SEXUALLY TRANSMITTED

INFECTIONS
KMTC@@@@
 Learning objectives
By the end of this session the student should be
able to:
• Identify common STDs
• Discuss the characteristics of common STDs
• Manage the common STDs using the syndromic
approach
 INTRODUCTION
• STIs are commonly transmitted from one person
to another primarily through sexual contact
• Individuals with STD require prompt and
comprehensive management in order to stop
them from spreading the infection from one
sexual partner to another.
 Characteristics of common STIs
• Keeping with the current management known as
syndromic management of STD the STIs are
grouped according to their signs and symptoms.
• A ‘syndrome’means a group of signs and
symptoms
• There are five main syndromes as follows
• Vaginal discharge (Pruritus) in women
• Urethral discharge in men
• Lower abdominal pain in women
• Genital ulcer disease in both men and women
• Opthalmia neonatorium in newborns
If a client presents with any of these syndromes its an
indication of STI and therefore requires prompt treatment.
Management using the 4Cs need to be emphasized
(counseling, compliance, condom use, contact tracing).
Syndrome Symptom Signs Most common aetiology

Vaginal discharge -Vaginal discharge Vaginal discharge Vaginitis:

-Vaginal itching -Trichomoniasis
-Dysuria (pain on -Candidiasis
urination -Bacterial vaginosis
-Pain during sexual Cervicitis
relations -Gonorrhoea
-Chlamydia
Urethral discharge -Urethral discharge Urethral discharge - Gonorrhoea
-Dysuria - Chlamydia
-Frequent urination
Lower abdominal pain -Lower abdominal pain -Vaginal discharge - Gonorrhoea
-Pain during sexual Lower abdominal pain - Chlamydia
intercouse and tenderness on - Mixed Bacteria
palpation
Temperature < 38
degrees
Genital ulcer Genital sore -Genital ulcer -Syphilis
-Enlarged inguinal -Chancroid
lymph nodes -Genital herpes
Opthalmia neonatorium -Swollen eyelids -Oedema of the eyelids -Gonorrhoea
-Discharge -Purulent discharge -Chlamydia
 VAGINAL DISCHARGES
o Normal vaginal discharge is clear, mucoid and with
no smell.
o Abnormal discharge is a lot more and has a
characteristic smell and colour. Therefore,
abnormal discharges indicate infection
Causes of vaginal discharges;
• Vaginitis
• Cervicitis
o Cervicitis is an infection of the cervix caused by
Neisseria Gonorrhoeae orChlamydia Trachomatis
 Vaginitis
o This is the inflammation of the vaginal wall which could be
caused by a fungusCandida Albicans, a yeast species found
in the vagina in small quantities .
o An increase in the quantity of the fungi cause inflammation of
the vaginal wall leading to the discharge.
o Candida Albicans overgrowth can be caused by;
• Pregnancy,
• Diabetes,
• Lowered immunity of the individual or
• If the client is on antibiotic or corticosteroid therapy.
o Vaginitis can also be caused byTrichomonas vaginalis ,
Gardnerella vaginalis or anerobic bacteria.
 Signs and Symptoms of Abnormal
vaginal discharge
• Increased quantity of the discharge than usual
• Unpleasant smell
• Colour depends on causative organisms (green, yellow or curd like)
The discharge may be associated with;
• Dysuria due to inflammation of the urethra
• Dyspareunia
• Itching of the vulva or vagina
• Inflamed and swollen vulva
In cervicitis there is;
• Redness, inflammation and bleeding from the cervix
• Swollen and tender Bartholins gland
• Abdominal pain
 Diagnosis
• Signs and symptoms
• Cervicitis- confirm by a speculum examination
• Laboratory investigations
 Management
o Management is based on the syndromic approach. If
there is no abdominal pain or tenderness follow the STI
flow chart for vaginal discharges.
o Give the client Clotrimazole 1 pessary intravaginally daily
for 6 days and Metronidazole 2g stat.(If client pregnant
do not give Metronidazole)
No improvement after 7 days
o change to second line of Rx; Norfloxacin 800mg stat and
Doxycycline100mg BD for 7 days.
o If pregnant give intramuscular Spectinomycin 2gm stat
and Erythromycin 500gm QID for 7 days
No improvement refer client for further investigation
o Inform client about the 4Cs approach
• Counselling-Counsel client on health seeking
behavior and ways of preventing STI reinfection and
spread
• Compliance- Advice clients to avoid self medication
and to take the full dose of the prescribed
medication to ensure full recovery.
• Condom use- Explain and demonstrate proper use
of the condom, if abstinence is impossible. Avail
the condoms to those who need.
• Contact tracing- Advice them to bring their sex
partners in for treatment. Advice on faithfulness to
avoid future STIs.
 Complications
• Susceptibility to HIV infection
• Inflammation of the pelvic organs causing
blockage of fallopian tubes leading to ectopic
pregnancy or infertility
• Bartholinns gland abscesses
• Septicaemia causing arthritis, endocarditis,
meningitis (gonococcal)
 URETHRAL DISCHARGE
• Usually refers to a discharge from the penis
although women can develop an infection in the
urethra resulting in urethral discharge
• Any discharge from the urethra is abnormal and a
sign of infection
• Most urethral discharges indicate the presence of
gonorrhoea or chlamydia or both or trichomoniasis.
• In the absence of lab investigation to isolate the
causative organism then the flow chart becomes an
essential tool
 Signs and Symptoms
o Discharge may be abundant and purulent or watery
and whitish
o Discharge may be associated with;
• Painful and frequent urination
• Testicular pain
• Itching of the glans penis, foreskin or urethra
• An oedematous, tight or cracked foreskin
There is increased severity of symptoms before or
during the first urination of the morning.
Diagnosis: patient history, physical exam of the penis,
and lab tests
 Management
o If discharge present treat as urethritis
• Norfloxacin 800mg stat and Doxycycline100mg
orallyBD for 7 days
• No improvement after seven days
• Give Spectinomycin2mg IM stat and Doxycycline
100mg QID for 7 days
o Use the 4Cs approach
 Complications
• Urethral abscesses
• Urethral stricture causing urinary blockage
which can result to renal failure
• Infection of epidydimis and testis (epidydmo-
orchitis) leading to infertility
• Inflammation of the urinary bladder(Cystitis)
• Inflammation of the prostate gland (prostatitis)
• Septicaemia, arthritis, endocarditis, meningitis
(gonococcus)
 LOWER ABDOMINAL PAIN
• Lower abdominal pain in a woman usually is a
symptom of inflamed ovaries, fallopian tubes
and, or uterus
• This is referred to as pelvic Inflammatory
disease and is a complication arising from
untreated infections in the vagina or cervix
• PID is usually caused by a combination of
bacteria- Neisseria Gonorrhoeae, Chlamydia
Trachomatis, streptococci, anaerobic bacteria)
• These bacteria are usually transmitted through
- Sexual transmission(majority)
- Chidbirth
- Abortion (Puerperal sepsis)
- Gynecologic surgery (Pelvic cellulitis and
thrombophlebitis)
 Signs and Symptoms of PID
• Lower abdominal pain and tenderness.
This may be associated with;
• Offensive vaginal discharge
• Both urethral and vaginal discharge
• Dyspareunia
• Low grade fever
• Urgent or frequent urination
• General malaise
 Diagnosis
• Patient history
• Lower abdomen examination( Assess intensity
of pain and the side)
• Bimanual examination
• Assess vaginal discharge-amount, texture,
colour, and smell.
• Lab tests
 Management

First line Rx
Norfloxacin 800mg stat, Doxycycline
100mg BD for 7 days and
Metronidazole 400mg BD for 10 days
No improvement after 7 days, refer.
Advice client to abstain from sex since
 Complications
• Increased susceptibility to HIV infection
• Chronic low back pain or chronic low grade fever
• Frequent miscarriages
• Ectopic pregnancy
• Infertility( scarring and blockage of fallopian
tubes)
• Other organs-Peritonitis, cystitis.
 GENITAL ULCER DISEASE
• Chancroid, Syphilis or herpes produces genital
ulcers and the infection affects male and female
equally.
• GUD is considered significant since it facilitates
transmission of HIV infection.
 CHANCROID
• Is caused by a gram negative bacterium called
Haemophilus Ducreyi .
• Incubation period in men is 4-7 days while in
women is 10 days
• Factors enhancing transmission include;
- Non- circumcision in men
- Commercial sex industry
- Pregnancy
 Signs and Symptoms
• Male patients
- Single or multiple painful ulcers on the penis
- Circumcised- ulcer is on the glans penis, the
shaft or the coronal sulcus.
- Uncircumcised- ulcer is within the mucosal
surface of the prepuce, on the skin surface or
on the edge of the prepuce. It may also appear
on the frenulum, coronal sulcus, glans penis or
the shaft of the penis.
• Female patients- the ulcers are often painless
• The ulcers are dirty looking with irregular
margins. The base of the ulcer is covered by
grey yellow necrotic purulent exudates
• The ulcer is friable and bleeds easily on touch or
any form of manipulation
• There is inflammation of the inguinal glands
and bubo formation and these spontaneously
release thick creamy pus
Diagnosis:
- History taking
- Physical examination- Location of the ulcer, how
many, how they look like
- Lab test
 Complications
Acute Chronic
Male
- Oedema and swelling of
prepuce - Secondary warts
- Fibroses
- Phimosis
- Cicatrization or auto
- Balanitis amputation of the penis
- Inguinal buboes
Female
- Oedema of vulva
- Vaginal and /or rectal
bleeding
- buboes
 SYPHILIS
• Is caused by a spirochete organism called
Treponema pallidum
• This is usually transmitted by
- Sexual contact
- Mother to unborn baby(vertical transmission)
- Physical contact with a patient in the secondary
stage of the infection who has mucosal or
cutaneous lesions
- Blood transfusion
 Stages
Has 4 stages
Primary Syphilis
 Incubation period of 10-90 days
 Primary chancre develops at the site of
innoculation (single lesion).
 It is painless, indurated with a clean base and
raised edges and does not bleed on contact. But
oozes clear fluid containing treponema pallidum
 In females it is on the cervix or vulva while in
men it is on the glans penis, foreskin or penile
shaft
 The chancre resolves spontaneously if left
untreated for several weeks but the disease
progresses to secondary stage
Secondary Syphilis
 Follows a few weeks or months after the
appearance of the primary chancre.
 The microorganisms begin to affect other
systems in the body
 Signs and symptoms manifest;
o Cutaneous manifestation
- skin rash(papular, macular or pastular)
- Soft, raised condylomata lata may be seen in
moist areas of the body
- There may also be patches on the mucous or
oral ulcerations(snail track ulcer)
o Fever and general malaise
o Generalized lympadenopathy
o Nephritis
o Hepatitis
o Meningitis or Uveitis
 Lesions resolve after several weeks but disease
progresses to the next stage.
Latent Syphilis
 In the absence of adequate treatment the disease
enters into latent stage
 No clinical manifestations but there is a history of
syphilis
 Blood test will give a positive serological evidence
Tertiary Syphilis
 Is the last stage and accounts for the morbidity and
mortality of syphilis
 Begins during the third year to fifth year of disease
and sometimes it takes an extended period of time to
manifest
 Has three categories of lesions;
o Gamma lesions- Painless ulcers with little or no
inflammation which may affect bones making
them fragile
o Cardiovascular lesions- they affect the aorta
causing aortitis or aortic valve disease and
coronary ostial occlusion
o Neurological lesions- It crosses the blood brain
barrier to reach CSF and cause symptomatic
neurosyphilis presenting as epilepsy,
hydrocephalus, syphilitic meningo-encephalitis,
cranial nerve palsy or dementia.
- There could also be assymptomatic
neurosyphilis where the patient is clinically
normal yet the CSF shows the presence of
treponema pallidum.

Congenital Syphilis
• An untreated infection in a pregnant woman is
likely to be passed on to the fetus in utero
through the placental barrier and thus the baby
will be born infected.
• This is referred to as Congenital syphilis and is
acquired through vertical transmission
 Signs of Congenital syphilis
• Syphilitic pemphigus
• Anaemia
• Jaundice
• Hepatosplenomegally
• Cleft lip and cleft palate
• Ulcers of the nasoperiosteum leading to watery
nasal discharge
• The babies are born small and they do not thrive
well
• At birth the baby might appear normal but later
develop the characteristic rash in the soles and
palms, then persisitent nasal discharge which is
sometimes blood stained.
• This progresses to anaemia, jaundice and
hepatosplenomegally
• The prognosis is poor but those who live longer
or reach adolescent age develop late congenital
syphilis. They manifest bony and dental
abnormalities and inflammatory lesions of the
cornea
 Diagnosis
• History taking
• Physical examination
• Lab test-VDRL,TPHA.
 GENITAL HERPES
• Is an ulcerative sexually transmitted disease
caused by the herpes simplex virus type 2 (HSV-
2)
• Incubation period is 2-7days
• Modes of transmission;
- Sexual contact
- Physical contact
- Vertical transmission
 Clinical features
• Localized clusters of vesicles which break down
to form ulcers
• Ulcers crust over then resolve
• Are found in the genitals and neighbouring skin,
urethra, cervix and rectum
• Tender lymphadenopathy may occur
In primary attack the virus ascends the peripheral
nerves to local ganglia where latency is
established. Nerve damage is made worse by
periodic recurrences.
Diagnosis: Is as for the other GUD
 Complications
- Sacro radiculomyelopathy-constipation, urine
retention,shooting pain down the legs(neurititc
pain)
- Excrutiating urethritis in women
- Aseptic menengitis
- Extra genital lesions
- Yeast vaginitis
- Disseminated herpes
In pregnancy recurrences are more frequent. In
primary attack, premature delivery may occur.
 Management of GUD
• Since these diseases have very serious
complications for the patient treatment should
be commenced immediately without waiting for
lab results (Follow Nascop flow chart)
• Erythromycin 500mg TDS for 7 days and
Benzathine penicillin2.4MU IM stat, or if allergic
to penicillin Erythromycin 500mg QID for 14
days
No improvement after 7 days
• Ceftriaxone 250mg IM stat
• If no improvement then refer for further
investigations
• Pregnant women should be referred for further
investigations and obstetric evaluation
• For congenital syphilis the baby should be
treated with Procaine penicillin 50,000units/kg/
body weight IM OD for 10 days
• For chancroid ulcers if they do not respond to
erythromycin then Ciprofloxacin is given as the
second line.
• Herpes has no cure and thus symptomatic
management
• Advice on keeping the infected area clean and
dry.
• Use saline water to clean the ulcers
• Aspirate the buboes if present (aseptic
technique)
• If oedema has caused phimosis circumcision is
advised
• Remember 4Cs
 OPTHALMIA NENATORIUM
• Is an acute conjuctivitis occuring in the first
month of life
• Caused byNeisseria Gonorrhoeae
• Found in the vagina of an infected woman and
during vaginal delivery the baby picks up the
infection
• Can also be transmitted during caesarian
section when there has been prolonged rupture
of membranes
 Signs and Symptoms
• Purulent discharge from both eyes of a new born
any time within 21 days of life
- Early stages- sticky eyes
- Later- pus is thick and greenish in colour
• Red and swollen conjuctiva
Diagnosis
• Presence of discharge in the eyes
• Lab test
• If mother infected
 Management
• On noticing the discharge treatment should be
started immediately to avoid loss of sight
• Start baby on Procaine penicillin 300,000 IU IM stat
and 1% Tetracycline eye ointment for 10 days
No improvement after 24 hours
• Erythromycin 100mg BD for 14days
• Continue with eye ointment for the prescribed
period
• Use of 4Cs
 Complications
• Corneal ulceration
• Blindness (Partial or total)

Prevention
• Screening of antenatal mothers and adequately
treating them before delivery
• Treatment of their sexual partners
• Prophylactic tetracycline eye ointment immediately
after birth(Government policy)