) is a debilitating chronic infectious

condition. It is defined as four or more acute inflammatory episodes of VulvoVaginal
Candidosis (VVC), also known as vaginal yeast infection, within a year 2223[1,2]. The
main symptoms of yeast infections are inflamma- tion, itching, an abnormal vaginal
discharge and painful sexual intercourse and urination. Such symptoms cause variable
but often severe discomfort and pain. Acute in- flammatory episodes usually are
treated with anti-fungal drugs of the azole class. They are efficient in clearing the
acute infection, but are unable to prevent recurrences, which occur on average after a
few months only. Guide- lines from a number of medical associations recommend a
long-term suppressive treatment regimen with an anti- fungal drug, usually
fluconazole, for at least 6 months, off label 2425[9,10], which can prevent recurrences
for the dur- ation of the therapy, whereas recurrence rates of 60-70% within 6 months
after treatment cessation were reported 2627[11,12]. A modified weaning scheme over
12–18 months achieved a lower recurrence rate (36%) within 6 months after complete
treatment cessation28 [13]. The cost of long- term treatment has been estimated at
AUD 900 ($ 862) in Australia29 [14]. Many RVVC patients turn to alternative
remedies like yoghurt and vinegar which only have very short-term palliative effects
3031[15,16].

Clinical impression is that RVVC patients, despite current treatment options, suffer
from a substantially im- paired health-related quality of life (HRQoL), but quantifi-
able evidence is scarce. Nyirjesy et al. applied several validated pain, stress and
depression measurements to a population of physician-diagnosed patients (N = 38)
and observed a proportion of 29% with a clinical depression32 [17]. Mendling et al.
reported SF-36 scores and further HRQoL-related information from a longitudinal
study on RVVC patients receiving different therapeutic treatments (N = 3x30),
indicating that mental health was more af- fected than physical health 33[18].

Abbalea et al. 34in their atudy reported that The proportion of women with problems
related to pain/discomfort of EQ-5D was 63% on average (from 55% in Germany to
78% in Italy) whereas the propor- tions in the general population did not exceed 35%
(from 23% in Spain to 35% in France). Anxiety/depres- sion was also significantly
affected, with 53% of women reporting some or severe problems on that dimension
(from 43% in UK to 62% in Italy), compared to below 20% in the general population.

All SF-36 domain scores, were significantly lower among women with RVVC than in
the general population. Results were homogeneous across countries with T-scores
varying from 34 to 37 for mental health scores and from 45 to 46 for the pain scores.
The most significantly affected domains were those related to mental health,
particularly the “emo- tional well-being” and “role limitation emotional” do- mains.

The health status of women with RVVC was not only lower than the general
population during an acute episode, but also outside infections. Large differences in
the propor- tions of subjects reporting problems were found for the anxiety/depression
dimension, between women with RVVC during infection-free periods (54%) and
women in general (≤20%). The difference was largest in Italy, where 60% reported
anxiety/depression problems outside episodes vs. 9.3% in the general population

Acute RVVC episodes impacted subjective health sta- tus negatively, but elicited
health status was also affected outside RVVC episodes notably due to a large impact
of the disease on anxiety or depression that lasts over time. Stress and a substantial
psychological burden that is as- sociated with the disease, up to depression, has been
de- scribed previously and confirms the findings of the present study 353637[17,37,38].

Sexual health

he World Health Organization (WHO) defines sexual health as the ‘‘state of

T
physical, mental and social well-being in relation to sexuality; it is not merely the
absence of disease, dysfunction or infirmity. It further states that ‘‘sexual health
requires a positive attitude and respectful approach to sexuality and sexual
relationships, as well as the possibility of having pleasurable and safe sexual
experiences, free of coercion, dis- crimination and violence. 3810

Although the Centers for Disease Control and Prevention (CDC) has recently made
improvements in sexual health a key priority, sparse data on the current state of sexual

health in United States exist. 3911 Landmark studies by Kinsey et al.4022 and Laumann

et al.4124 brought the lens of scientific rigor to the subject of sexual health. However,
there is still much to be done to advance the field and our understanding of the
population health basis of sexual health.

Sexually transmitted infections are associated with in- creased risk of poor birth and

reproductive health outcomes 42 43 44 45 46 47 48 12-18 as well as increased risk of HIV

transmission and acquisition. 49 50 51 19-21 However, a sexually transmitted disease

(STD) diagnosis may also have large impacts on sexual health and overall quality of
life. Given the fact that there an estimated 19 million new STD infections

annually,5222 the impact of an STD diagnosis on sexual health may represent a large
amount of avoidable morbidity. These issues have almost exclusively been examined

in the context of infection with human papillomavirus (HPV) 53 54 55 56 57 23-27 and

herpes simplex virus (HSV).58596028-30 Sexual health is often studied in the context of
reproductive and gynecologic conditions, and we are not aware of data on broader

examinations of sexual health. 6162636431-34 Stephens et al. in their study used the
WHO-QOL BREF and FSFI revealed almost 30% of respon- dents reported no sexual
activity in the previous 2 weeks. Women who reported no sexual activity during that
period also were more likely to agree with negative statements, such as feeling
insecure, isolated, angry, and limited by their health. Few differences were seen
between women with and without symp- toms and women with and without a
diagnosis of an STD with respect to sexual health measures.65 Approximately 28% of
women during the study period reported no sexual activity in the previous 2 weeks.35
Although these women were less likely to have symptoms, they were also more likely
to report that they often felt negative toward sexual health measures.For example,
women with no reported sexual activity were more likely to say they felt ashamed,
angry, iso- lated, and insecure. Because these data are cross sectional, it is unclear
whether the lack of sexual activity preceded the negative feelings or vice versa .35 The
continuing challenge in these efforts is that there are sparse data about overall sexual
health in populations. In studies of viral STD, persons infected with herpes reported
lower quality of life compared with a national sample, particularly among young
women24

it is important that programs view sexual health in broader terms than the absence of
disease. Creating tools such as indices or sexual health scores developed by
psychometricians that can be used to measure sexual health is a necessary first step
for programs to understand the sexual health of a community and to evaluate the
impact of campaigns and interventions that are implemented to im- prove sexual
health. 35

Jiehua Ma et al. also used the chinese version of FSFI to calculate the degree of
sexual dysfunction and found that women with non-malignant cervical diseases had a
significantly higher prevalence of female sexual dysfunction (FSD) (51.8% vs.
34.8%), low desire (43.2% vs. 26.3%), arousal disorder (41.6% vs. 28.3%), and
lubrication disorder (51.2% vs. 36.9%) compared with the control group. Cervicitis
was found to be inde- pendent risk factors for FSD. The prevalence of low desire
(42.8% vs 32.0% for cervicitis, p = 0.015) and FSD (49.7% vs 41.2% for cervi- citis,
p = 0.064) was much higher in women with cervicitis than in controls. Cervicitis
manifests with increased and purulent vaginal discharge accompanied by back pain
and abdominal discomfort. Thus, cervicitis might cause physical discomfort and
psychological stress, which would influence female sexual function.6636

Gungor et al. indicated that vaginal discharge impacts female sexual function.they
also found No significant relationship was observed between an abnormal vaginal
discharge and FSD prevalence; however, women with an abnormal discharge had
significantly better mean FSFI scores compared with women in the control group.
This might be due to the small sample size, to the relationship between frequent
sexual intercourse and vaginal infections, or to factors inherent to the FSFI
questionnaire6737

Sexual dysfunction is prevalent among females and is a serious health problem that
can affect the quality of life of the woman and her partner. Many studies have been
performed to develop tools for the diagnosis of female sexual dysfunction (FSD)
686938,39 and to identify risk factors for disease. One of the most commonly used and
validated instruments for evaluating FSD is the Female Sexual Function Index
(FSFI)—a self-reported and structured 19-item questionnaire [7040. Vaginal discharge,
usually a symptom of vaginitis, can make some females feel uncomfortable and may
be chronic or may recur after treatment. Bro 71 showed that 20% of women with a
complaint of vaginal discharge had normal findings on pelvic examination, whereas
14% of women without a complaint had an abnormal vaginal secretion on pelvic
examination. Rather than the etiology or a definitive diagnosis, perceptions of the
characteristics of the discharge such as odor, color, consistency, and duration might
make women concerned about their body image and decrease their self-esteem
Genital malodor can have many etiologic factors. Regardless of the cause, however, it
might seriously affect a woman’s self-esteem and relationships 72 Giraldo et al. 73
studied the FSFI scores of 58 women assigned to 3 groups: 11 in a recurrent
vulvovaginal candidiasis group; 18 in a localized provoked vulvodynia group; and 29
in a control group. They found that the 2 study groups had significantly lower FSFI
scores compared with the control group; and that the candidiasis group had lower
scores for all domains except for desire compared with the control group. They found
that Women with RVVC frequently have inflamma- tory processes of the vaginal
mucosa concomitant with the presence of vaginal discharge. These women are
virtually hypervigilant about their gynecologic condition, fearing bad genital odor,
vaginal discharge, and pain—a fact that may block sensory pathways, making it
difficult for these women to achieve orgasm and satisfaction in sexual intercourse.
Moreover Despite the fact that the FSFI questionnaire investigates women with
RVVC only during a period of 4 weeks and not neces- sarily have they had infection
in this period, it is well known that the severity and the high fre- quency of
inflammation of vaginal mucosa can lead women to a chronic state of soreness. SD
can

be triggered not only by acute infection but also by chronic inflammation , thereby
they concluded that Maybe the fear of women with RVVC of exposure to their
partners (bad odor, presence of discharge, and fear of more severe diseases) may
interfere with the domains of orgasm and satisfaction.

There has been a lot of discussion about the sexual life of women and its involvement
with gynecological disorders contributing to the development of sexual
dysfunction7475

Sexual dysfunction (SD) is present when one or more phases of the sexual response
cycle (desire, arousal, orgasm, and resolution) are abnormal or if there is persistent or
recurrent pain associated with intercourse 76 . According to the World Health
Organization (WHO), SD is an important public health problem that should be
routinely investi- gated, because it causes loss of quality of women’s and their
partners’ lives 77 Various disorders may trigger or simply be asso- ciated with SD.
Recurrent vulvovaginal candidiasis (RVVC) and localized provoked vulvodynia
(LPV) are two prevalent disorders in the realm of gyne- cology that may influence
female SD. Vulvar pain is a frequent complaint of patients with RVVC and LPV,
leading to dyspareunia 78 [5]. RVVC is an important trigger for inflammatory
processes that may result in vulvoperineal pain in many cases 79 [6]. The most
common causal agent is Candida albicans. It is estimated that at least 75% of women
of reproductive age may have one episode of Candidal vulvovaginitis during their
lifetime, and a subgroup of approximately 5% of these women will have recurrent
infection7980[6,7]. Usually, RVVC can cause vulvar edema, skin dryness, and lesions
motivating a persistent feeling of pain, fre- quently accompanied by pruritis, a
concomitant symptom 8081[7,8].
This pain is most often superficial giving an impression of burning and soreness
around the vaginal introitus and, sometimes due to repetitive fissures, can become
acute and excruciating 78[5].

The infectious and inflammatory process in the female genital tract may trigger
vulvoperineal pain and consequently dyspareunia 82[9]. Vulvar pain and pruritus plus
vaginal discharge may hypothetically cause, besides the organic problem, an
emotional discomfort, which may interfere with sexual func- tion. However, there is
no clear evidence in world literature that SD may result from RVVC 7478[1,5].

Nyirjesy et al. 78[5] showed just the association with no or low desire and dyspareunia
in women with RVVC, and did not analyze the others domains of sexual function.
Stewart et al. 74[1] gave emphasis on the psychological aspects in 83 women with
vaginitis and also noted frequent complaints about discom- fort during sexual
intercourse. RVVC is an important trigger for inflammatory processes that may result
in vulvoperineal pain in many cases79 [6]. The most common causal agent is Candida
albicans. It is estimated that at least 75% of women of reproductive age may have one
episode of Candidal vulvovaginitis during their lifetime, and a subgroup of
approximately 5% of these women will have recurrent infection 7980[6,7]. Usually,
RVVC can cause vulvar edema, skin dryness, and lesions motivating a persistent
feeling of pain, fre- quently accompanied by pruritis, a concomitant symptom8081
[7,8].

This pain is most often superficial giving an impression of burning and soreness
around the vaginal introitus and, sometimes due to repetitive fissures, can become
acute and excruciating78 [5].

The infectious and inflammatory process in the female genital tract may trigger
vulvoperineal pain and consequently dyspareunia 82[9]. Vulvar pain and pruritus plus
vaginal discharge may hypothetically cause, besides the organic problem, an
emotional discomfort, which may interfere with sexual func- tion. However, there is
no clear evidence in world literature that SD may result from RVVC7478 [1,5].
Nyirjesy et al.78 [5] showed just the association with no or low desire and dyspareunia
in women with RVVC, and did not analyze the others domains of sexual function.
Stewart et al. 74[1] gave emphasis on the psychological aspects in 83 women with
vaginitis and also noted frequent complaints about discom- fort during sexual
intercourse. A decrease in vaginal lubrication may result from pain and also worsen
pain, because the lack of lubrication already leads to discomfort during sexual
intercourse, generating hypervigilance against constant pain. This may increase
perineal hypertonia 83[14], compromising orgasm and satis- faction.

The constant presence of genital infection may be the cause or eventually the
consequence of potential difficulties with movement of the pelvic floor muscles. The
low capacity for contractility and perception of the pelvic floor musculature, due to
constant treatment and manipulation of the region, may interfere with the orgasmic
capacity of these women 84[30]. The fear of pain caused by constant irritation and
fissures would be enough to determine the SD identified in this study. Therefore
women are looking for a solution to the problem for a long time, which can lead to
embarrassment about the problem and lack of confidence in a health care solution.
This impacts negatively on well-being, sexual function, and relationship. It was also
in evidence in a study of early experience of dys- pareunia in young women 85[31].

Awareness

According to a study conducted by Piñeros et al. 86in Colombia half of the men and
women had heard about HPV before consultation. There were no significant differ-
ences in HPV awareness according to gender, age and number of life-time sexual
partners. On the contrary, awareness of HPV was higher among patients with higher
education, married persons and in those affiliated to the contributive regime. The
main source of information in both men and women was the media. Among those
who had heard about HPV, virtually all knew that HPV was a sexually transmitted
disease, al- though less than 50% of men and women knew that the infection can also
be passed through non-penetrant sex- ual intercourse and almost 60% responded
erroneously that HPV was also transmitted trough contact with infected objects. The
majority of patients knew that the use of condom would reduce the probability of
infection with HPV. They also found that Women with GW were more likely to
report a severe impact on sex life than men. Although almost all patients aware of
HPV knew that HPV was sexually transmitted, only half of them actually knew that
HPV infection can be transmitted through non-penetrating sexual intercourse. This
high- lights the importance of educating the population about HPV. In fact, education
level was the only factor posi- tively associated with HPV awareness in men and
women in our study. Higher levels of HPV knowledge among patients with higher
levels of education has also been reported elsewhere 878889[9,14,27].
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