Vaginal discharge flowchart

1 Patient complains of vaginal discharge, Risk factors for cervical infection in Malawi
vulval itching or burning 1) If the client’s husband has urethral discharge or genital ulcers, she has a
positive risk assessment, regardless of the next question.
2) If the client answers yes to two or more of the following
•She is younger than 25 years of age
2 Take history and examine patient •She has a single marital status
Do a speculum exam, if possible •She has had a new sex partner in the 3 months preceding this visit
Assess risk1 •She has had more than 1 sex partner in the 3 months preceding this visit.

5 • Reassure patient
3 No Any other genital No • Educate and counsel
Vaginal discharge present? 4 disease present? • Promote condom use and provide condoms
• Offer Provider Initiated Testing and Counselling
Yes • Review if symptoms persist or recur
Yes
6 Use appropriate flowchart
for additional treatment

10 • Educate and counsel

No No Treat for Bacterial Vaginosis and T. • Promote condom use and
7 9
Lower abdominal tenderness present? Is the risk assessment positive? vaginalis with: provide condoms
•Metronidazole 2 grams orally, • Provider Initiated Testing
single dose & Counselling
Yes Yes
11 Treat patient for N. gonorrhoeae, C.
8 Use Flowchart for Lower Trachomatis & T. vaginalis with: No
•Gentamicin 240 mg IM single dose Is discharge white and
Abdominal Pain curd-like or vulval
•Doxycycline 100 twice daily for 7 days 12
(In pregnancy use Erythromycin 500 mg 6- excoriations and/ or
oedema
hourly for 7 days)
•Metronidazole 2 gram, orally, single dose
Yes

14 • Educate and counsel on risk 13 Treat for candidiasis with:

reduction •Clotrimazole vaginal pessaries, 500 mg
• Promote condom use and provide intravaginally, single dose
condoms
• Offer Provider Initiated Testing &
Counselling
1
Client complains of lower abdominal pain

Lower abdominal pain

2
• Take history (including gynaecological history)
• Examine client (abdominal and vaginal,
including speculum examination)

Are any of the following present? 7• Reassure patient

• Missed/overdue period No • Educate and counsel on risk
Are the following present?
• Recent delivery/abortion/miscarriage No No reduction
3 • Abdominal guarding and/or rebound
5 •cervical excitation tenderness 6 Are there signs of
any other disease • Offer Provider Initiated Testing &
tenderness •Abdominal tenderness
present? Counselling
• Abnormal vaginal bleeding •Vaginal discharge • Promote condom use and provide
• Abdominal mass condoms
• Fever of more than 38°C Yes • Review if symptoms persist or recur
Yes
9 Treat for PID with:
•Gentamicin 240 mg, IM, single dose 8
•Doxycycline 100 mg, orally twice daily for
Yes 14 days Manage appropriately
•Metronidazole 400 mg, orally, twice a day or Refer
for 14 days

• Educate and counsel on risk reduction

• Ensure management of sex partner(s)
• Review in 3 days
4 Refer patient urgently
•for further assessment 10
•surgical intervention or No Client has improved?
•gynaecological opinion
Note: Before referral set up an
IV line and apply resuscitatory Yes
measures if necessary
11 Continue treatment until completed
•Educate and counsel on treatment compliance
and risk reduction
•Offer Provider Initiated Testing and Counselling
•Promote condom use and provide condoms
•Review when treatment completed, or sooner, if
necessary
 Urethral Discharge Flowchart
Patient complains
1 of urethral discharge
or dysuria

2 • Educate and counsel on risk reduction

• Take history and examine 7 • Promote and provide condoms
• Milk urethra if necessary • Proceed with Provider Initiated Testing
• Perform risk assessment & Counselling
• Review if symptoms persist

No
Is the following present? No
3 Sign of any other No Sign of any other
•Urethral discharge. 4 6 condition present?
STI present?
•Dysuria + positive risk assessment ‡
Yes Yes
Yes
5 8
Use appropriate flowchart Manage appropriately or refer
and/or treat appropriately
9 Treat patient and sex partners with:
•Gentamicin 240 mg IM single dose
•Doxycycline 100 mg orally twice a day for 7
days
NB. ‡ A man with dysuria is considered to have a
•Metronidazole 2 grams orally as a single dose
positive risk factor for an STI if he has had
• Educate on treatment compliance, risk reduction unprotected sex during the preceding two weeks
and condom use
• Provide condoms and counselling
• Proceed with Provider Initiated Testing &
Counselling
• Review in 7 days, if symptoms persist
Persistent/recurrent urethral discharge in men
N.B. This flowchart assumes that the patient has received and taken effective therapy for gonorrhoea and chlamydia prior to this consultation

1 Patient presents with persistent genital discharge

following treatment with a recommended first line
regimen

2 •Take history and examine

•Milk urethra, if necessary

3 Discharge •Collect urethral specimen for microscopy,

present? culture and sensitivity testing, if possible
Yes •Treat immediately with ceftriaxone IM 250 mg.
•Treat for TV, Mycoplasma genitalium
4 Are the following likely?
No
•Reinfection or 6 9 MANAGE AS TREATMENT
•Poor treatment compliance •Educate and counsel FAILURE DUE TO
•Ensure HIV counselling and testing has been ANTIMICROBIAL
Yes done RESISTANCE
•Promote/provide condoms
•Ensure treatment of sex partner(s) 1. Refer for, or manage with,
•Review in 3-5 days, and check test results, if laboratory guided
5 Retreat for urethral discharge treatment in consultation
available
syndrome with other experts
•Educate and counsel 2. Notify relevant health
No
•Ensure HIV counselling and testing 7 Clinically cured? authorities and GASP
has been done. Networks
•Promote/provide condoms Yes
•Ensure treatment of sex partner(s) PATIENT AND SEX
•Review in 7 days if symptoms persist PARTNERS TO BE
8 •Educate and counsel FOLLOWED UP AND
•Promote/provide condoms
MANAGED UNTIL CURED
•Ensure treatment of sex
MICROBIOLOGICALLY
partner(s)
 1 Patient complains of a genital sore or ulcer
Genital ulcer disease Flowchart

2 Take history and examine patient

4 • Reassure patient
No
Genital sores or ulcers No Signs of other STIs or genital 5 • Educate and counsel on risk reduction
3 present? condition present? • Promote condom use and provide condoms

Yes
Yes
7 Treat patient and sexpartner(s) with: 6 TREAT according to appropriate flowchart
•Benzathine penicillin 2.4 mega Units IM
OR
stat
Refer
•Ciprofloxacin 500 mg, orally, twice daily
for 3 days
Note: For management of inguinal buboes, if
•Acyclovir 800 mg, orally, 3 times a day
present, refer to Inguinal bubo flowchart
for 2 days
• Educate and counsel
• Offer HIV counselling and services
• Promote condom use and provide
condoms
• Ensure management of sex partner(s)
• Review in 3-5 days

No No 10 Refer for investigation and further management

8 Ulcer healed? 9 Ulcer(s) healing?

Yes Yes
12 11 • No need for further treatment
•Discharge patient
•Reinforce education and counselling on risk • Review if not healed in another 5 to 7 days.
reduction
•Promote condom use and provide condoms
 1
Client complains of swelling in the groin(s)
Inguinal Bubo Flowchart

2 • Take history
• Examine patient

No 5 • Reassure patient
Inguinal/femoral No Signs of other
3 • Educate and counsel on risk reduction
4 STIs or genital
bubo(s)present? • Provider Initiated Testing and Counselling
condition?
• Promote condom use and provide condoms

Yes

6
Yes Use appropriate flowchart

8 Treat for Lymphogranuloma venereum and Chancroid with the

No following medicines:
7 Ulcer(s) present? •Doxycycline 100 mg orally, twice a day for 14 days
•Ciprofloxacin 500 mg orally, twice a day for 3 days

Yes • If fluctuant aspirate through healthy skin

• Educate on treatment compliance
9 Treat for Syphilis, Chancroid, Genital Herpes, and • Counsel on risk reduction
Lymphogranuloma Venereum with the following medicines: • Promote and provide condoms
•Doxycycline 100 mg orally, for 14 days • Partner management
•Ciprofloxacin 500 mg orally, twice a day for 3 days • Provider Initiated Testing and Counselling
•Acyclovir 800 mg 3times a day orally for 3 days Advise to return for review in 7 days, and continue treatment if
improving or refer if worse
• If bubo fluctuant aspirate through healthy skin
• Educate on treatment compliance
• Counsel on risk reduction
• Promote condom use and provide condoms
• Ensure management of sex partner(s)
• Provider Initiated Testing and Counselling
Advise to return for review in 7 days, and continue treatment if
improving or refer if worse
1 Client complains of scrotal swelling and/or pain
Scrotal swelling
• Take history
2 • Examine patient

• Reassure patient
5
• Educate and counsel on risk reduction
No
4 No
3 Scrotal swelling and/or pain confirmed? • Provide analgesics, if necessary
Signs of other STIs or genital conditions?
• Provider Initiated Testing and Counselling
• Promote condom use and provide condoms
• Review if symptoms recur/persist
Yes
Yes
6 Manage according to
appropriate flowchart

8 Treat for N. gonorrhoeae and C. trachomatis with:

No •Gentamicin 240 mg, IM as a single dose
Testis rotated or elevated, or •Doxycycline 100 mg twice daily for 7 days
7 history of trauma?
• Educate and counsel
• Provider Initiated Testing and Counselling
Yes • Manage and treat sex partner(s)
• Promote condom use and provide condoms
• Review in 3 days if possible, or in 7 days

9
Refer urgently for surgical
assessment 10 No 11
Refer for further
Clinically improved in terms of swelling and/or pain? assessment

Yes

12 • Continue treatment to complete course of antibiotics

• Educate and counsel on risk reduction and HIV
infection
• Promote condom use and provide condoms
• Manage and treat sex partner(s)
• Review if not symptom-free at completion of treatment
1 Patient complains of itching or discharge on glans penis Management of balanitis and balanoposthitis in men

2 • Take history
• Examine patient

No
3
Foreskin is retractable? 4 Refer for urological assessment
(if not circumcised)

Yes
Yes 6
5 Treat as genital ulcer disease
Genital ulcers present?
(Follow GUD flowchart)
No
8 • Reassure patient
7 No
Erythema or erosions present? • Educate and counsel
• Advise on personal hygiene to wash frequently
Yes with soap and water
• Provider Initiated Testing & Counselling
Treat for candida infection with: • Promote condom use and provide condoms
9
• Clotrimazole 1% cream, twice daily for 7 days
OR
•Gentian Violet 1% aqueous solution daily for 7 days

• Educate and counsel on risk reduction

• Advise on personal hygiene to wash frequently with
soap and water
• Promote condom use and provide condoms
• Provider Initiated Testing & Counselling
• Review in 7 days

11 • Reassure patient
• Educate and counsel
No • Advise on personal hygiene to wash
10 Symptoms persist?
frequently with soap and water
• Promote condom use and provide
Yes condoms

12 Treat for trichomoniasis with:

•Metronidazole 2 grams, orally, single dose
• Reinforce health education
• Promote condom use and provide condoms
 1
Neonate with eye discharge

Ophthalmia neonatorum
2 • Take birth and medical history
• Examine infant

• Bilateral or unilateral 5
swollen eyelids with purulent No No • Reassure mother
Signs of any
3 discharge present? And/or 4 illness present? • Educate parents
• Redness of the conjunctiva? • Advise to return if necessary
Yes
Yes
7 Treat baby for gonococcal and chlamydial infection with: 6 Manage or treat appropriately
•Wash eyes with Saline or Water every 2 hours until the
discharge has cleared
•Gentamicin 5 mg/kg IM once (or 7.5 mg/kg if infant is
older than 7 days)
•Azithromycin 20mg/kg, orally every od for 3 days

Treat mother & her sex partners for gonococcal &

chlamydial infection with:
•Gentamicin 240 mg IM stat PLUS
•Erythromycin 500 mg, orally every 6 hours for 7 days
For the male partner , use:
•Gentamicin 240 mg IM stat PLUS
•Doxycycline 100 mg orally, twice day for 7 days

• Educate and counsel parents on risk reduction

• Promote and provide condoms
• Review baby in 7 days, or sooner if worse

8 No 9 Refer patient to a
Eye infection cleared?
specialist for opinion and
management
Yes
10 • Complete course of treatment
• Reinforce education and counselling for parents
• Promote condom use and provide condoms for parents
• Advise to return if necessary
 Ano-rectal infections
1
Patient with passive/receptive anal sex in last
6 months and/or anal symptoms

2
• Take history
• Examine patient, including ano-genital area
• Proceed with HTC

RISK ASSESSMENT 6
No 4 No • Unprotected sex in last 6 months? No Other medical
3 Ano-rectal ulcer present? 5 condition detected?
Anal discharge present? plus
• Partner with STI? or
• Multiple sex partners?
Yes Yes No Yes

11 Treat for Gonorrhoea, Chlamydia, Syphilis Yes

Yes 8 7• Treat appropriately OR
and HSV2, with: Anal and/or perineal pain? • Refer
•Gentamicin 240 mg IM single dose
•Doxycycline 100 mg twice daily for 7 days
•Benzathine penicillin 2.4 mega Units, IM No
single dose 9
1 8-hourly for 2 days
•Acyclovir 800 mg Treat for Gonorrhoea and Chlamydia with:
•Gentamicin 240 mg IM, single dose
• Educate and counsel on risk reduction •Doxycycline 100 mg twice daily for 7 days
• Promote condom use and provide condoms
• Follow up after 1 week

10
• Educate & counsel on risk reduction
12 If symptoms persist: • Promote and provide condoms
• Treat for LGV with:
•Doxycycline 100 mg twice daily for 21
days
OR
• Refer for other gastrointestinal
assessments