A thesis completed by published work, Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, South Africa December 2016. / Introduction With the largest epidemic in the world, the consequences of human immunodeficiency virus (HIV) in South Africa extend far beyond its disease burden. In fact, patterns of HIV-related infection and mortality in South Africa still reflect social cleavages and inequalities. Similarly, poverty-related issues such as poor education, unemployment and subsequent low socio-economic status, rural residence and inadequate access to health care are all implicated in human papillomavirus (HPV) associated cervical cancer-related mortality (of which South Africa also has the highest globally). Despite the knowledge of reproductive functions and sexuality being poor among adolescents in South Africa, the majority commence their sexual activity early with an estimated national average of 15 years for girls and 14 years for boys. Further, many South African adolescents engage in sexual risk-taking behaviours including concurrent partners and unprotected sexual acts that considerably increase their vulnerability to sexually transmitted infections including HIV and HPV. In recognising the unique health needs of adolescents in South Africa, the national government has already pin-pointed school health services as a strategic arm of primary health care re-engineering. The aim of this body of work is to elaborate on restructuring of adolescent health care by introducing the HIV and HPV vaccine concomitantly in South Africa via a school-based sexual and reproductive health service. Methodology Data from four studies were analysed and are presented in three published and two unpublished papers. The first study evaluated the synergism between HIV and HPV in the South African context and formed the basis of the literature review. The second study considered HIV vaccine implementation alone. The third study assessed dual HIV and HPV vaccine strategies among females and the final study compared the dual vaccination strategy against recognised biomedical HIV prevention interventions. The studies evaluated the implementation of a hypothetical HIV vaccine and the bivalent HPV vaccine both individually and in combination when administered to school-going adolescents in South Africa. The health outcomes and the cost-effectiveness of these strategies were assessed. Assumptions were made regarding the hypothetical HIV vaccine (based on HIV vaccine studies conducted to date) including a coverage rate of 60% (uncertainty range: 30-70%), vaccine efficacy of 50% (uncertainty range: 30-70%) and vaccine price per dose of US$ 12 (uncertainty range: US$ 3-24). The uncertainty ranges were tested in the sensitivity analysis. Mortality statistics, disease transition parameters (for the individual diseases and the models representing joint disease) and HPV vaccine characteristics were drawn from the South African literature. The joint effectiveness of the dual vaccine strategy was considered multiplicative. Nine year old adolescents attending South African schools in 2012 were eligible for the intervention (vaccination) that was introduced opportunistically as part of the national health initiative introducing school-based sexual and reproductive health services. The learners were targeted prior to their reported sexual debut. The HIV vaccine was considered against the comparator of HIV counselling and testing (HCT) and the national roll-out of antiretroviral therapy (ART) that constituted the standard of care in South Africa. The HPV vaccine was modelled as prevention against HPV-related cervical cancer and pre-cancerous HPV-related cervical states. The health service provider (provider) perspective was adopted and the cohort was modelled through a lifetime horizon of 70 years with annual cycles. The economic costs and health outcomes were discounted at 3% with an uncertainty range between 0% and 6% assessed. Cost valuations were for 2012 and costs were adjusted to this common year. The quality-adjusted life year (QALY) was used as the outcome measure of health related quality of life and was used to calculate the incremental cost-effectiveness ratio (ICER) of the comparator against the vaccination interventions. The core model was a semi-Markov simulation with annual cycles. The study population entered the model HIV and HPV disease free and were exposed to the risk of acquiring each disease annually. The model structure was parameterised drawing from South African data available in the literature. One-way sensitivity analyses evaluated the impact of single assumptions on cost and outcomes. Probabilistic sensitivity analysis (PSA) with a bootstrapping technique explored the uncertainty in the model and evaluated the robustness of the results. The PSA data generated determined if the intervention fell below the willingness-to-pay (WTP) threshold. As South Africa does not have a pre-defined WTP threshold, the Gross Domestic Product (GDP) per capita (for 2012) was used as a proxy in accordance with the World Health Organization’s Guide to Cost-Effective Analysis. Additionally, benchmark interventions were used in the final comparison study as a measure of cost-effectiveness. Ethical approval for the study was obtained from the Human Research Ethics Committee (Medical) of the University of the Witwatersrand. Findings The second study explored the implementation of the HIV vaccine on an individual and national, programmatic level. The simultaneous implementation of HIV vaccination services with current HIV management programmes would be cost-effective, even at relatively higher vaccine cost. At base vaccine cost of US$ 12, the ICER was US$ 43 per QALY gained, with improved ICER values yielded at lower vaccine costs. The ICER was sensitive to the duration of vaccine-mediated protection and to variations in the vaccine efficacy. Data from this work demonstrate that vaccines offering longer duration of protection and at lower cost would result in improved ICER values. Assessing this HIV vaccine model on a national programmatic level, yielded an ICER of US$ 5 per life-year gained (LYG) (95% CI US$ 3-12) compared with the comparator. This fell considerably below the national WTP threshold of cost-effectiveness. This also translated to an 11% increase in per capita costs from US$ 80 to US$ 89. National implementation of this intervention could potentially result in an estimated cumulative gain of 24 million years of life (95% CI 8–34 million years) among those adolescents aged between 10-19 years that were vaccinated. The 10 year absolute risk reduction projected by HIV vaccine implementation was 0.42% for HIV incidence and 0.41% for HIV mortality. The ICER was sensitive to the HIV vaccine efficacy, coverage and vaccine pricing in the sensitivity analysis. The third study assessed the impact of dual HIV and HPV implementation strategies. Programmes that involved the dual vaccine strategy were assessed as cost-saving. ICER values were sensitive to the HIV vaccine cost. The dual vaccine strategy resulted in 10 year absolute risk reductions in HIV incidence (5.24%), dual mortality (1.21%) and a reduction in HPV incidence (0.39%) compared with no vaccination. Importantly, the reduction in HIV incidence rate and dual mortality rate in the dual vaccine strategy exceeded the reductions noted with the use of the HIV vaccine alone. All scenarios assessed with the dual vaccine strategy were cost-effective. Lower vaccine prices and reduced discount rates were associated with improved ICER outcomes. The final study compared the biomedical interventions of oral pre-exposure prophylaxis (PrEP), voluntary medical male circumcision (VMMC) and the scaling-up of ART coverage against the vaccine strategies. When compared with other biomedical HIV prevention interventions, the dual vaccination intervention was the most cost-effective strategy (US$ 7 per QALY gained) and averted 29% of new HIV infections. VMMC (US$ 30 per QALY gained) proved more cost-effective than HIV vaccination alone (US$ 93 per QALY gained), though VMMC averted 6% more new infections than the HIV vaccine. PrEP interventions were the least cost-effective. Combined dual vaccination and VMMC strategies represent the only dominant intervention. Strategies involving oral PrEP were the least cost-effective. Conclusion The findings of this thesis have implications for school-based adolescent health care and HIV- and HPV-related disease prevention among adolescents, a highly susceptible population. The cost-effectiveness of the dual HIV and HPV vaccine strategy was demonstrated, and the improved health outcomes associated with the interventions quantified. Proposals were suggested regarding possible combinations of HIV prevention interventions that could yield the favourable health outcomes with the most efficient use of financial resources. Several important areas for future research were identified to shed light on improving adolescent health care and for optimising HIV prevention strategies. These include integrating HIV and HPV services as part of the re-engineering of primary health care in South Africa, and then formulating economic evaluations of HIV/HPV prevention strategies targeting adolescents specifically. Further, more effective methods of collecting data on socially marginalised populations such as young people need to be explored. Another vital research area is the discussion and implementation of existing school health documents with the ideals embodied in the school health programme envisaged under the National Health Insurance restructuring. Once these are integrated, the cost implication of the combined programmes need to be assessed. / MT2017

子宮切除術是最常進行的婦科手術之一，據統計，美國每年平均錄得約600,000宗進行子宮切除術的病例。全腹腔鏡子宮切除術為子宮切除術的一種，在手術中，病人的子宮將經由完全使用腹腔鏡的模式被摘除。 / 在普遍全腹腔鏡子宮切除術的流程中，名為舉宮器的手術儀器會被應用於手術中，以改變病人子宮的位置及方向。手術室內，除了負責為病人摘除子宮的醫生外，還需額外一名負責操作舉宮器的醫生在場，以促進手術的進行。於手術的過程中，為使摘除手術能更有效及順利地進行，這名醫生需以人手操作舉宮器以控制病人體內子宮的方位。一般而言，這項工作都是枯燥而疲憊的。然而，在負責進行摘除手術的醫生眼中，縱子宮的方位已被調整，其方位仍然未如理想的情況亦不屬罕見。 / 故此，一個能勝任代替醫生負責操作舉宮器的機械人助手將會是可行的解決方案之一。與此同時，機械人亦能將病人子宮方位的控制權交回負責進行摘除手術的醫生手中。 / 本論文提出一套以把醫生從操作舉宮器的工作中釋放為目標，並使子宮方位操作變得更準確及穩定的機械人系統。機械人系統由兩個部分構成，分別為一支一個自由度的電動舉宮器以及一台三個自由度的舉宮器方位操作機械人。 / 舉宮器方位操作機械人旨在模仿以往醫生操作舉宮器的動作，以負責把固定在它身上的舉宮器移動到及固定在指定的位置。舉宮器方位操作機械人共有三個關節，分別為旋轉關節、滑動關節以及線性關節。關節的佈置滿足特定的幾何約束以構成遠程運動中心，使機械人能把手術儀器從細小的開口（例如：子宮頸）中進行操作。本論文提出的舉宮器方位操作機械人備有配適器以兼容不同款式的舉宮器，例如市場上現存的舉宮器以及本論文提出的電動舉宮器，均可應用在本系統中。 / 本論文提出的電動舉宮器為系統中可選擇性的元件，它是個一自由度附帶可轉動末端的裝置，旨在延伸機械人系統末端執行器的可到達範圍。 / 本論文將論述這套機械人系統的設計，包括其機械設計與電子系統的部分、運動學與及工作空間。一台實驗用的樣機已被建造以作驗證設計之用。該樣機以醫學人體模型為對象的實驗結果亦會在本論文中提出。 / Hysterectomy is one of the most frequently performed gynecologic procedures. In average, around 600,000 cases are recorded annually in the United States. Total laparoscopic hysterectomy (TLH) is one of the approaches of performing hysterectomy in which uterus of a patient is removed from an entirely laparoscopic approach. / In ordinary TLH procedures, a surgical apparatus, uterus manipulator, used for changing the position and orientation of the patient’s uterus is involved. In the operating theatre, apart from the primary surgeon who is responsible for the removal of uterus, an assisting surgeon is also involved for operating the uterus manipulator. Throughout the surgery, she/he has to manipulate the patient’s uterus using the uterus manipulator manually to facilitate the removal procedure. This task is generally tiring and boring. In addition, it is also common that the manipulated position is not satisfactory from the primary surgeon’s point of view. / Thus, a robotic assistant which is capable of taking up the task of this assisting surgeon as well as allowing the primary surgeon to have full control on the position of the patient’s uterus may be one of the potential solutions. / In this thesis, a robotic system aiming at providing more precise and stable manipulating motion and freeing the assisting surgeon who is responsible for operating the uterus manipulator is presented. The presented robotic system is composed of two parts, a motorized uterus manipulator of one degree of freedom and a robotic uterus manipulator positioner of three degrees of freedom. / Objective of the uterus manipulator positioner presented is to imitate what is doing by the assisting surgeon when operating the uterus manipulator. It holds and manipulates the uterus manipulator attached to it. The uterus manipulator positioner is a robotic system consisted of three joints, a revolute joint, a sliding joint and a translational joint. Arrangement of the joints is forced to satisfy specific geometric constraints so that a remote center of motion (RCM) is created to allow manipulation through small openings such as the cervix. Adaptors are included to enable the use of different uterus manipulators. Existing uterus manipulators and the motorized uterus manipulator presented in this thesis can be adapted to the system. / The motorized uterus manipulator presented in this thesis is an optional element of the robotic system. It is a device of one degree of freedom with a movable tip aiming at enhancing the reaching capability of the end-effector of the robotic system. / In this thesis, design of the robotic system in both mechanical and electronic aspects is presented. Kinematics and workspace of the system is also discussed. To verify the design, a prototype is built. Finally, verification experiments with the prototype on manikin are provided. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Yip, Hiu Man. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 96-98). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts also in Chinese. / Abstract --- p.i / 摘要 --- p.iv / Acknowledgement --- p.vi / Table of Contents --- p.viii / List of Figures --- p.x / Chapter Chapter 1. --- Introduction --- p.1 / Chapter 1.1. --- Total Laparoscopic Hysterectomy --- p.1 / Chapter 1.2. --- Existing Uterus Manipulators --- p.4 / Chapter 1.3. --- Existing Uterus Manipulator Positioners --- p.6 / Chapter 1.4. --- Existing Medical Robots --- p.9 / Chapter 1.5. --- Existing RCM Mechanisms --- p.11 / Chapter 1.6. --- Motivation and Contribution --- p.12 / Chapter Chapter 2. --- Conceptual Design --- p.15 / Chapter 2.1. --- Design Requirements --- p.15 / Chapter 2.2. --- Conceptual Design of Prototype --- p.16 / Chapter Chapter 3. --- Design of Prototype --- p.23 / Chapter 3.1. --- Mechanical Design of the Robotic System --- p.25 / Chapter 3.1.1. --- Design of the Robotic Uterus Manipulator Positioner --- p.25 / Chapter 3.1.2. --- Adaptor --- p.35 / Chapter 3.1.3. --- Design of the Motorized Uterus Manipulator --- p.36 / Chapter 3.2. --- Kinematics of the Robotic System --- p.38 / Chapter 3.2.1. --- Coordinates of Points on a Sphere --- p.39 / Chapter 3.2.2. --- The 2-DOF Uterus Manipulator Positioner --- p.40 / Chapter 3.2.3. --- The 3-DOF Uterus Manipulator Positioner --- p.42 / Chapter 3.2.4. --- The 4-DOF robotic system --- p.45 / Chapter 3.2.5. --- Velocity --- p.50 / Chapter Chapter 4. --- Design of Control System --- p.52 / Chapter 4.1. --- Robot Controlling Unit --- p.52 / Chapter 4.1.1. --- Size Reduced Controlling Unit --- p.53 / Chapter 4.2. --- User Interface --- p.62 / Chapter 4.2.1. --- Foot-Controlled Interface --- p.63 / Chapter 4.2.2. --- Hand-Controlled Panel --- p.68 / Chapter Chapter 5. --- Prototype and Experiments --- p.70 / Chapter 5.1. --- Developed Prototype --- p.70 / Chapter 5.2. --- Experiments --- p.72 / Chapter 5.2.1. --- Robot Controller --- p.73 / Chapter 5.2.2. --- Control Algorithm --- p.77 / Chapter 5.2.3. --- Experiment on the Prototype --- p.79 / Chapter 5.2.4. --- Experiment with Manikin --- p.87 / Chapter Chapter 6. --- Conclusion and Future Work --- p.90 / Chapter 6.1. --- Conclusion --- p.90 / Chapter 6.2. --- Robot Positioning Platform --- p.92 / Chapter 6.3. --- Reinforcement of the Robotic System --- p.94 / Chapter 6.4. --- Extension of User Interfaces --- p.95 / List of References --- p.96

Além da deficiência física, a diminuição ou perda da sensibilidade geniturinária é um dos maiores impactos para mulheres com Lesão Medular (LM). Devido à perda da mobilidade funcional e as barreiras arquitetônicas, estas muitas vezes não tem acesso aos cuidados adequados para a saúde ginecológica. Como aproximadamente 80% das lesões da medula espinal acometem indivíduos do sexo masculino, os estudos raramente focam as necessidades e questões referentes às mulheres. Objetivo: Avaliar a prevalência de infecções genitais não virais em mulheres com deficiência física por lesão medular, comparativamente às mulheres saudáveis Método: Estudo de corte transversal, caso controle. Foram estudadas 52 mulheres com LM (grupo estudo) e 57 mulheres saudáveis (grupo controle). Todas responderam a um questionário estruturado e foram submetidas à coleta de conteúdo vaginal para pesquisa de Trichomonas vaginalis e leveduras, bacterioscopia com coloração pelo método Gram, cultura geral (meio ágar sangue), cultura para fungos (meio Sabouraud) e coleta de conteúdo endocervical para pesquisa de Chlamydia trachomatis e Neisseria gonorrhorae (reação em cadeia da polimerase) e cultura para Mycoplasmas sp (meios U9, A7). Resultados: As mulheres com lesão medular, comparativamente ao grupo controle, apresentaram maior frequência de Candida sp no exame micológico direto (p= 0,017); entretanto não foi observada diferença estatisticamente significativa na frequência de isolamento de espécies fúngicas entre os grupos. O grupo estudo apresentou maior frequência de isolamento de Escherichia coli (p= 0,002) e de Corynebacterium sp (p= 0,023) e menor frequência de Lactobacillus sp (p < 0,001) em conteúdo vaginal. Em ambos os grupos não foram encontrados casos positivos para Trichomonas vaginalis. A avaliação do escore de Nugent para diagnóstico de vaginose bacteriana demonstrou maior freqüência de flora intermediária (Nugent 4-7) no grupo estudo (p= 0,039). As pesquisas de Chlamydia trachomatis e Neisseria gonorroheae foram negativas em todas as mulheres. Com relação ao isolamento de Mycoplasmas sp, os resultados foram semelhantes em ambos os grupos. Conclusão: A menor freqüência de isolamento de Lactobacillus sp e a maior freqüência de isolamento de Corynebacterium sp e de Escherichia coli na vagina em mulheres com LM, assim como a elevada frequência de flora intermediária pelo escore de Nugent verificada nas mesmas, fortemente sugerem um desequilíbrio da microbiota vaginal, diferente de uma flora dominada por Lactobacillus sp em tais mulheres. Desde que os Lactobacillus sp são essenciais para a manutenção da flora vaginal e a inibição do crescimento de outras bactérias, sua ausência relativa em mulheres com LM pode influenciar a ocorrência de infecções do trato urogenital. Adicionalmente, a mais elevada frequência de detecção de fungos pela microscopia em mulheres com LM sugere que estas podem albergar uma maior concentração vaginal desses microorganismos do que outras mulheres / Besides their physical disability, decreased or absent genitourinary sensitivity has a huge impact in women with spinal cord injury (SCI). Due to the absence of functional mobility and the architectonic barriers these women frequently do not have access to adequate gynecological care. Since about 80% of spinal cord injuries affect men, studies have rarely focused on the needs of women with SCI. Objective: To evaluate the prevalence of non-viral genital infections in women with SCI compared to mobile women. Methods: Fifty two women with SCI (study group) and 57 mobile women (control group) were evaluated in a case-control study. All answered a structured questionnaire and were submitted to the following microbiological tests: fresh examination of vaginal secretions for Trichomonas vaginalis and yeasts, Gram stain, general culture (agar-blood medium), yeast culture (Sabouraud medium) and endocervical sampling for Chlamydia trachomatis and Neisseria gonorrhorae (polymerase chain reaction) and Mycoplasmas sp. (U9, A7 medium). Results: A higher percentage of women with SCI had Candida sp detected by direct mycological examination than did women in the control group (p= 0.017). However there were no significant differences between the two groups in the frequency of yeast-positive cultures. The study group had a higher isolation frequency from the vagina of Escherichia coli (p= 0.002) and Corynebacterium sp (p= 0.023) and a lower frequency of Lactobacillus sp (p < 0.001). In both groups, there were no cases positive for T. vaginalis, C. trachomatis or N. gonorrhoeae. The evaluation of Nugent score for bacterial vaginosis showed a higher frequency of intermediate flora (Nugent score 4-7) in the study group (p= 0.039). Related to Mycoplasma sp isolation, the results were similar in both groups. Conclusion: The lower frequency of Lactobacillus sp isolation and the higher frequency of Corynebacterium sp and Escherichia coli isolation from the vagina in women with SCI, and the higher frequence of intermediate Nugent score, strongly suggests a disequilibrium of the vaginal microbiota away from a Lactobacillus sp dominated flora in these women. Since lactobacilli are essential for maintaining vaginal health and inhibiting growth of other bacteria, their relative absence in women with SCI may influence the occurrence of urogenital tract infections in these women. The higher frequency of yeast detection by microscopy in women with SCI suggests that these women may harbor a higher vaginal yeast concentration than do other women

Diss. (sammanfattning) Linköping : Univ., 2004. / Härtill 5 uppsatser.

Além da deficiência física, a diminuição ou perda da sensibilidade geniturinária é um dos maiores impactos para mulheres com Lesão Medular (LM). Devido à perda da mobilidade funcional e as barreiras arquitetônicas, estas muitas vezes não tem acesso aos cuidados adequados para a saúde ginecológica. Como aproximadamente 80% das lesões da medula espinal acometem indivíduos do sexo masculino, os estudos raramente focam as necessidades e questões referentes às mulheres. Objetivo: Avaliar a prevalência de infecções genitais não virais em mulheres com deficiência física por lesão medular, comparativamente às mulheres saudáveis Método: Estudo de corte transversal, caso controle. Foram estudadas 52 mulheres com LM (grupo estudo) e 57 mulheres saudáveis (grupo controle). Todas responderam a um questionário estruturado e foram submetidas à coleta de conteúdo vaginal para pesquisa de Trichomonas vaginalis e leveduras, bacterioscopia com coloração pelo método Gram, cultura geral (meio ágar sangue), cultura para fungos (meio Sabouraud) e coleta de conteúdo endocervical para pesquisa de Chlamydia trachomatis e Neisseria gonorrhorae (reação em cadeia da polimerase) e cultura para Mycoplasmas sp (meios U9, A7). Resultados: As mulheres com lesão medular, comparativamente ao grupo controle, apresentaram maior frequência de Candida sp no exame micológico direto (p= 0,017); entretanto não foi observada diferença estatisticamente significativa na frequência de isolamento de espécies fúngicas entre os grupos. O grupo estudo apresentou maior frequência de isolamento de Escherichia coli (p= 0,002) e de Corynebacterium sp (p= 0,023) e menor frequência de Lactobacillus sp (p < 0,001) em conteúdo vaginal. Em ambos os grupos não foram encontrados casos positivos para Trichomonas vaginalis. A avaliação do escore de Nugent para diagnóstico de vaginose bacteriana demonstrou maior freqüência de flora intermediária (Nugent 4-7) no grupo estudo (p= 0,039). As pesquisas de Chlamydia trachomatis e Neisseria gonorroheae foram negativas em todas as mulheres. Com relação ao isolamento de Mycoplasmas sp, os resultados foram semelhantes em ambos os grupos. Conclusão: A menor freqüência de isolamento de Lactobacillus sp e a maior freqüência de isolamento de Corynebacterium sp e de Escherichia coli na vagina em mulheres com LM, assim como a elevada frequência de flora intermediária pelo escore de Nugent verificada nas mesmas, fortemente sugerem um desequilíbrio da microbiota vaginal, diferente de uma flora dominada por Lactobacillus sp em tais mulheres. Desde que os Lactobacillus sp são essenciais para a manutenção da flora vaginal e a inibição do crescimento de outras bactérias, sua ausência relativa em mulheres com LM pode influenciar a ocorrência de infecções do trato urogenital. Adicionalmente, a mais elevada frequência de detecção de fungos pela microscopia em mulheres com LM sugere que estas podem albergar uma maior concentração vaginal desses microorganismos do que outras mulheres / Besides their physical disability, decreased or absent genitourinary sensitivity has a huge impact in women with spinal cord injury (SCI). Due to the absence of functional mobility and the architectonic barriers these women frequently do not have access to adequate gynecological care. Since about 80% of spinal cord injuries affect men, studies have rarely focused on the needs of women with SCI. Objective: To evaluate the prevalence of non-viral genital infections in women with SCI compared to mobile women. Methods: Fifty two women with SCI (study group) and 57 mobile women (control group) were evaluated in a case-control study. All answered a structured questionnaire and were submitted to the following microbiological tests: fresh examination of vaginal secretions for Trichomonas vaginalis and yeasts, Gram stain, general culture (agar-blood medium), yeast culture (Sabouraud medium) and endocervical sampling for Chlamydia trachomatis and Neisseria gonorrhorae (polymerase chain reaction) and Mycoplasmas sp. (U9, A7 medium). Results: A higher percentage of women with SCI had Candida sp detected by direct mycological examination than did women in the control group (p= 0.017). However there were no significant differences between the two groups in the frequency of yeast-positive cultures. The study group had a higher isolation frequency from the vagina of Escherichia coli (p= 0.002) and Corynebacterium sp (p= 0.023) and a lower frequency of Lactobacillus sp (p < 0.001). In both groups, there were no cases positive for T. vaginalis, C. trachomatis or N. gonorrhoeae. The evaluation of Nugent score for bacterial vaginosis showed a higher frequency of intermediate flora (Nugent score 4-7) in the study group (p= 0.039). Related to Mycoplasma sp isolation, the results were similar in both groups. Conclusion: The lower frequency of Lactobacillus sp isolation and the higher frequency of Corynebacterium sp and Escherichia coli isolation from the vagina in women with SCI, and the higher frequence of intermediate Nugent score, strongly suggests a disequilibrium of the vaginal microbiota away from a Lactobacillus sp dominated flora in these women. Since lactobacilli are essential for maintaining vaginal health and inhibiting growth of other bacteria, their relative absence in women with SCI may influence the occurrence of urogenital tract infections in these women. The higher frequency of yeast detection by microscopy in women with SCI suggests that these women may harbor a higher vaginal yeast concentration than do other women