1

SEXUALLY TRANSMITTED
INFECTIONS
By Nakaweesi Susan Kigongo
 SEXUALLY TRANSMITTED DISEASES
/HIV/AIDS
2

Learning objectives
By the end of the session, each learner
will be able to:
1.Define STDs and STIs
2.List the common STDs
3.Describe clinical features, causative
agents and incubation periods of STIs
4.Describe the common complications
of STDs
 Introduction
3
 They are infections which are
generally acquired through
unprotected sexual intercourse with
another person who is infected with
particular diseases.
 The organisms may pass from person

to person in blood, semen, vaginal

fluids and other body fluids or from
mother to child during pregnancy,
4

 Effective STI case mgt is the cornerstone for

STD control through breaking the chain of
transmission from infected to non infected
persons.
 The syndromic approach to STI case mgt was

adopted as a cost effective intervention where

treatment can be provided at the first point of
contact of the patient and the health care
delivery system. It also facilitates integration
of STI case mgt into primary health and
reproductive health.
 Basic facts about STDs
5
 Infectious diseases caused by micro-
organisms
 They are mainly transmitted from one

infected person to another during

unprotected sexual intercourse.
 They lead to serious complications if

they are not treated or if they are

poorly treated.
 Most people are asymptomatic or
 Common causes of STDs
6
 Bacteria
 Protozoa (parasites)

 Viruses (HPV, genital herpes, HIV)

 Fungus
 Risk factors for acquiring STDs
7

 Unprotected sexual intercourse; like genital,

oral penetration by an infected partner
 Improper and inconsistent use of condom
significantly increases the risk of getting
STDs.
 Multiple sexual partners
 Rape, or sexual assault are usually done
forcefully and exposes the victims to
trauma and therefore easy point for
bacteria and virus from the penetration.
 Risk factors for acquiring
8
STDs
Drug abuse, needle sharing spread many
serious infections including HIV, Hep B & C.
Although this can be acquired through
injection they can be transmitted sexually.
Alcohol abuse; substance abuse can inhibits
one‘s judgment making one more willing to
participate in risky behaviors
Transmission from mother to child during
pregnancy, child birth e.g. HIV, gonorrhea,
Chlamydia & syphilis.
 Risk factors for acquiring STDs
9
 Having an STD; being infected with one STIs
make it easier for another STIs to take hold
example, having herpes, syphilis, gonorrhea
or Chlamydia exposes one to contracting HIV.
 During period of transition from childhood to
adulthood, adolescent period is highly
associated with experimentation and risk
taking behaviors. They less mind of safe
sexual practices.
 Political instability where rape, forced
relationship are common.
 General control and prevention of
10
STIs
1. The most effective way of avoiding STIs
is to abstain from sex.
2. Correct and consistent use of condoms
Avoid excessive use of alcohol or use of
drugs
3. Vaccination; early vaccination before
sexual exposure is effective in preventing
certain STIs like HPV, Hep B
4. Mutual communication between
partners and being faithful (zero grazing)
11

 Life skill education to young adolescent &

those becoming sexually active on the
consequences of entering into early sexual
debut.
 Safe male circumcision; this is said to help
reduce one‘s risk of acquiring HIV from
infected women (heterosexual transmission).
 Male circumcision also helps prevent
transmission of genital HPV and genital
herpes.
 Complications of STIs
12

 Abortion  Infertility
 Premature labour  Pelvic pain

 Intrauterine  Hair loss

death  Eye infection

 Still birth  PIDs

 Congenital  Arthritis

syphilis  Divorce

 Recurrent genital

sores
 1.Chlamydia
13

 Common STIs caused by Chlamydia

trichomatis, a gram negative
bacterium.
 It is the cause of the most frequent

reported STDs
Mode of transmission
 It is spread through having
unprotected sex, vaginal & or oral
with an infected person.
 Signs and symptoms
14

In women In men
 Increased vaginal
 Watery discharge
discharge
 Vaginal bleeding
from the penis
 Burning/itching
 Bleeding between
around the penile
periods, during and
tip
after sex
 Frequent
 Lower abdominal

pain (LAP) micturition

 Burning pain or  Pain in testicules
15

Investigations
 Vaginal and Urethral swabs

 Urinalysis

Treatment
1. Azithromycin (Azuthromax) 1g single
dose
2. Erythromycin 500mg 6 hourly for 7 days

3. Levofloxacin (Levaquine) 500mg once

daily for 7 days.

 Complications
16

 PIDs
 Infertility

 Ectopic pregnancy

 Cervicitis

 Arthritis

 Bartholin‘s abscess

 Ophthalmic neonatorium
 2. Gonorrhea
17
 Caused by Neisseria gonorhoeae
bacterium that infects the mucus
membranes of the reproductive tract
including the cervix, uterus and fallopian
tubes in women & the urethra in women
and men.
 It can also affect the mucus membrane of

the mouth, throat, eyes and rectum.

 Gonorrhea can also be spread perinatally

from mother to child during delivery

 Signs and symptoms
18

In men
 Dysuria

 Sores on genitalis

A white yellow or green urethral

discharge that usually appears 1-4
days after infection
 Testicular or scrotal pain

 Burning in the throat

 Signs and symptoms
19

In female
 Dysuria
 Yellowish white (pus) vaginal
discharge
 Rectal discharge
 Genital sores
 Anal itching, soreness to oral sex
 Painful bowel movement
 Pharyngeal infection may cause a
 Complications
20

 Untreated gonorrhea can cause

permanent problems including risk of
acquiring HIV, hepatitis B&C
In neonates: Ophthalmic
neonatorium
In women
 PIDs
 Internal abscess and chronic pain
 Blockage of fallopian tube and
21
 UTI
 Bartholin‘s abscess
 Puerperal sepsis
 Ophthalmic neonatorium

In men
 Orchitis
 Spread to blood causing disseminated

gonococcal infections (DGI)

characterized by arthritis dermitis
 Treatment
22

 Ceftrixone 1gm in a single IM dose

 Azithromycin 1g orally in a single dose

 Doxycycline 100mg orally twice a day

Alternatives
 Cefixine 400mg in single dose orally

 Doxycycline 100mg orally twice a day

 3. Chancroid
23

 A localized genital infection caused

by bacillus
 Incubation period 2-5 days.

Signs and symptoms

 A small painful ulcer appears on the

genital parts. The ulcer is soft &

irregular, called soft chancre.
 Enlargement and inflammation of
the inguinal with pus.
24

Treatment
 Erythromycin 500mg thrice a day for

7 days
 Cotrimoxazole 960mg twice a day for

7 days
 4. Genital warts
25

(Condylomata Accuminata)
 This is a viral infection which
develops in genitals, perineum and
anus.
 In female, it rarely occurs in the

vagina.
 They grow rapidly during pregnancy

and regress in the peuperium.

 The infection, it may result in
 Treatment
26
 Application of 10% Podoophyllin to
the wart 2-3 times a week.
Note:
 Podoophyllin burns therefore; the
skin around it must be protected with
application of Vaseline.
 The medicine is washed after 4 hours

of application.
 Cauterization is another alternative
27

 The patient must be investigated for

syphilis to rule out the Condylomata
of the infection.
 Podoophyllin is contraindicated in
pregnancy so treatment is usually
delayed until after birth.
 5. Genital herpes (Herpes simplex)
28

 These are small painful blisters on

the vulva, perineum, vagina and or
the penis or perineum in male caused
by herpes simplex virus.
 Incubation period 2-21 days
 Signs and symptoms
29

 Small painful blister which bursts and

leave small red painful wounds
 Dysuria from irritation of urine
 Pyrexia
 Purulent vaginal discharge
 Muscle pain and headache with initial

attack
 Enlarged inguinal nodes which may

be tender on touch.
 Treatment
30

 5% Acyclovir cream application to

lessen 5 times daily for 5 days
OR
 Acyclovir 200mg orally 5 times daily

for 5 days.
 Warm saline bath to relief pain and to

prevent secondary infection

 Treatment of partner is important to

prevent re-infection.
31

Note: Pregnant women with active

genital herpes at term are usually
done elective cesarean section to
prevent risk of infections to the baby.
 6. Pelvic Inflammatory Diseases
32
(PID)
 This is infection of the upper genital
tract (uterus, fallopian tubes, ovaries
and peritoneum.
 It is a common complication as a

result of STDs (gonorrhea,

Chlamydia)
 Signs and symptoms
33

 Fever
 Abdominal pain and tenderness
 Extreme excitation (tenderness of
the vaginal fornices on moving it
cervix)
Treatment
 Metronidazole 400mg orally twice for

10 days
Plus
 Complications
34

 Salpingitis
 Infertility

 Chronic abdominal and pelvic pain

 Menstrual disorders

 Dysparuenia
 Prevention
35

 Safer sex practices

 Fidelity in marriage

 Avoid promiscuity

 Health education on STI

 Adequate detection and treatment of

infected persons.
 Investigations and serological tests of
pregnant mothers for adequate prompt
treatment.
 OTHER VAGINAL DISCHARGES
36

Leucorrhoea
Normal vaginal discharge
experienced by most women.
This is a symptomatic or not.
Characteristics
It is profuse
No irritation
White (sometimes slightly yellow) in
colour
37

 Odourless; it occurs due to increased

vaginal blood supply & increased
production of cervical mucus.
 Persistent or recurrent urethritis may be

due to drug resistance, poor compliance or

re-infection.
 There is increasing evidence of high
prevalence of Trichomonas vaginalis
among men, for which patients with
recurrent urethritis should be treated.
38

Advice
1. Frequent swabbing of vagina
2. Application of soft higher
absorbable pads if discharge is much
& frequent changing
3. Wearing of cotton/linen pants
 Syphilis
39

 Caused by spirochete known as

Treponema Pallidum with incubation
period of 9-90 days
Modes of transmission
 Vertical through mother to child
during the intrauterine life (trans
placental)
 Direct contact with infected
discharges
 Signs and symptoms-Primary stage
40
 Identified by the presence of sores or lesions
(chancre) which disappears at the sight of the
contact and from 10th -90th day after initial
exposure.
 The sore/chancre is firm, painless, superficial

ulcerated & may persist for 4-6 weeks and

heals of spontaneously.
 Painless regional lymphadenopathy may
develop within 1-2 weeks after the
appearance of the chancre. This stage may be
missed since the sore is usually painless.
 Secondary stage
41
 This is when the infection spread to the
blood stream. It occurs about 1-6 months
after the primary infection.
 It is characterized by flu like syndrome

(mild pyrexia, headache, anorexia and

sometimes weight loss)
 Lymphadenopathy and the appearing of

systemic reddish pink rashes on trunk &

the extremities, pain, soles of the feet and
body parts such as the anus and vagina.
 Secondary stage
42

 A flat-broad whitish lesions which develops

from the rash, this is very infectious
(Condylomata Lata)
 A grey white patches on the tongue, soft

palate and the throat known as Snail Tracks.

 Loss of hair (alopecia) may also occur
 Serological tests are positive
 This stage may last up to 9 months and is

followed by latent period where no clinical

signs are present.
43

Latent period
 A period of natural cure without clinical

presentations, lesions disappear & the

patient feels perfectly well.
Tertiary stage
 The disease affects the cardiovascular

system as well as nervous systems.

 It is usually after 1-10 years after initial

infection.
 When no RX was given, the
following may be present
44

 Swelling known as gamma may

appear on the skin, mucus membrane
and bones. Swelling on the skin may
ulcerate resulting into chronic ulcers.
 Spread to CVS may give rise to aortic

aneurysm (aortic insufficiency or

coronary arteriosclerosis)
45

 Spread to nervous system may give

rise to memory loss, confusion,
mental disability, unsteady gait
(general paralysis of the insane).
 Joint degeneration, failing sight and

deafness may occur.

 Diagnosis
46
 VDRL (venereal disease research
laboratory ) test
 RPR (rapid plasma reagent) test which

confirms the presence of the disease,

however, diagnosis may be made
from clinical history and
examinations.
 Rahm test and Wasserman are some

of the test for syphilis

 Treatment
47

1. Benzathin benzyl penicillin 2.4 mu once

weekly for 3 weeks
2. Allergic patient will be treated with
erythromycin 500mg orally 6 hourly for
2 weeks
3. Babies of mothers diagnosed with or
showing signs of syphilis are given
Benzathin penicillin 50000IU as a single
dose into lateral aspect of the thigh
 Education of clients
48

 Drug compliance to ensure care and

prevent resistance
 Risk of vertical transmission.
 Patient treatment is mandatory
 Partner‘s counseling & testing for

HIV
 Abstinence during treatment or
correct & consistent use of condoms.
 Effects of untreated syphilis and
pregnancy and child birth
49

 Mid trimester abortion usually after

20 weeks
 Premature labour
 Intrauterine fetal death
 IUFGR
 Still birth usually macerated
 Congenital syphilis
 Effects of untreated syphilis
50

 Aortic aneurysm and insufficiency

from spread to cardiovascular system
 Loss of memory, confusion, mental

disability & general paralysis of the

insane
 Coronary artery stenosis
 Joint degeneration, failing sight and

deafness.
 Education of clients
51
 Education on treatment compliance
 Promotion and provision of condoms

and demonstrating their use,

 Partner notification and offering
treatment,
 Offering or referring for HIV VCT
services if necessary Partners should
be treated irrespective of whether
they are insufficiency from spread to
 Hepatitis B
52
 Caused by hepatitis B virus found in
the DNA.
 It is associated with 3 antigens of their

antibodies.
 It is a disease of the liver and can be

fulminating (sudden onset).

 In adult, screening for active or chronic

disease is based on testing for the

presence of this antigen and
 Modes of transmission
53

 Blood and blood products

 Direct contact with saliva, tears,
sweats from an infected person
 Trans-placental; during pregnancy &

at birth
 Through vaginal fluids and semen

when playing live sex

 Vertical transmission via breast milk

(mother to child)
 Risk factors
54

1. Unborn children with infected

mother
2. Babies of infected mothers who are
breastfeeding
3. Health workers due to exposure &
other fluids from infected person
4. Drug abusers who share needles
especially from injection
 Signs and symptoms
55

Early signs and symptoms

 Skin eruptions
 Urticaria
 Arthralgia
 Lastitudes (general weakness)
 Anorexia
 Nausea and vomiting
 Headache, fever and mild abdominal

pain
56

Later signs and symptoms

 Clay colour stool
 Dark urine
 Increased abdominal pain
 Jaundice which may be severe

Screening and diagnosis

 All persons are at high risk for
contracting hep B must be screened
on a regular basis.
57
The Hep B antigen screening test is
usually done in rise in Hep B antigen
at the onset of clinical symptoms &
usually indicated and active infection.
If Hep B antigen appears persistently in
the blood, the person is identified as a
carrier.
If the test result is positive, further
laboratory study may be ordered such
 Management
58

1. No specific management for Hepatitis B

2. Recovery is usually spontaneous in 3-
16 weeks
3. Advise on bed rest, high protein diet,
low fat diet and increased intake of fluids
4. Advise person to avoid drugs & alcohol
and other medications metabolized in the
liver.
59

5. Women with definite exposure in

Hep B should be given Hep B
immunoglobulin (HBig) and begins the
Hep B vaccine series within 14 days of
the most recent contact to prevent
infection.
6. Advise on high level of personal
hygiene
 Prevention
60

Vaccination is the most effective mean

recommended for all non-immunized person
who have had;
 Multiple sexual partners within the first 6
months,
 IV drug users and whose partners are IV
drug users
 Health center workers,
 Person seeking for an STIs treatment,
 Sex workers
61

The vaccine is given in series of 3

doses over a period of six months, with
the first two doses given at least 1
month apart and 1st and 3rd dose at
least 4 months
 Patient education
62
 Explain the meaning of hepatitis B
including transmission
 Explain the need for immune-
prophylaxis for household members
 Advise persons who test positive to
maintain high level of personal
hygiene e.g. hand washing at least
three times, proper disposal of pads &
avoid sharing sharps
63

 If partners are not vaccinated, they

should use condoms correctly &
consistently
 Teach all persons not infected to avoid
kissing, sharing dishes, or saliva,
wears
 Educate on cleaning of any spillages
of blood or body fluids immediately
with soaps & water.
 Basic facts about STIs
64

 STDs are infectious diseases caused by

one or more micro-organisms that are
mainly transmitted from one infected
person to another during unprotected
sexual intercourse.
 Main clinical features

 Causative agents

 Incubation period

 Frequency
65

Etiological grouping of
selected common STDs and
their clinical features STDs
 STD MAIN CLININICAL FEATURES CAUSATIVE INCUBATIO
(BACTERIAL AGENTS N PERIOD
STDs and their clinical features STDs
STIs )
Gonorrhoea Pus discharge from urethra or the Neisseria 2-6 Adays
66
cervix, dysuria, frequency Gonorrhoea
Syphilis Primary chancre is painless, well Chlamydia, 2-4 days
demarcated ulcer, other features mycoplasma
depend on the clinical stage homins and
others
Non- Thin non-itchy discharge from the Chlamydia 7-14 days
gonococcal cervix or urethra organismLGV
urethritis/cer strains
vicitis
Lymphogran Swollen painful inguinal glands Calymatobacte 1-10 days
uloma (buboes) occasionally with an ulcer and ria
venerium may occasionally be bilateral granulomatis
(LGV)
Granuloma Heaped up (beefy) ulcer, usually Overgrowth of May be
inguinale painless which may be associated with Gardenerella endigeneo
inguinal lympnode swelling vaginalis us
Bacteria Thin discharge with a fishy smell from Heamophilus 1-3 weeks
vaginosis the vagina ducreyi
 STD-VIRAL MAIN CLININICAL FEATURES CAUSATIVE INCUBATION
AGENTS PERIOD

67 Herpes Recurrent small multiple painful Herpes Simplex 2-7 days

Genitalis ulcers which begin as vesicles Virus (initial
infection)

Hepatitis B Jaundice with inflammation of the Hepatitis B virus

virus liver
infection
(HBV)

HIV/AIDS According to WHO clinical criteria Human Months-10

for the case definition for AIDS Immunedeficienc years or
y Virus more
Venereal Finger like growths on the genitals Human Papiloma Weeks-
warts/HPV Virus months
 STD FUNGAL MAIN CLININICAL FEATURES CAUSATIVE INCUBATIO
Etiological grouping of selected common
STIs ) AGENTS N PERIOD
STDs and
Fungal STDs
their clinical features
White curd like discharge coating the
STDsMay be
Candida
68Genital walls of vagina that is itchy, soreness, Albicans endogenou
candidiasis excoriation and cuts s and
recurrent
Ring worm Patches of hypo/hyper pigmentation in Tinea
(fungal) the pubic area Organisms

Protozoal STD Greenish itchy discharge from the vaginal Trichomonas variable
Trichomoniasi with offensive smell vaginalis
s

OTHERS Vesicles containing the mites in pubic Sarcoptes 30 days

Scabies area scabeii

Pediculosis May see knits in pubic hair, itching in Phthrius

(vermin) pubic area pubis (pubic
lice)
69

Common STD Syndromes and

Causative Organisms
 STD Syndromes Causative organisms
1. Urethral discharge (urethritis)  Neisseria gonorrhoea-common 
70 Gonococcal Non gonococcal Chlamydia trachomatis-common 
Trichomanas vaginalis-uncommon 
Ureaplasma urealyticum-uncommon 
Herpes simplex-uncommon
2. Vaginal discharge i. Vaginitis / Trichomanas vaginalis-  Candida
vaginosis Trichomonasis Candidiasis albicans  Gardnerella vaginalis  N.
Bacterial vaginosis ii. Cervicitis gonorrhoeae  Chlamydia trachomatis
Gonococcal Non gonococcal
2. Vaginal discharge i. Vaginitis /  Treponema pallidum  Heamophilus
vaginosis Trichomonasis Candidiasis ducreyi  Herpes simplex  Calymato
Bacterial vaginosis ii. Cervicitis bacteria granulomatis  Chlamydia LGV
Gonococcal Non gonococcal strain
4. Lower abdominal pain ( Pelvic N. gonorrhoeae  Chlamydia
inflammatory disease) trachomatis  Mycoplasma hominis 
Anaerobic bacteria  Other
miscellaneous bacteria
5. Inguinal adenopathy ( buboes) • Chlamydia LGV strains  Treponema
Lymphogranuloma venerium pallidum
 Balanitis Candida albicans  Chlamydia
trachomatis
71Chancroid • Syphilis  Heamophilus ducreyi

. Painful scrotal swelling N. gonorrhoeae  trachomatis  Other

( epididymorchitis) miscellaneous bacteria

Conjunctivitis with pus in the New born N. gonorrhoeae  C. trachomati

(ophthalmic neonatorum) • Gonococcal
• Non gonococcal
7. Bartholins abscess N. gonorrhoeae  C. trachomatis

Genital growths (warts) • Syphilitic  T. pallidum  Human papilloma virus 

(condylomata lata) • Viral (condylomata Molluscum contagiosum virus
acuminata) • Molluscum contagiosum
72
Risk factors for STI/STDs
1. Multiple sexual partners
2. Lack of and inconsistent condom use
3. Lack of circumcision in men
4. Alcohol/drug use. May be less
discriminating about whom they
choose to have sex with.
5. Alcohol may make it more difficult to
negotiate condom use or to use
 Risk factors for STI/STDs
73
6.Early sexual involvement by younger age
group
7.Socio-cultural factors like early marriage
8.Economic factors like poverty
9.Gender related factors like limited
negotiation powers for women when it comes
to sex
10.Legal and human rights constraints, stigma
and discrimination
10. Inequality in access to social and health
services
 SYNDROMIC APPROACH TO STD
MANAGEMENT:
74

Advantages
 Improved clinical diagnosis, avoids
wrong diagnoses and ineffective
treatment.
 It enables treatment of symptomatic
patients in one visit; otherwise
patients would spend time queuing or
being referred for laboratory tests,
results of which may not be available
75

 It is easy for primary health care workers

to learn.
 Treatment is provided at the first point of
contact with the health care delivery
system enabling treatment for STIs to be
provided even in peripheral health units.
 Referrals are limited to complicated cases
since the same kind of treatment is
provided at most health units in the
country
 The disadvantages
76

1. It doesn‘t adequately care for people

with STDs who have no symptoms,
especially women with STDs as they
are often asymptomatic
2. Wasting drugs, on treatment for STDs
that patients do not actually have.
3. In some cases, especially women, the
symptoms and signs are poorly
predictive of STI e.g. vaginal
 Advantages of syndromic approach
77

 Syndromic diagnosis avoids many

complications.
 Many health care providers use the

syndromic approach to avoid delay in

treating their patients while waiting
for laboratory results.
 Diagnosis and Rx flow charts for

Syndromic approach step by step

instructions to diagnose and treat
 The advantages of STD treatment
algorithms
78

 They are problem oriented and

improve clinical diagnosis
 Can be used as a training tool for

providers
 Enable standardization of treatment

 Enables disease surveillance

 Enables evaluation of training

 Enables treatment in one visit.

 Syndromes
79

1. Urethral discharge syndrome

2. Genital ulcer syndrome
3. Abnormal vaginal discharge
syndrome
4. Lower abdominal pain syndrome
5. Other STI syndromes
6. Congenital STI syndrome
 Urethral discharge syndrome
80

 Urethral discharge is one of the

commonest STI syndromes among
men, and is associated with serious
complications.
 It is characterized by purulent
urethral discharge with or without
dysuria.
 The amount of discharge varies
depending on the causative
 Urethral discharge syndrome
81

 Patients with this syndrome often

complain of a discharge from the urethra.
 They may have symptoms of burning

sensation while passing urine and

frequency of micturition.
 If the discharge is not readily apparent, it

may be necessary to milk the penis and

massage it forwards before the discharge
becomes apparent
 Urethral discharge syndrome
82
 Examination might reveal a purulent
discharge from the urethra.
 If the discharge is copious, do not

milk or squeeze the penis.

 If the patient is not circumcised,
examine with the fore skin retracted
to ascertain whether the discharge is
from the urethra or from beneath the
prepuce. It may be frank pus or may
 Urethral discharge in men with or
without dysuria
83

 Commonly caused by Neisseria

gonorrhoeae and Chlamydia
trachomatis in over 98% of cases
Also associated with;
 Trichomonas vaginalis, Ureaplasma
urealyticum and Mycoplasma spp.
 Mixed infections especially of
Neisseria gonorrhoeae and Chlamydia
trachomatis occur.
 Management of Urethral Discharge
84
 Managed according to the syndromic chart.
 Treatment should cover the commonest causes.

 The drugs of first choice are ciprofloxacin for

N.gonorrhoea and Doxycycline for chlamydia.

 In the absence of these, Cotrimoxazole may be

given to cover gonorrhoea while tetracycline

could be used to cover chlamydial infections.
 However, increased resistance to Cotrimoxazole

has been reported in the region.

 Other components of STD case
management package
85

i. Education on treatment compliance

ii. Promotion and provision of condoms
and demonstrating their use,
iii. Partner notification and offering
treatment,
iv. Offering or referring for HIV VCT
services\
v. Partners should be treated irrespective
of whether they are symptomatic or
not.
86

 Persistent or recurrent urethritis may

be due to drug resistance, poor
compliance or re-infection.
 There is increasing evidence of high

prevalence of Trichomonas vaginalis

among men in Sub Saharan Africa,
for which patients with recurrent
urethritis should be treated.
 Counsel and educate all clients on:
87

 Treatment compliance
 Condom use and provide condoms
 Partner management
 Offer or refer for HIV VCT services if
necessary
 Schedule a return visit
 Abstinence from sex till all symptoms
have resolved
 GENITAL ULCER DISEASE
88 SYNDROME
 GUD is one of the commonest
syndromes among men and women.
 The aetiology of the syndrome varies

in different geographical areas and

can change over time.
 Single or multiple ulcers can present.
 In addition, the clinical manifestations

are quite variable and can be altered

by HIV infection.
89
 Genital ulcers have an epidemiologically
synergistic relationship with HIV.
 HIV alters the natural history of syphilis

as well as increasing treatment failure

with single dose therapies.
 For Chancroid, the natural history is also

altered where more aggressive lesions

may manifest as well as treatment failure
especially with single dose therapies.
90

 Genital herpes can also be affected

by HIV resulting in more persistent
lesions.
 Evidence of enhanced HIV
transmission in presence of STIs is
more conclusive for ulcerative STIs.
 In Men, GUD under the prepuce

may present as a discharge,

similarly, GUD in women mayalso
91

 Uncircumcised male patients with a

genital discharge should have the
prepuce retracted and examined for
ulcer lesions
 Female patients should have the
labia separated and inspected.
 Speculum examination may be
necessary.
 Non-vesicular Genital ulcer:
92
 Ulcer on penis, scrotum or rectum in
men and on labia, vagina or rectum in
women with or without inguinal
adenopathy.
 Non vesicular ulcer syndrome is
caused by syphilis, chancroid,
lymphogranuloma venereum,
granuloma inguinale or atypical cases
of genital herpes on the other hand
 Management of Genital ulcer
93
 Treatment should be given as soon as possible
owing to the increased risk of HIV
transmission.
 The treatment for this syndrome is similar for

both males and females.

 Treatment should be based on the local
epidemiology of genital ulcers.
 Treatment should be according to the flow

chart, distinction should be made between

vesicular and non- vesicular genital
ulceration.
94
 Because of the increased risk of HIV
transmission, RX for genital herpes is
now strongly recommended.
 Other components of STI case mgt

including partner notification and RX

should be given.
 Counsel and educate all clients on;

Rx compliance, Condom use and

provide condoms, Partner mgt, HIV
 Abnormal vaginal discharge
95syndrome
 Physiological vaginal discharge which

may increase during certain

situations. AVD is one of the most
common STI syndrome among
women, and one of the most
complicated to manage. The
commonest causes are endogenous
vaginal infections (bacterial vaginosis
and vaginal candidiasis) that are not
 Abnormal vaginal discharge syndrome

96
AVD is usually due to infection of the
vagina (Vaginitis and vaginosis) and
rarely due to muco- purulent cervicitis,
although the latter is more serious.
 Bacterial vaginosis, vulvovaginal
candidiasis and trichomoniasis are the
commonest causes of Vaginitis.
 Gonococcal and chlamydial infections

cause cervicitis. Distinction between

the is not possible
97
 The symptom of vaginal discharge is highly
indicative of vaginitis and poorly predictive of
cervicitis which is in most cases
asymptomatic.
 Thus all women with vaginal discharge should

receive Rx for trichomoniasis and bacterial

vaginosis.
 Microscopy of a cervical smear and speculum

examination are highly recommended to rule

out early lesions of cervical carcinoma.
 Management of vaginal discharge
98

 The flow chart differentiates between

candidiasis and other vaginal discharges.
 All women with abnormal vaginal
discharge are treated for bacterial
vaginosis and trichomoniasis and
candidiasis.
 At the moment, it is not possible to

identify women with cervicitis, and all

women with a non- curd like discharge
should be treated for cervicitis.
99

 While other components of the syndromic Mgt

package should be promoted in Mgt of AVD ,
patients should be explained endogenous and
recurrent nature of vaginitis to avoid marital
disagreement.
 Women whose partners have urethral
discharge should be treated for cervicitis
 Persistent AVD shd be evaluated for cervical
cancer.
 Speculum examination and referral for
 Lower abdominal pain
100 syndrome
 The commonest and most serious STI
syndromes among women with very
serious RH and socio-economic
consequences.
 It can be acutely or chronically and is

often very difficult to diagnose given

the many differential diagnoses.
 Patients will often complain of
abdominal pain, bleeding,
101

 Patients should be carefully evaluated for

abdominal tenderness, cervical motion and
adenexial tenderness, enlargement of
uterine tubes, and tender pelvic masses.
 The temperature may be elevated.

 Female patients with other STIs should be

carefully evaluated to exclude this condition

since some may not complain of abdominal
pain. This requires bimanual vaginal
examination.
102
 A thorough history and examination to
exclude other surgical emergencies
which present in a similar way must
be done, and if necessary, referral for
specialist attention done
 LAP and dyspareunia, vaginal
discharge, lower abdominal
tenderness on palpation, or high
temperature is suggestive of PID i.e.
 Management of Lower Abdominal
103 Pain:
 Patients with other surgical emergencies
should be referred immediately for in
patient admission and management.
 This syndrome is treated with ciprofloxacin,

metronidazole and ciprofloxacin

 Antibiotic treatment is clearly syndromic

and is directed at the aetiological agents

since specific diagnosis is not possible.
104

 Out- patient treatment should be

prolonged due to the chronicity of the
condition.
 Patients with IUDs, should have the device

removed after initiating treatment for at

least 2 days. Such patients will require
contraceptive counseling.
 The other components of STI case Mgt

should also be provided to patients with

LAP syndrome.
105

Other STI
syndromes
 1. Inguinal Buboes
106
 These are localized swellings or
enlarged lymph glands in the groin
and femoral area, hence the local
term “grenade” used to describe this
syndrome.
 They may be painful and fluctuant.
 They are usually associated with LGV

and chancroid.
 In the case of chancroid, an
 Management
107

Fluctuant swellings should be aspirated

daily with a large bore needle passing
through normal skin, but they should
never be incised as this can result in sinus.
Non sexually transmitted local and
systemic infections (e.g. infection of the
lower limb or gluteal region) can also
cause swellings in the inguinal region and
should be excluded.
 2. Painful Scrotal swelling
108

 Sexually transmitted epididymitis or

epididymorchitis is inflammation of
the epididymis and/or testis, usually
unilaterally.
 It is of acute onset and painful and

may be accompanied by urethral

discharge.
 Exclude other non STI causes of
scrotal swelling such as trauma,
109

 Other causes of epididymo orchitis

especially in older men include; E.coli,
Klebsiella spp, Pseudomonas
aeruginosa, Brucella spp and
Mycobacteria tuberculosis.
 In children, mumps epididymo-orchitis

may accompany parotid enlargement.

 This condition if not treated early can

cause secondary male infertility.

 3. Balanitis
110
 Balanitis refers to inflammation of the
glans penis and the prepuce.
 There may be discharge, erythema and

erosion of the glans; however, the

prepuce is retractable.
 Is often caused by infection with
candidiasis and rarely by trichomoniasis.
 Treatment should be according to the flow

chart and includes improvement of local

hygiene.
111

 In recurrent cases or if symptoms

don‘t resolve, the partner should be
treated as well.
 Circumcision may be recommended in

recurrent cases, but should be done

only after symptoms have resolved.
 4. Bartholin’s abscess
112

 This complication of gonococcal or

chlamydial infection of the Bartholin‘s
gland in women presents as an extremely
painful swelling at the vaginal introitus.
 It should be managed as a surgical
emergency.
 Initiate treatment as for cervicitis and

refer the patient immediately for incision

and drainage in hospital.
 5. Genital warts
113

 Caused by a virus – Human papilloma

virus.
 They usually have the appearance of

flesh-coloured cauliflower-like
growths on the genitals.
 The penis and foreskin (prepuce) of

men and the labia or vagina are the

most common sites of the warts.
 The warts can be variable in number
 Treatment
114

 Warts are treated with local application of

Podophyllin (10 - 25% solution) once a
week.
 After treatment of warts, the medication

must be washed off in 2 - 4 hours after it

is applied to the warts or the patient risks
developing sores at the site of treatment.
 If used too frequently and extensively,

Podophyllin can lead to severe blood and

liver damage.
115

 Podophyllin is toxic and can be

absorbed through the skin, so it should
not be used in pregnant women.
 Genital warts often require more than

one course of treatment.

 If the patient fails to respond to the

three weekly treatments, he/she

should be referred
 Congenital STI syndrome
116

 Infection of babies in utero or during

delivery is one of the leading
complications of untreated STIs among
mothers.
 This can result in congenital STIs among

newborns.
 Among the most serious congenital
infections are infections with syphilis, HIV
gonococcal and chlamydial organisms and
herpes simplex.
 i. Neonatal Conjunctivitis:
117
 This refers to conjunctival infection of
neonates by STI organisms in the infected
mother‘s birth canal.
 Neonates acquire this infection during
passage through an infected birth canal
during delivery.
 It can lead to corneal ulceration and
ultimately to blindness.
 Blindness in children is associated with

high infant morbidity and mortality.

 Main clinical Presentation:
118

 Begins during the initial thirty days

after birth.
 Characterized by bilateral purulent

eye discharge. The conjunctiva is

inflamed and eyelids swollen.
 If untreated, the cornea may be

affected giving rise to corneal

ulceration that can lead to
perforation and blindness. Corneal
 Opthalmia neonatorum
119

 May be caused by a number of

organisms but the most common are
N.gonorrhoea and C. trachomatis.
 There are other non STI causes of

neonatal conjunctivitis predisposed by

difficulty labour such as ERM,
ventouse or other assisted vaginal
delivery. Attempts to differentiate
between the two based on clinical
 Treatment
120
 Rx should cover both STI causative
organisms.
 Systemic Rx is recommended as well

as irrigation of the eyes.

 Use gloves and wash their hands
thoroughly after handling the eyelids.
 Ceftriaxone injection, 125 mg single

dose IM Alternative Rx to cover

gonococcal infections is
121

 This treatment will also cover Chlamydia.

 Topical TEO in full blown has been shown

to have no added benefit.

 Local irrigation of the eye with saline or

sterile water should be carried.

 Staff should cover the eye with gauze

while opening the eyelid as pus may be

under pressure.
 Staff handling the eyes must use gloves

at all times.
122

 Parents of babies diagnosed with

Opthalmia neonatorum should be
treated for cervical infection of
N.gonorrhoea and C. trachomatis.
 Prevention of Opthalmia neonatorum

through screening and Rx of infected

mothers and ocular prophylaxis of all
newborns in high prevalence areas
with 1% TEO at the time of delivery
 Congenital syphilis:
123

 This is a serious debilitating and

disfiguring condition that can be fatal.
 About one third of syphilis infected

mothers have adverse pregnancy

outcome, one third give rise to a
healthy baby, while the remaining third
may result congenital syphilis infection,
although the stage of syphilis may
confound these outcomes.
124

 Main clinical Presentation: Some

cases of congenital syphilis can be
asymptomatic, while others may
present with early congenital syphilis,
and others may manifest symptoms
of late congenital syphilis after two
years.
125
 Early syphilis begins to show after 6-
8 weeks of delivery and manifests
with snuffles, palmer and plantar
bullae, hepatosplenomegally, pallor,
joint swelling with or without paralysis
and cutaneous lesions.
 Late signs include microcephaly,
depressed nasal bridge, arched
palate, and perforated nasal septum,
 Management of congenital syphilis:
126

 Procaine penicillin, 50,000 IU per Kg body

weight daily for 10 days is recommended.
 Symptomatic patients should be admitted

 Treatment for all babies less than 2 years

should assume cerebrospinal involvement.

 Aqueous benzyl penicillin should be
administered, 50,000 IU/kg body weight
every 12 hours for a total of 10 days.
127

 Alternative Rx is procaine benzyl

penicillin, 50,000 IU/kg body weight,
single dose daily for 10 days.
 Both parents should be treated for

syphilis with Benzathine penicillin.

 The adverse effects of syphilis on

pregnancy can be prevented by

routine screening and Rx of syphilis
infected mothers in antenatal clinics.
 Primary preventive measures
128

i) Correct and consistent use of

condoms and other safer sex practices.
For those who cannot abstain and yet
cannot have mutually faithful
relationship
ii) Abstinence from sex or for groups
such as students & youths not yet
married, postponed sex till marriage.
iii) Mutually faithful sexual relationship
129

iv) Safer Sex practices. Safer sex

practices are many and varied but all
revolve on the principle of avoiding
exchange of sexual or body fluids of the
partners, yet enabling the individual(s) to
obtain what they desire out of sex.
v) Male circumcision of HIV negative
persons; has also has been associated
with reduced HIV transmission
 Secondary prevention includes:
130

i) Early diagnosis and prompt and

correct treatment of STDs
ii) Promotion of STD care seeking
behaviour including reduction of
barriers to care
iii) Notification of partners and
treatment
iv) Screening for asymptomatic cases
such as pregnant mothers treatment
131

Condom use: Condoms are penis shaped

thin walled sheaths molded from natural
rubber.
 They are designed to provide a barrier

against microorganisms without

significantly reducing the sense of feel.
 If used correctly and consistently, they

provide good protection against STDs,

HIV and unwanted pregnancies.
 Hints for effective condom use:
132

i) Know your condom: Get used to

handling it and opening the package.
 Don‘t wait for a sexual encounter to try

the condom on
iii) Put the condom on: The condom
should be rolled onto the erect penis.
 Use two hands; use one to squeeze the

tip of the condom (to expel air) as you

roll it on.
133

iv)Handle the condom with

reasonable care (watch out for
fingernails and jewelry).
 Roll the rim all the way to the base of

the penis.
 Take the condom off:
134
 Do this while the penis is erect.
 The most frequent causes of condom

failure results from the condom

slipping off the limp penis while it is
still inside the vagina.
 Grasp the ring top of the condom and

hold it tightly around the penis that is

still in the vagina.
135

 Withdraw the penis with condom still

firmly grasped.
 Slide the condom off, pinching shut

the grasped ring top end.

136

vi) Dispose -off the condom.

Condoms cannot be reused.
 They should be disposed of in such a

way that they will not be found by

children who might play with them.
 Put them in a pit latrine, or bury
them in a pit or burn them