Review of

Sexually
Transmitted
Infections
Why are STIs important?

 STIs remain a major health problem in many

areas of the world

 Strong correlation between STIs and HIV

 Relatively common and any health provider

should have knowledge of them
What is Syndromic
Management?
STI management based on:

 identification of consistent groups of symptoms

and easily recognized signs
and
 medication that treats the majority, or most
serious organisms responsible for producing the
syndrome
Advantages of
Syndromic Management
 Allows treatment of large numbers of people
 Simple
 Cost effective
Criteria for Drug
Selection
 High efficacy
 Low cost
 Low toxicity
 Little resistance
 Single dose
 Oral administration
 Can be used in pregnancy & lactation
Case Management:
When your participant has
suspected STI’s
 Be respectful
 Be non-judgmental
 Maintain confidentiality
 Ensure privacy during exams
 For all conditions (except bacterial vaginosis and
Candidiasis) the sexual partner should also be examined
and treated
Case Management of
STI’s
 Identify the syndrome
 Educate the patient
 Recommend HIV testing
 Provide antibiotic treatment
 Supply condoms
 Provide counseling
 Partner notification
Syndrome Types:

 Urethral Discharge
 Cervical Infections
 Pelvic Inflammatory Disease
 Genital Ulcer Diseases
 Vaginal discharge
What Pathogens Cause
Urethritis?
 Chlamydia trachomatis
 Niesseria Gonorrheae

therefore
 Syndromic Management must treat
both
of these organisms

(A less common causes of urethritis (5%)

include trichomonas & herpes)
What is this?
Gonorrhea
Gonorrhea

Etiology:
-Neisseria gonorrhea gram negative diplococcus
-affects mucosal surfaces of urethra,
endocervix, rectum and pharynx
- cause of female infertility from pelvic
inflammatory disease
What is this?
Gram negative diplococci…
gonorrhea
remember the
“kissing beans”
Gonorrhea

Other Features
 Transmission: sexual
 Incubation 2-5 days
 May be asymptomatic in women
Gonorrhea: Clinical Signs

Men:
-Urethral discharge (milk
urethra)
-Discharge is white or
yellow; sometimes
mucoid
Gonorrhea: Clinical Signs

Women
 Cervix mucopurulent discharge from cervical os
 Purulence = yellow colour on swab
(Cervical ectopy = exposed endocervical mucosa)
 Erosions
 Friability = Bleeding of cervix when swabbed
 Cervical tenderness: tenderness with excitation
Gonorrhea: Diagnosis

 Gram smear: gram negative diplococcus

 Culture:
- test of choice; collect swab directly from:
Urethra: insert swab gently 1-2 cm. into the
urethra and rotate slowly.
Cervix: first remove external vaginal secretions
from cervix then insert swab into cervix and
rotate and allow 5 seconds for absorption.
Syndromic Treatment of
Urethritis
Gonorrhea Chlamydia

 Ciprofloxacin  Doxycycline 100mg

500mg po
 Azithromycin
po bd x 7 days
2gm po
 Azithromycin 1 gm
po
Which would be the best
syndromic treatment?
 Azithromycin 2 grams PO

Why?

 Single dose
 Treats both GC and Chlamydia
 Directly observed therapy
What is this?
Non-gonococcal urethritis…
usually chlamydia
Chlamydia

 Etiology: Chlamydia trachomatis

 Also causes Lymphogranuloma venereum (LGV)
 Similar presentation to GC ( urethritis, cervicitis,
proctitis) but with less severe symptoms and
more frequently subclinical
 Subclinical nature often delays diagnosis and
causes severe complications (i.e. PID &
infertility)
Chlamydia

 Transmission: sexual
 Age: more common in young age due to
cervical ectopy
 Gender: more common in women
Chlamydia: Symptoms

 Men:
-Scant urethral discharge
-mild dysuria
 Women:

-Vaginal discharge
-Dysuria
-Intermenstrual bleeding
-Post coital bleeding
-Symptoms of cervicitis, salpingitis,
urethritis
Chlamydia: Signs

 Cervix mucopurulent discharge from cervical os

 Purulence = yellow colour on swab
 Cervical ectopy = exposed endocervical
mucosa
 Cervical bleeding Friability = Bleeding when
swabbed
 Cervical tenderness with excitation
Chlamydia: Diagnosis

 Chlamydia Rapid :test that detects Chlamydia

antigens
 Others PCR, culture
Chlamydia: Treatment

 Recommended regimens:
-Doxycycline 100mg PO bid x 7days
-Azithromycin 1g PO single dose
 Contact notification
 Screening: young sexually active people should
be screened since most infections are
asymptomatic
Definition of PID

 Infection of the female genital tract above the

internal os of the cervix.
 Endometritis, salpingitis, salpingo-oophoritis,
tubo-ovarian abscess and pelvic peritonitis
 Caused by ascending infection from the cervix
 Pathogens-Neisseria gonorrhea, chlamydia
trachomatis and anaerobic bacteria.
Pelvic Inflammatory
Disease (PID)
 Most common etiology:
-Chlamydia
-Gonorrhea
-Associated with bacterial vaginosis and douching
-Mixed aerobic and anaerobic bacteria
 Transmission: same as GC and Chlamydia
Pelvic Inflammatory
Disease (PID):
Symptoms
 Mild cases:
-Lower abdominal pain
-vaginal discharge
 Symptoms of BV or mucopurulent cervicitis
-Dysparunia
-Vaginal bleeding
Pelvic Inflammatory
Disease (PID):
Symptoms
 Severe cases:
-Fever
-Chills
-Malaise
-Nausea
-Vomiting
Pelvic Inflammatory
Disease (PID):
Clinical Signs
 Adnexal tenderness
 Cervical motion tenderness
 Uterine fundal tenderness
 Lower abdominal tenderness
 Rebound tenderness
Simple diagnostic criteria

 Abdominal, uterine/cervical, and adnexal

tenderness
 And
 At least one of the following:
 Oral temperature > 38º C;
 Pelvic mass or suspected inflammatory complex
on bimanual exam;
 Mucopurulent cervicitis.
 Effects of Delayed Care

Gonorrhea or Chlamydia Chlamydia only,

PID, delay seeking care 17.8% of those who
3 or more days - 3 times
as likely to develop
delayed care
infertility or ectopic as developed infertility
those who seek care or ectopic pregnancy
promptly compared to 0% who
(£ 2 days)
sought care promptly

Hillis et al., AJOG, 1993

Pelvic Inflammatory
Disease (PID):
Treatment
 Mild PID: Outpatient treatment:
Ceftriaxone 250mg IM single dose
Plus
Doxycycline 100mg PO bid X 14 days
Plus
Metronidazole 400mg Po bid X14 days
 PID - Treatment
 PID
treatment regimens must provide empiric, broad‑spectrum
coverage of likely pathogens
 Antimicrobialcoverage should include N. gonorrhoeae, C.
trachomatis, anaerobes, Gram‑negative facultative bacteria, and
streptococci.
 Treatment should be initiated as soon as the presumptive
diagnosis has been made, because prevention of long‑term
sequelae has been linked directly with immediate administration
of appropriate antibiotics.
 PID
Hospitalization vs. Outpatient
In the past, many specialists
recommended that all patients
who had PID be hospitalized so
that bed rest and supervised
treatment with parenteral
antibiotics could be initiated
However, hospitalization is no
longer synonymous with
parenteral therapy.
 PID – Follow Up
Patients
should demonstrate substantial clinical
improvement within 3 days after initiation of therapy.

Patients who do not improve within this period

usually require hospitalization, additional diagnostic
tests, and surgical intervention.

Iforal or parenteral therapy is given, a follow‑up

examination should be performed within 72 hours
using the criteria for clinical improvement described
previously.

Ifthe patient has not improved, hospitalization for

parenteral therapy and further evaluation are
recommended.
 Management of Sex Partners
 Male sex partners of women with PID should be
examined and treated if they had sexual contact with
the patient during the 60 days preceding the patient's
onset of symptoms.
 Evaluation and treatment are imperative because of
the risk for reinfection of the patient and the strong
likelihood of urethral gonococcal or chlamydial
infection in the sex partner.
 Male partners of women who have PID caused by C.
trachomatis and/or N. gonorrhoeae often are
asymptomatic.
 Sex partners should be treated empirically with
regimens effective against both of these infections,
regardless of the etiology of PID or pathogens isolated
from the infected woman
Genital Ulcer
Disease
(GUD)
Important things to
remember
about GUD…
 Clinical diagnosis of GUD is inaccurate
 Clinical presentation of GUD (syphilis/herpes/chancroid)
may be altered by the presence of HIV
 Genital herpes may be the most prevalent cause of GUD in
Zambia
 Lab diagnosis is unhelpful at the first visit as mixed
infections are common
What are the causes of
GUD?
 Genital Herpes
 Syphilis
 Chancroid-
 Granuloma inguinale
 Lymphogranuloma venereum (LGV)

The decision to treat Chancroid, Granuloma

inguinale or LGV depends on local epidemiology
Genital
herpes
Genital Herpes Management

 Keep lesion clean and dry

 Educate on risk reduction
 Promote and provide condoms
 Advise to return in 7 days if not healed
 Treat if within 3 days of appearance of symptoms
Genital Herpes Treatment

 There is no cure

 The course of the attack can be modified if

Acyclovir is started as soon as possible
following the onset of symptoms (the warning
stage)

 Topical therapy is not recommended

Treatment can reduce:

 The formation of new herpes lesions

 The duration of pain
 The time needed for healing
 The duration of viral shedding

Treatment does not:

 Influence the natural history of recurrent
disease
Genital Herpes Treatment

First Infection:
 Acyclovir 400 mg PO tid x 7 days

Recurrent Infections:
 Acyclovir 400 mg PO tid x 5 days
What is this Ulcer?
What are these lesions?
Syphilis

 Etiology:
-Treponema pallidum
 Transmission:
-Sexual during early stages
 Other features
-Primary, secondary and tertiary stages
Syphilis: Symptoms

 Primary syphilis:
-Single, oval, painless ulcer with clean base
-Usually on external genitalia
-Can be intravaginal or perianal
-Lymph nodes: bilateral, firm, non tender without
erythema
Syphilis: Symptoms

 Secondary Syphilis
-Generalized rash, non pruritic
-Involves palms of hands and soles of feet
-Mucous membrane patches
-Genital/perianal warts
-Patchy alopecia
-Generalized lymphadenopathy
-Fever, headache, malaise
What do these lesions
indicate?
Syphilis: Diagnosis

 Rapid Plasma Reagin (RPR) - a

nontreponemal test
-Measures non specific antibody. May
be false positives.

 Treponemal pallidum
hemagglutination (TPHA)
-Not used for screening
-Used for confirmation of positive RPR
(to identify false positives)
-Also used in the diagnosis of late
syphilis when RPR may be negative
Syphilis Diagnosis

 Clinical presentation
 RPR
 Confirm with TPHA
 Usually do not treat if RPR is negative
except
 In early primary syphilis when RPR may be
negative
Syphilis: Treatment

 Primary, secondary and early latent

-Benzathine penicillin G 2.4 million units IM
single dose
 Alternative: Pen allergic
-Doxy 100mg PO bid X 2 weeks
or
-Tetracycline 500mg PO qid x 2 weeks
 Contact tracing
Syphilis: Treatment

 Late syphilis: > 2 years duration

-Benzathine penicillin G 2.4 million units weekly
X 3 weeks
 Contact tracing
Chancroid

 Etiology: Haemophilus ducreyi

 Transmission: sexual contact
 Other features: Chancroid ulcer increase HIV
transmission
Chancroid Symptoms

 Symptoms:
-Painful ulcer (may be multiple)
-Painful inguinal lymphadenopathy in 50%
-Lymph nodes may be fluctuant and may rupture.
Chancroid Clinical
Presentation
Clinical
 Location - Men: glans penis
- Women: introitus, labia,
intravaginal

 Ulcer: surrounding erythema and undermined

edge, tender, non indurated with purulent base
 “kissing ulcers”
Chancroid Diagnosis

 Work up:
-Syphilis testing
-Consider herpes
 Chancroid Treatment
 Azithromycin 1.0 g single dose
or
 Ciprofloxacin 500 mg bid X 3 days
or
 Erythromycin 500 mg PO QID X 7days
 Contact tracing
 Needle aspiration of fluctuant lymph node
 painful ulcer…
“probably”
chancroid
Granuloma inguinale
(Donovanosis)
 Etiology Calymmatobacterium granulomatis;
gram negative
 Transmission: Sexual
Granuloma inguinale:
Symptoms
 Painless genital ulcer
 Multiple lesions
 Sometimes inguinal swelling
Granuloma inguinale:
Clinical Signs
 Four types:
1) Ulcer: with ready bleeding
2) Hypertrophic: wart like lesions
3) Necrotic: with deep ulcerations
4) Sclerotic: with extensive fibrosis
Granuloma inguinale:
Diagnosis & Treatment
 Diagnosis: Biopsy
 Treatment
 Septrin 1 tab (double strength) bid x 3 weeks to
3 months (until lesions are healed)
Or
 Doxycycline 100mg Po bid X 3 weeks to 3
months (until lesions are healed)
Genital Ulcer Disease
Management
 Treat for syphilis
Plus
 Treat for chancroid

If indicated . . .
 Add treatment for LGV +/or
granuloma inguinale if indicated
 Aspirate fluctuant glands (do not
do surgical incision)
 Educate and counsel on risk
reduction
GUD Treatment

Options for Syphilis Options for Chancroid

 Benzathine  Ciprofloxacin
Penicillin 2.4 500 mg bid x 3
million units IM
days
If Penicillin allergic:  Erythromycin
 Doxycycline 100 500 mg qid x 7
mg PO bid x 15
days
days
 Azithromycin 1
 Tetracycline 500
mg PO qid x 15 gram single
days dose
GUD Treatment

Options for granuloma Options for LGV

inguinale

 Azithromycin
 Doxycycline
500 mg PO
daily until 100mg PO bid
healed X 14 days
 Erythromycin
 Doxycycline
100mg PO bid 500 mg PO qid
until healed x14days
Vaginal
Discharge
Vaginal Discharge

The source of vaginal discharge can be either

from:

 A cervical infection
OR
 A vaginal infection
Causes of Infection

Vaginal Cervical

 Trichomonas  Neisseria
Vaginalis Gonorrhea
 Candida  Chlamydia
albicans Trachomatis
 Bacterial  Herpes
vaginosis
Important points to
remember about Vaginal
Discharge…
 Vaginal discharge is most commonly due to vaginal
infection

 Vaginal discharge is a poor predictor of cervical infection

Signs associated with
vaginal discharge due to
vaginal infection
Candidiasis Bacterial Vaginosis
 Vulvar erythema  Scant to moderate
 Clumped white discharge discharge
(cottage cheese)
 White, homogeneous,
Trichomonas

covering vaginal walls
Purulent yellow discharge
 No erythema
 Mucosal erythema
 Strawberry cervix
 Bubbles in fluid
Symptoms associated with

vaginal discharge due to

vaginal infectionBacterial Vaginosis
Candidiasis
 Burning pain, pruritis  Fishy odor
 Scant vaginal discharge
 Increased vaginal
 External dysuria
discharge
 Often asymptomatic
Trichomonas
 Profuse vaginal discharge
 Vulvar pruritis
 Occasional malodor
Trichomoniasis

 Etiology: trichomonas vaginalis (protozoa)

 Transmission: sexual
Trichomoniasis:
Symptoms
 Increased vaginal discharge, often profuse
 Vulvar pruritis
 Malodor of vaginal discharge
Trichomoniasis: Clinical
Signs
 Vaginal discharge:
-purulent (yellow)
-copious
-bubbles in vaginal fluid
 Mucosa
-erythema
-“strawberry cervix” (petechiae on ectocervix)
Trichomoniasis
Trichomoniasis: Diagnosis

 Wet Mount:
-Rub swab against vaginal wall (not endocervix)
-Insert swab in transport medium
-Examine within 15 minutes; look for motile
flagellated trichomonads
Trichomoniasis:
Treatment
 Metronidazole 2 g PO single dose
or
 Metronidazole 400 mg PO bid X 7 days
 Do not consume alcohol
 Contact tracing and treatment; may be
asymptomatic
What are these cells
called?
Clue cells; are
epithelial cells
covered with
bacteria….like
lace
Bacterial Vaginosis (BV)

 Transmission: Not sexual

 Caused by an absence of Lactobacillus and an
overgrowth of bacteria.
 Vaginosis = no inflammatory response
 Douching is a major cause of BV
 Associated with PID, premature labour and
other labour complications
Bacterial Vaginosis:
Symptoms
 Genital malodor “fishy odor”; worse after
intercourse
 Increased vaginal discharge
Bacterial Vaginosis:
Clinical Signs
 Determine if the vaginal discharge is coming
from the vagina or the cervix
 Assess character of the vaginal discharge:
-Scant to moderate white, homogeneous, vaginal
discharge coating vaginal walls
-No erythema
Bacterial Vaginosis:
Diagnosis
 Four criteria for the diagnosis of BV
1) Vaginal fluid pH > 4.7 (WHO > 4.5)
2)+ Whiff test
3)Grey discharge
4)Numerous clue cells are seen; an irregularly
bordered squamous epithelial cell with at
least 75% of the outline obliterated by
clusters of bacteria
Bacterial Vaginosis:
Treatment
 Treat only if symptomatic
 Metronidazole:
 500mg Po bid X 7 days or
 Single Dose 2 Gram single dose
 Discourage vaginal douching
 Routine treatment of partners not necessary
Vulvovaginal Candidiasis

 Etiology: Candida albicans

 Transmission: not sexual
 Causes: - antibiotic therapy
- immune suppression
- diabetes
- steroid therapy
Vulvovaginal Candidiasis:
Symptoms
 Vulvar burning
 Vulvar pruritis
 Scant vaginal discharge
 dysuria
Vulvovaginal Candidiasis:
Clinical Signs
 Determine if the vaginal discharge is coming
from the vagina or the cervix
 Assess character of the vaginal discharge:
-Scant, clumped, white, adherent to vaginal
mucosa
-Vulvar erythema
Vulvovaginal Candidiasis:
Diagnosis
 Vaginal fluid pH < 4.5
 “Whiff” test: negative
 Wet mount: after KOH hyphae are seen
Vulvovaginal Candidiasis:
Treatment
 Fluconazole 200mg PO single dose
 Intravaginal cream or suppository (pessary)
-clotrimazole
-miconazole
Syndromic Treatment
for Vaginal Infection:

Treatment for Candidiasis

 Single dose fluconazole 200mg PO stat

 Miconazole or clotrimazole 200 mg

intravaginally
daily x 3 days
Or
 Clotrimazole 500 mg intravaginally as a
single dose
Counseling:
 Sex partners do not need to be treated
 Avoid douching or antibiotic use
 Consider diabetes, HIV infection, steroid use
The END