DISCUSSION

Few data is obtainable on the extent of STIs in Egypt²⁵. In developing world, STIs present major health, social, and economic burden².

This study reported 38.0% of patients had candidiasis. This is similar to El-Moselhy et al.^26,27 and Geremew et al.⁽¹⁰⁾ figures; 35.6%, 36.0%, 32.5%; respectively. Garg et al.²⁸ observed 19.0%.

In the current study, it was found that 21.0% of the patients had scabies. This finding is double that of El-Moselhy et al.²⁶ (10.0%) and greatly higher than Sarkar et al.²⁹ (1.8%); who studied genital scabies, while whole-body scabies was included in our study. Scabies is common among lowest socioeconomic population¹⁶, this is similar to our findings as the presence of risk-factors e.g. crowding, poor hygiene, and sexual muddle might increase its spread. Scabies is considered from patients’ respect as non-STI and is  presented in clinic with no stigma.

We showed 5.0% of our patients had PP. This figure is higher than El-Moselhy et al.^26,27, Sarkar et al.²⁹ figures’; 3.3%, 4.0%, 0.9%; respectively. PP is common among lowest socioeconomic populations; crowding, poor hygiene, and sexual muddle are dominated.

We claimed 14.0% of the patients had GW. Gewirtzman et al.⁶ cleared human papilloma virus (HPV) infection is the commonest STI worldwide. Our figure is comparable to Bosch et al.³⁰; globally HPV prevalence, in normal cytology females is ~10.0%. Kenyon et al.³¹ stated HPV is 7.0%-13.6% in North Africa and Middle East. El-Moselhy et al.²⁶ reported 13.0%. Dunne et al.³² reported 26.8% in USA.

We illustrated 7.0% of the patients had GCC. Geremew et al.¹⁴ and Pandey et al.³³ found prevalence 20.8%, 34.6% in Ethiopia and Nepal; respectively. Korenromp et al.³⁴ and El-Kettani et al.³⁵ found 0.37%, 3.8%; respectively. These figures differences may be clarified; the small figure was reported among general population. High figures may be referred to differences regarding the studied populations and diagnostic methods. In Egypt, Ali et al.³⁶ and El-Moselhy et al.^26,27 found N. gonorrhea was 26.0%, 3.3%, 6.0%; respectively. The high figure represents GC urethritis and GCC. NGCC [Gram-positive cocci (3.0%) and Gram-negative bacilli (4.0%)] was higher; 2.2%²⁶, 2.0%²⁸, and 2.0%²⁷, 4.0%²⁷ for each pathogen.

We showed CT infection was 5.0%. In Egypt, CT prevalence was 1.3%-52.0% among different categories of patients³⁷. Our figure is parallel to El-Kettani et al.³⁵ (3.8%) and Mosbah &Nabiel³⁸ (4.4%) figures’, higher than El-Moselhy et al.²⁷ (3.0%) and lower than Javanmard et al.³⁹ (11.4%).

Bacterial vaginosis (BV) was detected in 11.0% of the patients had BV. Our figure is higher than El-Moselhy et al.^26,27 (8.9% and 8.0%, respectively), double in the study of Pandey et al.³³ (5.8%), and one-fourth that of Garg et al.²⁸; 41.0%.

MC was 9.0% among our patients. This is higher than El-Moselhy et al.^26,27 and Sarkar et al.²⁹ figures; 4.4%, 6.0%, 3.7%; respectively.

Trichomoniasis was 14.0% among our patients. Our figure is higher than Garg et al.²⁸; 4.0% and similar to Geremew et al.¹⁴; 14.2%.

Eight-percent of the patients had genital herpes. Our figure is lower than that of Xu et al.⁴⁰ (13.2%), Kenyon et al.³¹ (15.4%), and Gottlieb et al.⁴¹ (52.0%) figures’. It close to other studies (6.7%, 7.0% and 8.4%, respectively)^(26,27,29).

We claimed 4.0% of our patients had HBV infection. HBV sexual transmission is significant route for women’s infection⁴². This figure is identical to our past figure; 4.0%²⁷.

We clarified 1.0% of our patients had acquired immune-deficiency syndrome (AIDS). Our figure is identical to Pandey’s et al.³³; 1.0% and higher than Kenyon et al.³¹ figures; (0.2%-0.4%).

The lowest educational level among our patients was a significant risk-factor. STIs are common among non-educated^25,26. This accordant with El-Moselhy et al.²⁶; (OR=1.9) and Gottlieb et al.⁴¹ (OR=1.8). House-wife was significant risk-factor. This concordant with El-Moselhy et al.²⁶. We cleared that no enough income was significant risk-factor; poverty might influence woman’s sexual risk¹⁶. Our result was parallel to Kelly et al.¹⁶ and Xu et al.⁴⁰; more HSV prevalence among under-poverty level population. Gottlieb et al.⁴¹ observed high HSV prevalence among minorities (OR=2.1). Conjointly, low social-position of our patients was significant risk-factor. This finding is concordant with Osman et al.²⁵ and Xu et al.⁴⁰. Gottlieb et al.⁴¹ didn’t found this association. Social characters in developing communities are associated with STIs propagation⁶. These could be explained by poor economy in developing communities directed governments to expense little on healthcare and prevention programs; healthcare becomes low affordable to the patients. Urban residence, significant risk-factor, might be attributed to residence of slums. This leads to rise of illegal sex and STIs prevailing⁴³. Shared- and un-stable residence represented significant risk-factors; had impact on sexual mix-up, families can’t spend conservative effect on individuals’ socio-cultural behaviors e.g. sexuality and affects female’s sexual risk¹⁶. We showed ex-married patients, divorced, and widow, were significant risk-factor. Our result concordant with Aral et al.⁴⁴ and Abdullah et al.⁴⁵; they reported high risk of unmarried females. We could suppose married patient had her own husband. While, divorced and widow might involve in accidental relations. Family disturbances; husband’s long travelling abroad and domestic violence were insignificant risk-factors; could be attributed to miss and/or hate of partner.

Age ≤14year at first menses and late age (≥28year) at marriage were a significant risk-factors for STIs acquisition. Globally, mean age at first menses has decreased⁴⁴. Moreover, >13years elapsed from menses to marriage was a significant risk-factor. These results could be explained; late marriage and much time elapsed till marriage might put females under stress. Socio-cultural changes have led to raise mean age at females’ marriage. This elevation might led to many free sexual relations; many of them are pre-marital causal-sex⁴⁴. In developing countries, like Egypt, with social and economic-position characterized by delay and economic inflation, over-population, slums, and retarded education and healthcare services fueling conditions leading to spread of STIs epidemic.

Contraceptive using was a significant risk-factor. This concordant with El-Moselhy et al.²⁶. Intrauterine device (IUD) raise risk of genital tract infection by STIs; IUD facilitates biological infection mechanically.

Pre-marital sexual practice was significant risk-factor. Overtime rise in pre-marital relations has been certified. Alterations in sexual behavior have situated females at excess risk for STIs with the worldwide trend to early age at first coitus⁴⁴. The increase in pre-marital sex was facilitated by the improvement of birth-control methods, advances in movement of the women's freedom, social situations and ideas enhanced delay marriage, women's entrance into the labor force, and elevated divorce rate. The major problem female’s pose is inability to safeguard herself against STIs⁴⁴. Sexual activity with symptomatic partner was a significant risk-factor. This could be explained by low socioeconomic-position and poor sexual behavior. Scabies and PP didn’t necessitate vaginal intercourse. There are some speculations about non-vaginal sexual activities; females might be used/accepted these practices as contraceptive methods. In Egypt, high risk sexual practices are un-agreeable²⁵. We reported 89.0%, 11.0% of our patients have practiced vaginal and non-vaginal sex, respectively. Aral et al.⁴⁴ cleared normal vaginal sexual practice is the commonest form; ~80.0%. El-Moselhy et al.²⁶ showed non-vaginal sex was more common among STIs patients; ~20.0% of women experienced oral and/or anal sex. Frequency of sexual activities ≥10time/month was significant risk-factor. This could be explained; 56.0% of our patients were currently married; more ability to make sex. El-Moselhy et al.²⁶ cleared ~24.0% of STIs women had vaginal intercourse ≥12times/month. Life-time sexual partners’ number ≥2 was significant risk-factor. This consisted with Osman et al.²⁵ and Xu et al.⁴⁰. Interchange sexual activities for benefits was a significant risk-factor. This accordant with El-Moselhy et al.²⁶ and Abdullah et al.⁴⁵; trade sex is prevalent in statuses recognized by poorness and social degradation, it represents great part in STIs epidemiology in most developing countries.

Religious non-commitment was significant risk-factor. This result concordant with El-Moselhy et al.²⁶ and Abdullah et al.⁴⁵. Commitment was significant protective-factor. In the Holy Quran, Allah strictly prohibited illegitimate relations and harlotry. Religious commitment has major role in sex avoidance till marriage. In Egypt, religion beliefs, cultural standards, and norms prohibit pre-marital and extra-marital sex. Smoking (cigarette/sheesha) and substance-use/alcohol-intake were significant risk-factor. These consistent with El-Moselhy et al.²⁶ and Abdullah et al.⁴⁵. Intravenous substance-use is un-agreeable high risk behavior; linked with increased STIs transmission²⁵. Substance-use/alcohol-intake is linked with risky sexual activities and behaviors; would raise risk of acquiring STIs^26,45. Sharing in criminal/socially unaccepted activities history was insignificant risk-factor. Offenders are at risk of acquiring STIs^26,46.

Partner (husband) not using preventive measures to guard against STIs was significant risk-factor. STIs are common among patients practicing unprotected sex^10,25,26,44. The commonest methods for STIs prevention were the separation between partners with clothes and sex avoidance. The use of other protective measures as condom is scarce. This could be clarified; in developing areas, condom use is low, in Egypt it’s uncommon method for prevention and contraception^10,25. There is males’ unfavorable behavior opposed condom use. The shame of buying condoms might be another barrier. This result was consistent with Abdullah et al.⁴⁵. Past-history of STIs among the patients was significant risk-factor. El-Moselhy et al.²⁶, Gottlieb et al.⁴¹, and Aral et al.⁴⁴ found that risk. Among husbands with past STIs infections, females might consider themselves immune or at minimum risk to catch STIs. In most developing countries STIs diagnosis and treatment for women are the greatest stigma^17,25,26; these force women to conceal and abstain from seeking health appraisal and advice²⁵. Divorced or widow females are more shame to seek healthcare for STIs. The shame about STIs might work as an obstacle to fast healthcare searching, related to case of confidentiality or searching to treat symptoms using self-care^17,25. Women might carry quietly STIs symptoms without searching for healthcare. Were et al.⁴⁷ confirmed value of detecting partners of STI patients; used to increase interventions and patients’ treatment. Patients not advising their partners to request counseling was considered as risk-factor. This could be explained; STIs stigma, self-care, privacy, or occasional relations^17,25,26. Early counseling and early diagnosis of husband with STIs could protect his wife. Non-professional healthcare personnel (partner, friends, relatives) counseling was significant risk-factor. Minimum access to effective healthcare may affects woman’s sexual risk¹⁶. This might be explained by stigma, fear, and confidentiality^17,25.

CONCLUSION

Candidiasis and scabies were the commonest STIs. STIs significant risk-factors were low socioeconomic-position, house-wife, urban residence, shared residence, late age at marriage, practice with symptomatic partner, use of contraceptives, pre-marital sexual activities, religiously non-committed, and patient and partner previous STIs. Define STIs risk-factors could help in their prevention and control.