Module 4

Diagnosis and Treatment of

Specific STI Syndromes

1
Objectives
 Make decisions and actions on each of the
national flow-charts
 Use the national flow-charts to make a
syndromic diagnosis for a variety of STIs
cases
 List the correct drug therapies and
dosages for each diagnosis
 Make arrangements for a follow – up visit
2
 Urethral
Discharge

3
 Agents
 Most common:
- Neisseria gonorrhoea
• Acute onset with profuse and purulent
discharge
- Chlamydia trachomatis
• Sub acute onset with scant mucopurulent
discharge
 But this is not always true and mixed infections
are common and
 2nd most common:
- Trichomonas vaginalis 4
Rare agents
 Rarely:
- Mycoplasma genitalium
- Ureaplasma uraelyticum

5
 Clinical Presentation
 Burning sensation on urination,
dysuria
 Urethral discharge

 Meatal excoriation

6
Complications
 Local spread and Dissemination
 Stricture and infertility

 Reiter's syndrome (post infectious

arthritis, urethritis, and conjunctivitis,

formerly called Reiter syndrome)

7
Urethral discharge

8
 Urethral discharge
complains of urethral discharge
or dysuria

Take history & Examine [Milk urethra if necessary]

• Educate on
Other RR
Discharge No
STIs? No • Offer HCT
present?
• Promote &
Yes provide
Yes condoms
Treat for GC & CT
Use appropriate flow
•Educate on risk chart
reduction
•Offer HCT
•Promote & provide
condoms
• Partner management
• Advise to return in 7 9
days if symptoms persist Figure 1
 Recommended treatment
Ciprofloxacin 500 tablet mg po stat
Or
Spectinomycin 2 grams IM stat

PLUS

Doxycycline 100 mg po bid for 7 days

Or
Tetracycline 500 mg qid for 7 days
Or
Erythromycin 500mg qid for 7 days if the patient has
contraindications for tetracyclines (children, pregnancy)
10
 Management of
Recurrent/Persistent Urethritis
 Look for objective signs of urethritis
 Possible causes for recurrence/reappearance
 non-compliant or i.e. inadequately treated or
 re-infected
 Re-treat with initial regimen
 T. Vaginalis
 Treat with Metronidazole 2 gm p.o. Stat [avaoid alcohol]
 Drug resistance
 Refer
 morning milking syndrome due to fear of acquiring STD 11
Genital
Ulcers

12
Genital ulcer

13
Vesicular
HSV2: Genital Herps
Non-Vesicualr
T. Pallidum: Syphilis
H. Ducreyi: Chancroid
C. Trachomatis Serovars L1-L3: LGV
[Link] (C. Granulomatis): Granuloma
ingunale 14
 Syphilis
 Acute and Chronic infection caused by T.
pallidum
 Transmission: Sexual, MTC & contaminated
blood
 Incubation period 21 days ( 10-90 days and
depends on inoculum's dose)
 Diverse presentation

15
 Primary syphilis
 Solitary genital ulcer
- Non tender hard ulcer
- Painless inguinal adenopathy

16
Syphilis cont’d
 Secondary syphilis
- Disseminated spirochetemia
- 8 weeks after infection
- Skin rash is common feature
- Alopecia ; moth-eaten appearance
- Atypical facial plaques
- Mucosal ulcerations
- Condylomata lata
- Painless generalized lymphadenopathy

17
 Secondary Latent syphilis
 where there are no clinical signs but
syphilis serology is reactive

1. Early latent = infection less than one year

2. Late latent= infection occur for over one

year

18
Tertiary syphilis

- Gumma
- Cardiovascular: aortitis leading to
valve incompetence and aneurysm
- Neuro-syphilis

19
 Neurosyphilis
• Stroke like presentation ( meningovascular)
• Asymptomatic but positive VDRL on CSF
• Tabes dorsalis
• Paralysis of the insane
• Cranial palsy (cranial nerve VIII, III, optic
atrophy)

20
 Chancroid
 Lesions are painful, progressing from a small
papule to pustule and then to ulcer with soft
margins described as soft chancre
 Inguinal adenopathy that becomes necrotic
and fluctuant (buboes) follow the ulcer
 Not found to be a common cause of genital
ulcer syndrome in the validation study
 The incubation period is usually 2-10 days
 Transmitted exclusively by sexual contact
 A cofactor for HIV transmission; high rates of
HIV infection among patients

21
 Lymphogranuloma Venereum
(LGV)
 Caused by C. trachomatis serovars L1, L2, or L3.
 LGV primarily infects the lymphatics
 Most common clinical manifestation is tender
inguinal and/or femoral lymphadenopathy - most
commonly unilateral
 Women and homosexually active men may have
proctocolitis or inflammatory involvement of
perirectal or perianal lymphatic tissues resulting
in fistulas and strictures
22
 Lymphogranuloma Venereum
(LGV)
 A self-limited genital ulcer sometimes
occurs at the site of inoculation
 By the time patients seek care, the
ulcer usually has disappeared
 There is little information on the
prevalence of LGV as a cause of genital
ulcer in Ethiopia.

23
 Granuloma inguinale
 Chronically progressive ulcerative disease
without systemic symptoms
 The etiologic agent is Calymmatobacterium
granulomatis
 Incubation period generally is 1-4 weeks,
may be up to 1 year
 It is transmitted primarily by sexual contact
 There is little information on the prevalence
of Donovanosis as a cause of genital ulcer in
Ethiopia.

24
 Complications of GU
Disease Etiology Complications

Syphilis T. pallidum secondary syphilis, Latent syphilis,

Aortitis with valvulitis, Aortic aneurysm,
Gumma, Neurosyphilis
G. herpes Herpes Recurrence,
simplex virus
Aseptic meningitis and encephalitis
Chancroid H. ducreyi Penile auto-amputation

LGV C. trachomatis, Genital edema, Salphingitis,

L1,L2,L3 Infertility, PID
Garanuloma C. Genital pseudoelephantiasis,
inguinale granulomatis Adhesion, Urethral, vaginal or rectal
stenosis
25
 Patient complains of genital sore or ulcer

Take history &

examine •Educate on RR
Solitary non- • Promote &
No provide
Vesicular recurrent No recurrent condoms
Ulcers or > three ulcers Non-vesicular •Offer HIV
ulcer, testing
Ye Ye
s s
Treat syphilis, chancroid,
Treat HSV2 HSV2
•Educate on risk reduction
•Promote & provide condoms
•Offer HIV testing & Partner
management

ulcers healed No
ulcers improved Refer
Yes
•Educate & provide
condoms Continue Rx
•Offer HIV testing 26
Figure 3
•Consider episodic Rx
 Recommended treatment

Benzathine penicillin 2.4 million units IM stat

or (in penicillin allergy)
Doxycycline 100 mg bid for 14 days
Plus
Ciprofloxacin 500mg bid orally for 3 days.
Or
Erythromycin tablets 500 mg qid for 7 days
Plus
Acyclovir 400mg tid orally for 10 days (or 200mg five
times per day of 10 day)
If only vesicular, recurrent & multiple ulcer
Acyclovir 400mg tid orally for 10 days (or 200mg five
times per day of 10 day) 27
 Vaginal
discharge
syndrome
28
Vaginal discharge

29
 Common causes of vaginal discharge
 Sexually transmitted
 Neisseria gonorrhoeae4
 Chlamydia trachomatis5

 Trichomonas vaginalis3

 Endogenous infection
 Gardnerella vaginalis1 (bacterial Vaginosis)
 Homogenous discharge with typical fishy odor (due to presence of volatile
amines)

 Candida albicans 2
 Cheese-like odorless discharge (may vary from watery to homogenous
30
thick discharge
 Initial evaluation of patients
with vaginal discharge include

 Risk assessment
 Age less than 25 years
 Having multiple sexual partner in the last three
months
 Having new partner in the last three months
 Having ever traded for sex

 Clinical speculum examination to determine

site of infection
31
 Vaginitis & Cervicitis

VAGINITIS CERVICITIS
Trichomoniasis, candidiasis, Gonorrhea & chlamydia
bacterial vaginosis

Most common cause of Less common cause of

vaginal discharge vaginal discharge
Easy to diagnose Difficult to diagnose
No complications Major complications
Partner treatment unnecessary Partner treatment needed

Complication: PID; Premature rupture of membrane

Pre -term labor; Infertility; Chronic pelvic pain
32
 VD or vulval/Itching /burning

Take Hx, examine patient (external,

speculum & bimanual) & assess risk
Educate on risk reduction
Abnormal discharge No
Offer HCT
present?
Promote & provide
Yes condoms
Yes
Lower abdominal tenderness or
Use LAP flowchart
cervical motion tenderness
No
Yes Treat GC, CT, BV, TV
Is Risk assessment +?
No Treat for
Vulvar oedema/curd like Yes
Discharge, Erythema, Excoriations CA
Treat for BV present?
No
Educate, Offer HCT
33
Promote & provide condoms
 Recommended treatment
RISK ASSESMENT RISK ASSESMENT
POSITIVE NEGATIVE
Ciprofloxacin tablets 500 mg Metronidazole 500 mg
po stat bid for 7 days
or
Plus
Spectinomycin 2 gm IM stat
Clotrimazole vaginal tabs
Plus
200 mg at bed time for
Doxycycline 100 mg po bid
for 7 days 3 days
Plus
Metronidazole 500 mg bid
for 7 days
34
 Recommended regimens for
pregnant women

 Metronidazole is not recommended for use in the

first trimester of pregnancy

 Treatment may be given where early treatment

has the best chance of preventing adverse
pregnancy outcomes

 Metronidazole, 200 or 250 mg orally, 3 times daily for 7

days, after first trimester
 Metronidazole 2g orally, as a single dose, if treatment
is imperative during the first trimester of pregnancy
35
 Lower
Abdominal
Pain
36
 PID
 Infection of pelvis not related to pregnancy or
surgery
 Ascending infection of the uterus , fallopian tubes,

ovaries and or adjacent structures

 Sexually transmitted: [Link], [Link]

 May or may not be sexual: Anaerobes i.e. (poly

microbial)
 [Link], Bacteroids, Streptococcus, E. Coli, H.

Influenza
37
 Diagnosis of PID
Diagnosis is often difficult & inconsistent clinical
presentations are common
Bilateral or unilateral lower abdominal pain (except
endometritis) & vaginal discharge support diagnosis

 History
 P. Exam:
 temperature
 Erratic bleeding

 Palpate abdomen for

 Missed period

 Recent delivery
tenderness, guarding & mass
 vaginal bleeding &
 Miscarriage
abnormal discharge
38
 Complications of PID
 Peritonitis and intra-abdominal abscess
 Adhesion and intestinal obstruction
 Ectopic pregnancy
 Infertility
 Chronic pelvic pain

39
 complains of lower abdominal pain

Take history & examine (abdominal &

vaginal)
cervical
excitation,
•Missed/overdue tenderness or
period, lower Any other
•Pregnancy abdominal No illness?
•Recent delivery/ No tenderness &
abortion /Miscarriage VD Yes Yes
• Abdominal guarding/
rebound tenderness Treat for PID Manage
• Vaginal bleeding & review in 3 appropriately
•Abdominal mass days

improved? No Refer
Ye patient for
• Refer patient
s for Yes
surgical or admission
• Continue treatment
gynaecological
assessment • Educate on RR
• set up IV line • Offer HCT
• Condom use 40
• Resuscitate if Figure 9
 Recommended treatment
Out patient in patent
Ciprofloxacin tablet 500 mg po Ceftriaxone 250 mg IV/IM daily
stat
OR OR
Spectinomycin 2 gm im stat Spectinomycin 2 gm im bid
Plus Plus
Doxycycline tablet 100 mg po bid Doxycycline 100 mg bid for 14
for 14 days days
Plus Plus
Metronidazole 500 mg bid for 14 Metronidazole 500 mg bid for 14
days days or chloramphenicol 500 mg
Admit if there is no improvement IV qid.
within 72 hours

41
 Indications for hospitalizations
in PID
 Uncertain diagnosis
 Acute abdomen can not be excluded
 Pelvic abscess is suspected
 Severe illness precludes management on an
outpatient basis
 Pregnancy
 The patient is unable to follow or tolerate an
outpatient regimen
 The patient has failed to respond to
outpatient therapy

42
 Scrotal
Swelling

43
Scrotal swelling
Painful testis/ epididymis

 < 35 years N. Gonorrhoea & [Link]

 > 35 years other organisms, TB possible
(Other infectious causes are brucellosis, mumps, onchocerciasis
or W. babcrofti)
 In pre-pubertal children is coliform,
pseudomonas or mumps virus
 Mumps epidedimorchitis is usually noted within a
week of parotid enlargement
 Other causes of scrotal swelling
 testicular torsion; Trauma; Tumor
 incarcerated inguinal hernia

44
 Presentation

 Clinical presentations
 Testicular infarction and atrophy

 Abscess formation

 Chronic epididymitis

 Impotence and Infertility

 Complications
 Epididymitis

 Infertility

 Impotence

 Prostatitis
45
complains of scrotal
swelling/pain

Take history and

examine •Reassure
patient/educate
No •Promote and provide
Swelling/pain condoms
confirmed?
•Offer HIV testing
Yes •Analgesics
Treat GC & CT
Testis rotated
No •Educate on RR
or elevated, or
history of •Promote & provide
trauma? condoms
Yes •Partner management
Refer immediately •Offer HIV testing
for surgical opinion •Review in 7 days or
earlier if necessary, if
worse, refer 46
 Recommended treatment
Ciprofloxacin 500 mg po stat
Or
Spectinomycin 2 gm im stat
Plus
Doxycycline 100 mg PO bid for 7 days
Or
Tetracycline 500 mg PO bid for 7 days.
47
 Inguinal
Bubo
syndrome
48
Swollen glands

49
 Inguinal Bubo

 a painful, often fluctuant, swelling of the

lymph nodes in the inguinal region (groin)

 The common sexually transmitted pathogens

that are associated with inguinal bubo include
 C. trachomatis (serovar L1, L2 and L3): LGV:
 H. ducreyi: Chancroid
 [Link] (Calymmatobacterium granulomatis): Granuloma
ingunale

 Rarely systemic symptoms except LGV 50

 Inguinal Bubo T. pallidum
 Sometimes T. pallidum can be a cause of
inguinal lymphadenopthy

 unlike the other causes, it doesn't generally produce

necrosis and abscess collection in the lymph nodes.

 In conditions where the clinical examination doesn't

reveal a fluctuant bubo, syphilis should be additionally
considered and treated accordingly

 Surgical incisions are contraindicated and the pus

should only be aspirated using a hypodermic needle.

51
 Inguinal Bubo
 Men affected more than females

 Common predisposing factor for the spread of

HIV

 Complications:
 Abscess formation and PID

 Lymphatic obstruction

 Stenosis and Infertility

52
 complains of inguinal
swelling

Take history and

Examine
Educate on
No No RR
Inguinal/femoral Other Offer HCT
bubo(s) present? STIs
Condom use
Yes Yes
Ulcer(s) present?
Yes Use appropriate flowchart
No
Rx LGV, chancroid, GI
•Educate on RR Use GU
•Provide condoms flowchart
•Partner management
•Offer HIV testing
•Advise to return in 53
 Recommended treatment

Ciprofloxacin 500 mg bid orally for 3 days

Plus

Doxycycline 100mg bid orally for 14 days

Or
Erythromycin 500 mg po qid for 14 days

54
 Neonatal
Conjunctivitis

55
 Neonatal Conjuctivitis

 It is a purulent conjuctivitis occurring in a

baby less than one month of age.
 Sight-threatening condition

 Common presentation are Redness, swelling of the

eye lid & discharge from the eye (sticky eye)
 The most important causes are gonorrhoea (20-75%)
& chlamydia (15-35%)
 If caused by gonorrhoea, blindness often follows

 For babies older than one month, the cause is

unlikely to be an STI
56
 Management
 Prevention
 As soon as the baby is born, carefully wipe both
eyes with dry, clean cotton wool;

 Then apply 1% silver nitrate solution or 1%

tetracycline eye ointment into the infant’s eyes;
other options: 0.5% Erythromycin ointment or
2.5% povidone iodine solution;
 Treatment
 Ceftriaxon 125mg IM stat (max 50mg/kg) or
 Spectinomycin 25mg/kg IM stat (max 75mg) plus
 Erythromycin 50 mg/kg PO in four divided doses
for 14 days 57
 Neonatal Herpes

 The risk for transmission to the neonate

from an infected mother is high (30%-
50%) among women who acquire genital
herpes near the time of delivery

 Low (<1%) among women with history

of recurrent herpes at term or who
acquire genital HSV during the first half
of pregnancy 58
 Neonatal Herpes
 Prevention of neonatal herpes
 preventing of genital HSV infection during late

pregnancy
 Avoiding exposure of the infection to herpetic lesions

during delivery
 In women with active genital herpetic lesions

delivery by caesarean section is recommended to

prevent neonatal herpes
 Abdominal delivery does not completely eliminate the
risk for HSV transmission to the infant
 In addition to severe skin disease, the neonate may
develop aseptic meningitis or encephalitis and it is
frequently fatal
59
 Neonate with eye
discharge

Take history and

Examine

•Reassure mother
Bilateral or No •Advise to return
unilateral swollen if necessary
eyelids with
purulent
discharge

Yes
Yes
Rx child & mother for GC
& Chlamydia
•For mother only:
•Educate on RR Improved
•Provide condoms No
•Offer HIV testing Refer
•Advise to return in 60
 Recommended treatment
for neonatal herpes
 Acyclovir 10 mg /Kg IV three times
daily for 14 days for localized mucosal
or dermal infections

 Acyclovir 20 mg /Kg IV three times

daily for 21 days for disseminated
infections

61
 Remarks on drugs used for
STI treatment
 Erythromycin should be taken on an
empty stomach because bio availability is
affected by food, GI upset is a
recognized side effect
 Ciprofloxacin should not be given to
pregnant women or children
 Spectinomycin could cause renal damage
and requires parentral administration
62
Remarks on drugs used for
STI treatment
 Ceftriaxone is expensive and may not be
available
 Doxycyclin & Tetracyclin contraindicated in
pregnant women and children
 Tetracyclin should not be taken with milk
 Acyclovir the only drug available for treatment
of herpes in Ethiopia. It is safe and can be
used during pregnancy. Acyclovir cream is not
effective for treatment of genital herpes
63
Introduction to Pre-packaged
STI Treatment Kits (samples)
 Contents:
- antibiotics (genital ulcers and urethral
discharge)
- condoms
- instruction booklet
- partner notification cards
- special warning pamphlet
- additional elements for injections (genital
ulcers)
64
Flow-chart for Follow up visit

Lets review the follow-up visit flow –

chart on page 85 (Reference Manual)

65
 Follow –up visit for patients
with STIs
 Importance of follow up visit:
- ensure care & exclude incubating STIs
particularly syphyllis
- some patients may not respond to initial
treatment & reassessment may be needed
- the response to treatment may not be
dramatic with concomitant HIV
- VCT could be offered during follow up
visit

66
Group work!!!!

 Let us look at Exercise 4.1- Use of Flow-

charts (Handout)
 Divide into 3 groups

67
STIs

68