Sexually Transmitted Infections -

Syndromic Approach
 Review

Q.1. What are the purposes of Breast care?

A.1. Purposes of the breast care are to clean the breast
and prevent complications and infection to the baby. It
also helps to assess the breast for any complications
such as mastitis, engorgement and cracked and inverted
nipple.
Q.2. What is Perineal care?
A.2. It is the aseptic irrigation of the vulva and perineum
following delivery or an operation of the birth canal.

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 Objectives

 At the end of the session, students will be able to:

 Define Sexually Transmitted Infections

 List down different STIs and their causes

 Enumerate the routes of transmission and factors influencing

the risks of STIs
 Explain the management of STI using syndromic approach.

 Explain how to prevent STIs

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 Reproductive tract infections (RTI)

 Infection of the reproductive tract.

 In women, this includes infections of the outer
genitals, vagina, cervix, uterus, tubes, or ovaries.
 In men, RTI involve the penis, testes, scrotum, or
prostate.
 RTI include both sexually transmitted infections (STI)
and non-sexually transmitted infections.

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 Sexually transmitted infections (STI)

 Infections caused by germs such as bacteria, viruses, or

protozoa that are passed from one person to another
through sexual contact.
 Sexually transmitted organisms may be sometimes
transmitted by nonsexual modes of transmission.
 Sexually transmissible infections (STI) are also known as
sexually transmitted diseases (STDs).

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 STDs versus STIs

 The terminology used to describe infections and diseases

acquired through sexual contact
 The term STI was approved by WHO and hence became the
standardized term.

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 Modes of transmission of RTI
STIs: Sexual contact
Non STIs: Disturbances of the normal endogenous flora and by
medical interventions like
 Unsafe sex
 Unsafe procedures like unsafe abortions, unsafe delivery, other
trans-cervical procedures
 Unsafe blood transfusions
 Due to disturbances of the normal vaginal flora containing
bacteria and fungi.
 Break in normal vaginal flora
 Postpartum and post abortion infections
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 IUD procedures
 Factors contributing in the spread of
RTI/STI

 Iatrogenic infections

 Endogenous infections
 Multiple sexual partners (communities are
disrupted communities, migrant labours and
commercial sex workers)

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 Factors that increase the risk of RTI
1. Biological Factors
– Age
– Sex
– Immune Status
2. Behavioural Factors
– Personal sexual behaviours
– Risky behaviours
3. Social Factors

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 Quick Recall: Risk factors for RTI/STI
RTI
 Poor general health
 Poor genital hygiene
 Poor menstrual hygiene
 Unhygienic practices by service providers during delivery, abortion, and
IUCD insertion in women
STI
 Unprotected sex
 Multiple Partners
 Sex with Partner having sore on the genital region, urethral discharge or
infected vaginal discharge
 Previous STI infection(s) in the past year

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 Special concerns for STI/RTI in women
 Women are more susceptible to infection and are less
likely to seek treatment than are men.
 The potential complications of untreated STI/RTI are
more serious in women
 Infections can be transmitted to the offspring of pregnant
women as well.

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 Risk groups
 Adolescent girls and boys who are sexually active and
indulging in unsafe sex
 Women who have several partners
 Female and male sex workers and their clients
 Men and women whose jobs force them to be away from
their families or regular sexual partners are away for long
periods of time
 Men having sex with men including transgender
 Street children, prison inmates, etc.
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 Body sites where STI/RTI could occur

 Outer genitals, vagina and cervix (lower

reproductive tract infections)

 Uterus, fallopian tubes, and ovaries (upper

reproductive tract infections)

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 Common RTI and Causative Organisms

1. Bacterial
Vaginosis (BV)
2. Vaginal yeast
infection

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 Common STI and Causative Organisms

1. Syphilis:
A STI due to infection by
Treponema Pallidum that
initially causes sores that
will heal on their own but,
if left untreated, can
cause serious
complications or even
death.

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Common STI and Causative Organisms

2.Gonorrhoea:
A STI due to infection by
Neisseria gonorrhoea
that can cause infertility
in both men and women.
It also causes
ophthalmia neonatarum.

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 Common STI and Causative Organisms

3.Chlamydial
infection:
A STI due to infection
by Chlamydia
trachomatis in both
men and women. It is
often asymptomatic

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Common STI and Causative Organisms

4.Trichomonas
infection:
A STI due to infection by
Trichomonas vaginalis in
both men and women. It
is often asymptomatic.

Discharge in
females

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Common STI and Causative Organisms

5.Chancroid:
A STI due to infection by
Haemophilus ducreyi,
that causes lymph node
swelling and painful
ulcers in the genital area.

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Common STI and Causative Organisms

6.Genital herpes:
A STI due to Herpes
simplex virus that causes
painful genital ulcers.

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 Common STI and Causative Organisms

7.Genital and cervical

warts:
Due to Human papilloma
virus (HPV) - Growth or
warts in the genital area
caused by some forms of
HPV. Other forms of HPVs
can lead to cervical cancer.

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 Common STI and Causative Organisms
8.HIV infection:Caused by (Human
immunodeficiency virus) a retrovirus that weakens the
immune system and causes AIDS.

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 Common STI and Causative Organisms
9.Hepatitis B and Hepatitis C infection:
Caused by virus that can cause liver damage, and possibly
even liver failure

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 Common STI and Causative Organisms
10.Donovanosis:
A STI due to infection by Calymmatobacterium granulomatis
or Kleibsella granulomatis that can cause serious ulcers at
the site of infection. These ulcers can grow together and
cause permanent scarring and genital destruction.

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 Common STI and Causative Organisms
11.Lymphogranuloma venereum (LGV):
A STI due to a subtype of
Chlamydia trachomatis that
causes inflammation of and
prevents drainage of the
lymph nodes in the genital
area. LGV can cause
destruction and scarring of
surrounding tissue.

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 Common STI and Causative Organisms
12.Molluscum contagiosum:
A STI due to a virus that causes relatively benign skin
infections. Molluscum contagiosum infection can lead to
secondary bacterial infections.

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 Common STI and Causative Organisms

13.Genital scabies:
A STI in both men and
women caused by itch
mite, sarcoptis scabiei.

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Common STI and Causative Organisms

14.Pubic lice:
A STI in both men and
women caused by pubic
lice (phthirus pubis).

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 Syndromic Approach

 Diagnosis is based on the identification of syndromes

 Should be used only when a patient presents with a
STI/RTI complaint
 Should not be used to screen for STI/RTI

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 Syndromic Approach

 The clinical entities may present as:

(i) vaginal or urethral discharge;

(ii) vesicular and/or nonvesicular genital ulcers;

(iii)inguinal bubo;

(iv)lower abdominal and/or scrotal pain; and

(v) genital skin conditions.

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 Syndromic Approach
Signs and symptoms of STI/RTI in women
 Unusual vaginal discharge:
– Bacterial Vaginosis (BV), Chlamydia, gonorrhoea,
trichomonas infection, vaginal yeast infection
 Genital itching:
– BV, trichomonas infection, vaginal yeast infection
 Bleeding after intercourse:
– Chlamydia, gonorrhoea, chancroid and genital herpes
 Blisters or ulcers (sores) on the mouth, lips, genitals
or anus
– Chancroid, genital herpes, and syphilis

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 Syndromic Approach
Signs and symptoms of STI/RTI in women
 Abnormal and/or heavy vaginal bleeding:
– Chlamydia, gonorrhoea
 Lower abdominal pain (pain below the belly button; pelvic
pain):
– chlamydia, gonorrhoea
 Persistent vaginal candidiasis:
– HIV/AIDS
 Burning or pain during urination:
– chlamydia, genital herpes, trichomonas infection and
gonorrhoea

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 Syndromic Approach
Signs and symptoms of STI/RTI in women
 Jaundice and/or fever, headache, muscle ache, dark
urine:
– Hepatitis B, hepatitis C
 Warts or bumps on the genitals, anus, or
surrounding areas:
– HPV (genital warts)
 Fever, fatigue, headaches, muscle aches, mild liver
inflammation:
– CMV
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 Syndromic Approach
Signs and symptoms of STI/RTI in women
 Small, dimpled bumps or lesions that are flesh colored,
(vary from white to yellow to pink):
Molluscum contagiosum
 Small, red lesions or ulcers in the genital or anal area;
lymph node swelling in the genital area; chronic ulcers on
the genitals or anus:
LGV (Lympho Granuloma Venereum)
 Red nodules or bumps under the skin on the mouth,
genitals, or anus that ulcerate, become tender, and often
bleed easily:
Donovanosis 34
 STI/RTI CASE MANAGEMENT

It is important because it:

 Prevents long-term complications.

 Reduces the length of time of infection and the further

spread of STI/RTI.
 Reduces the level of STI/RTI in the population

 Allows for education and counseling

 Improves the quality of people’s lives.

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 The 7 steps of comprehensive STI/RTI
case management
1. Take history
2. Conduct physical examination
3. Provide treatment
4. Provide health education on prevention
5. Provide condoms and demonstrate use
6. Offer Partner treatment
7. Follow up or refer as needed

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 The syndromic case management
approach
Advantages:
 Fast—diagnosis and treatment in one visit.

 Highly effective for selected STI/RTI syndromes.

 Relatively inexpensive

 No need for patient to return for lab results.

 Avoids the wrong treatment

 Can be used by providers at all levels

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 Management of STI/RTI at PHC level

 Taking a history and doing a physical examination he

arrives at a diagnosis of STI/RTI.
 If laboratory available- confirms the diagnosis.
 Treats STI/RTI case by providing medicines/drugs and
information on how to take them.
 Prevents another STI/RTI by educating the patient
 Promotes and provides condoms.
 Offers partner/s treatment
 If not responding refers to higher center

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 ANMs/Nursing Personnel role in case
management
 Referring patients to the clinic
 Referring patients or Clients who are having risk
for screening asymptomatic clients
 In Client education for treatment compliance and
follow up
 In Partner management by motivating them for
treatment and follow up and in community
awareness
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 COMPLICATIONS OF STI/RTI
 Pelvic inflammatory disease
 Adverse outcomes of pregnancy: spontaneous abortion or
stillbirth, Low birth weight, Congenital or perinatal infections
 Infertility
 Ectopic pregnancy
 Cervical cancer

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 COMPLICATIONS OF STI/RTI IN
NEWBORN BABIES
 Congenital syphilis
 Gonorrhoea
 Chlamydia
 HIV/AIDS
 Herpes simplex infection
 Hepatitis B
 Prematurity

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 PREVENTION OF STI/RTI

Primary prevention
 Creating awareness and imparting knowledge Advising on
practicing safe sex
 Correct and consistent use of condom
 Having single partner, avoiding multiple partners
 Maintaining sexual hygiene
 Removing stigma and bias
 Safe delivery and safe abortion services
 Screening of every pregnant women

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 PREVENTION OF STI/RTI
Secondary prevention
 Early diagnosis and prompt treatment by trained health
care personnel prevents spread of infection
 Correct and adequate treatment
 Treatment of both the partners simultaneously
 Strengthening the referral system
 Accessible and affordable STI/RTI services in locality

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 PREVENTION OF STI/RTI

Tertiary prevention
 Prevention of late complications, complications of
infertility and children

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 Case study for practice

 Case 1: Rani, a recently married 23 year old woman

presents with dull, persistent lower abdominal pain. She
is not sure of increased vaginal discharge, and her
periods are of normal cycle. She has never been
pregnant.
 Q: How would you apply the Syndromic Case
Management approach to her case?

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 Case study for practice

 Case 2: Seetha, a 42 yr female presents with purulent

vaginal discharge of 5 days duration. She has no ulcers
or any other lesions on the genitalia and no previous
history.
 Q: How would you apply the Syndromic Case
Management approach to his case?

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 Summary
 STD means sexually transmitted diseases caused by
microbes that are passed from one person to another through
sexual contact.
 There are many reasons for high prevalence of STI/RTI,
which include lack of access to health care and medicines,
lack of awareness of STI, and in-out migration.
 Syndromic approach is the diagnosis is based on the
identification of syndromes

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 Assignment

 Divide the students into groups of 5. Ask each

group to do case studies 3 and 4 from the
annexures under the supervision of the faculty
incharge in the ANM/GNM school. Use the
handout on syndromic case management
approach to complete the case studies

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 Post-Session Knowledge Assessment

Q.1. Sexually transmitted organisms may be sometimes

transmitted by nonsexual modes of transmission also
A.1. True
Q. 2. In women, overgrowth of endogenous microorganisms
normally found in the vagina may cause RTI
A. 2. True
Q.3. STIs are not very common among commercial sex workers
A.3. False

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 Post-Session Knowledge Assessment

Q.4. Unhygienic practices by service providers

during delivery, abortion, and IUCD insertion in
women may cause STIs
A.4. True
Q.5. Syphilis is caused by Niesseria organism
A.5. False

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