Military’s women’s risk factors for and symptoms of genitourinary infections during deployment
Lowe, Nancy K
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.
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.
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
Normally, the urinary bladder is a sterile environment. The urethra in women is short, which increases the likelihood that perineal bacteria could ascend into the bladder.19 Normal flora of the gastrointestinal tract and perineum are the most common etiological agents of UTI, including Escherichia coli (80%), Staphylococcus saprophyticus (10%), Proteus mirabilis (5%), and Klehsiellapneumoniae (4%).77,19,20 Recently, some sexually transmitted infections, including TV, have been implicated as a cause of UTI.21
Four normal protective factors minimize the probability of a UTI: (1) the low pH from lactobacillus colonization in normal vaginal secretions inhibit growth of coliform bacteria from the rectal area; (2) a protective mucin coating and secretion of a fucosyltransferase enzyme inhibit adherence of bacteria to the urethra; (3) the low pH, high osmolarity and high urea content of urine makes it naturally bacteriocidal; and (4) the regularity, force, and flow of voiding expels bacteria from the urinary tract.20 Despite these protective mechanisms, 30% to 50% of all women will have a UTI during their lifetime.20,22
The three cardinal symptoms of UTI are dysuria, frequency, and urgency.20,22,23 Dysuria is reported as an internal discomfort during voiding as opposed to external discomfort associated with vaginitis. Although the terms dysuria, frequency, and urgency are meaningful to health care providers, women do not typically use those words to describe their symptoms. “It feels like peeing barbed wire” was a particularly graphic description by one Norwegian woman participant in a qualitative study.24 Hematuria is common but not diagnostic of UTI. Low back pain and low-grade fever are rare.20
Factors that inhibit the normal protective mechanisms increase the risk of UTI. The mechanics of sexual intercourse expose the urethra to perineal bacteria; frequent sexual intercourse and douching increase the likelihood of bacterial migration to the bladder.21 Nonoxynol-9 in spermacides selectively kill lactobacillus, but not E. coli, and the use of antibiotics, particularly [beta]-lactams, inhibit vaginal lactobacilli and allow overgrowth of bacteria.20 Other risk factors for UTI include constrictive undergarments and restrictive voiding patterns.21 Subsequent infections after the first one occur in 20% of women, but 90% of these are due to a different microorganism, thus these are recurrences, rather than relapses.21
Situational Deployment Factors that Increase Women’s Risk for Vaginitis and UTI
Four physical elements of the environment of military operations include geography, terrain, weather, and infrastructure.25 Extreme temperatures, exposure to harsh weather, and uneven terrain are the norm. Discomfort is compounded by heavy uniform and equipment requirements, lack of privacy, minimal hygiene facilities, and the stress of fear and uncertainty. The battle dress uniform is a tightly woven fabric that decreases airflow. The vulvar area is always moist and sweats more than any other area of the body, except for the axilla, therefore any situation that increases the warmth and moisture will alter the vaginal ecology.26 Even if women wear cotton underwear and avoid nylon or spandex, the lack of adequate laundry facilities is problematic. Yeast spores can be killed by washing underwear in water at 70[degrees]C,27 but water that hot is rarely available in a field environment. Field laundries may attain that water temperature, but women soldiers are often reluctant to send their undergarments to the field laundry.
Showers may not be provided in the field, necessitating travel to a shower facility. If there are field showers, privacy is minimal, and water conservation is usually in force; therefore, adequate and frequent cleansing of the genital area may be very difficult. An Army field manual states that “all personnel must bathe at least once a week and have a clean change of clothing.”28 This is hardly considered adequate by most women. The location, condition, and esthetics of field latrines increase the likelihood of cystitis. To avoid using the latrines, the field manual states that women soldiers tend to drink fewer fluids and hold urine longer. UTIs are among the most frequent health problems that military women experience under field conditions.29
Finally, the only health care provider in the field or other austere environments may be a medic or corpsman, often a man, whose primary training is in emergency medical treatment and resuscitation. Their training rarely includes primary care for women, and medical aid bags are not likely to include the medications that women need for vaginitis or UTIs. In fact, nearly one-fourth of 841 military women said that they would not seek care during deployment for gynecological symptoms citing their belief that the providers are inadequately trained for women’s primary care issues, embarrassment, and the conviction that the visit would not be kept confidential.5 Thus, military women face unique circumstances when deployed to austere environments that increase the likelihood of genitourinary infections.
Sample and Procedure
The target population was active duty and reserve women in the Army and Navy who had been deployed within the past 5 years. Deployment was defined as 2 or more weeks of sea duty, field duty, or temporary duty in a foreign country in support of a military operation. Units with more than 10 female members were randomly selected from a list of military units provided by the U.S. Defense Manpower Data Center. Unit commanders approved the distribution of surveys by unit staff members. Surveys were completed anonymously by women who chose to do so and were returned either to the unit staff member for bulk mailing or directly to the researchers in postage-paid envelopes. The project was approved by the University Institutional Review Board, appropriate agencies of the Army and Navy, and the Department of Defense Health Affairs.
Of the 4,254 surveys sent to 88 military units, 1,537 women responded (36.1 % response rate). More than one-half (N = 841, 54.7%) of these respondents had been deployed and provided data for this report. This sample consisted of women in the Army, Navy, and Air Force, a majority of whom were in the enlisted or non-commissioned officer ranks (Table II). The deployed women had a mean age of 28.3 years (range, 18-56 years). One-half of the sample was Caucasian, and one-third was African American. Three-fourths of the women had at least some college education, and one-half were married or living with a significant other.
The investigators generated the survey items from the literature on common genitourinary infections and austere military environments, and expert reviewers supported the content validity of the survey. A pilot test by 16 Army Reserve women resulted in minor revisions. The entire survey required approximately 15 minutes to complete and included general information about deployments, available health care providers, risk factors for genitourinary infections, symptoms of genitourinary infections, and demographic information. This report focuses on the women’s responses to items about risk factors for and symptoms of genitourinary infections during deployment.
The 841 women reported 1,405 deployments ranging from 1 to 8 months. During over one-half of the deployments (N = 738, 52.5%), women described their living conditions as a tent. Other living quarters during deployments included barracks (N = 260, 18.5%), ships (N = 221, 15.5%), and warehouses or other permanent or temporary structures (N = 186, 13.5%).
Vaginal infections during deployment were reported by 253 women (30.1%) and UTIs by 155 women (18.4%). A lifetime history of from 1 to 20 or more vaginal infections was reported by 652 (77.5%) women and from 1 to 20 or more bladder infections by 447 (53.2%) women. A Mann-Whitney U test showed that as the number of lifetime vaginal or UTIs increased, the incidence of vaginal or urinary infection during deployment also increased (z = -9.387, p
Risk Factors for Genitourinary Infection
Table III presents the percentage of the total sample of women who experienced each of 16 behavioral risk factors for genito-urinary infections during deployment. Percentages are also shown for those women who did and did not report a vaginal infection or a UTI during deployment. For the total sample, holding the urine, using tampons, taking birth control pills, and taking antibiotics were the four most frequently reported risk factors. In addition to these four behaviors, more than 40% of the women who experienced a vaginal infection or UTI during deployment also indicated that they had used douches, had sexual intercourse, and had worn noncotton underwear.
Chi-square comparisons showed that women who experienced vaginal infection or UTI were significantly more likely to take antibiotics, take cortisone or steroid medications, use spermicides, use tampons, use feminine hygiene sprays, douche, have sexual intercourse, have more than one sexual partner in 1 month, wear nylon/latex underwear, and hold urine to avoid using latrines than women who did not experience these infections (Table III).
To examine the combined effects of multiple risk factors on the occurrence of vaginal or UTI infection during deployment, a risk factor score was computed for each subject by counting the number of risk factors reported for a possible range of 0 to 16. The risk factor score range was 0 to 12 (mean = 4.2; SD = 2.26); 50% of the sample reported more than four risk factors, and 25% reported more than six. Student’s t test analysis showed that the risk factor score was significantly higher for women who reported either vaginal infection (t = 9.40; df = 776; p
As previously described, the deployment environment is often austere and primitive with respect to laundry, shower, and bathroom facilities. The number of women who experienced 11 common situations characteristic of austere deployment environments is shown in Table IV. Except for tight, constricting uniform pants, all of the characteristics were experienced by 42% to 84% of the women. Chi-square analyses showed that all 11 situational characteristics were more common among women who experienced vaginal infection during deployment than those who did not. When women who experienced UTI during deployment were compared with those who did not, only tight, constricting uniform pants and increased stress were significantly more commonly reported.
Eight of the 11 symptoms of vaginal infection were reported by 25% or more of the deployed women, and [Chi]^sup 2^ analyses showed that all 11 symptoms were significantly more common in women who experienced vaginal infection during deployment than in those who did not (Fig. 1). Among women who did experience vaginal infection, 7 of the 11 symptoms were reported by 50% or more of the women. Even among women who reported no vaginal infection during deployment, 34.4% experienced vaginal itching, 22.1% reported thin and watery vaginal discharge, 18% reported a bad odor of vaginal discharge, 17.2% reported vaginal discharge heavier than usual, and 15.5% reported perineal burning when urine touched the skin.
Of the five common symptoms of UTI, all were reported by 20% or more of the sample during deployment, [Chi]^sup 2^ analyses showed that all five symptoms occurred significantly more frequently (>55%) in women who experienced UTI than in women who did not (Fig. 2). However, even among women who did not report a UTI, three of the five symptoms were reported by more than 30%.
This is the first study to report military women’s experience of genitourinary infection risk factors and symptoms during deployment. A strength of the study is that the sample demographics were similar to the general population of military women in age, rank, race, education, and marital status.1-4 Although the survey was retrospective in nature, the high frequency with which women reported these risk factors and symptoms highlight the significance of genitourinary infection as a health concern for all women during deployment.
Consistent with previous research and the pathophysiology of vaginal infection in women, our findings showed that behavioral risk factors are associated with increased frequency of vaginal infection. Specifically, women who reported vaginal infection were more likely to also report risk factors associated with altered immune status (cortisone or steroids), altered vaginal flora (antibiotics, nylon/latex underwear), a more alkaline vaginal pH (douching, coitus, multiple sexual partners, spermacides, feminine hygiene sprays), foreign bodies in the vagina (tampons, douching), and potential damage to the vaginal mucosa (coitus).11-14,16 In addition, our findings provide strong evidence that characteristics of the deployment environment are also associated with occurrence of vaginal infection. Although the connection between factors such as inadequate laundry, shower, or hand-washing facilities, unsanitary latrines, or lack of privacy and vaginal infection is speculative, they represent an aberrant environment and lifestyle for most contemporary women that may increase physical and psychological stress. Survival of yeast spores on underwear laundered at temperatures less than 70[degrees]C may be responsible for some of the vaginal infections.27 The battle dress uniform is made of sturdy, heavy material, and pant legs are tucked into boots. These characteristics that are designed to protect the service member limit perineal airflow and foster changes in vaginal ecology. The fact that more than 25% of the women reported 8 of 11 symptoms commonly associated with vaginal infection and more than 20% reported all five symptoms associated with UTI supports an association between these environmental characteristics and genitourinary infection.
A situation that may be related to their impression that the latrines are unsanitary (70.7%) is our finding of the frequency with which women reported that they did not drink fluids to avoid going to the latrines (56.5%). Unlike their male counterparts who are able to void unobtrusively nearly anytime and anyplace, the mechanics of voiding for women require significant bodily exposure and therefore latrines must be used. Of great concern to commanders is that limited fluid intake not only predisposes women to the development of UTI but also to heat injury, dehydration, and risk of hypovolemic shock associated with trauma.
Predeployment briefings for women should include information about feminine hygiene in austere environments, behaviors that increase and decrease risk for genitourinary infection, and symptoms associated with these conditions. Women should also be informed about appropriate self-treatment options and signs of serious infection. The goal is to maximize women’s readiness and maintain optimal health during deployment.
The frequencies of UTI or vaginal infection during deployment found in this survey may have been based on either self-diagnosis or diagnosis by a health care provider. Since, as previously described, more than one-half of these same deployed women were not comfortable seeing the available health care provider, and a fourth said they would not go to sick call,5 it is reasonable to assume that a significant proportion of the reported genito-urinary infections during deployment were based on self-diagnosis. Because the risk factors and symptoms differentiated women who did and did not report infection, the women’s self-diagnoses of vaginal infection or UTI were probably correct. If they did not see a health care provider for treatment, the women either treated themselves with over-the-counter products brought with them or suffered in silence. However, appropriate self-treatment requires differentiation between the most common vaginal infections, BV/TV and candidiasis vaginitis, and the availability of suitable medications. Medications appropriate for BV/TV and UTI are not available over-the-counter and are not likely to be among the medications issued to medics. Our research supports both the need for and the feasibility of a sensitive and specific self-diagnosis/treatment kit and its distribution to military women upon deployment.5,30 The underlying principle should be to empower military women to manage their unique health needs in an environment traditionally designed for men.
We are grateful to the 1,537 military women who anonymously completed our survey. Their thoughtful responses to a large number of very personal questions provide the data needed to make important changes in military health care for women.
The TriService Nursing Research Program Grant 96-N0029 from the Department of Defense funded this project.
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Guarantor: Nancy K. Lowe, PhD CNM
Contributors: Nancy K. Lowe, PhD CNM*; LTC Nancy A. Ryan-Wenger, AN USAR[dagger]
*Oregon Health and Sciences University, School of Nursing, 3455 SW U.S. Veterans Hospital Road, Portland, OR 97239-2941.[dagger] Ohio Slate University, College of Nursing, 1585 Neil Avenue, Columbus, OH 43210-1289.
Previously presented at the 12th Biennial Phyllis J. Verhonick Nursing Research Course, Military Nursing Research, Meeting the Challenges of Readiness in Health Care, April 29 to May 3,2002, in San Antonio, TX, and at the Health Issues of Military and Veteran Women: A Research Symposium, June 6 and 7, 2002, in Washington, DC.
This manuscript was received for review in June 2002 and accepted for publication in October 2002.
Reprint & Copyright (C) by Association of Military Surgeons of U.S., 2003.
Copyright Association of Military Surgeons of the United States Jul 2003
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