Sexually Transmitted Infections (STIs)

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CLINICAL DESCRIPTION

Refer to the Management of Sexually Transmitted Infections using Syndromic Management Approach, Guidelines for Service Providers.

All patients who present with STI symptoms should be offered HIV Testing and Counselling.

Note: Women with abnormal vaginal discharge or symptoms of an STI MUST HAVE A VAGINAL SPECULUM EXAMINATION AS PART OF THEIR EVALUATION TO EXCLUDE CERVICAL CANCER!!

Note: Prompt and effective treatment of STIs helps prevent spread of HIV infection

General Management

  • Ensure adequate privacy in patient management.
  • Establish a correct diagnosis whenever possible. This involves doing blood tests and obtaining tissue samples for laboratory analysis to identify the specific causative agent and institute specific treatment (in the hospital setting).
  • Make efforts to trace, treat and counsel all sexual contacts.
  • Provide health education and counselling on each return visit.
  • Advice on 'safer sex' practices to prevent re- infection, i.e., abstinence, correct use and storage of condoms, mutual faithfulness of uninfected partners, decrease in number of sexual partners, use of non-penetrative sexual techniques and the importance of partner notification and treatment.
  • Offer a supply of condoms at each patient's visit.

Note: Periodically check the patient's understanding of the above issues by asking him/her to repeat the information give

Syndromic management of STIs

The syndromic approach is based on the fact that most common causes of an STI generally present with certain groups of signs and symptoms (syndrome) and treatment given is supposed to target the commonest possible causes of that syndrome. It should be noted, however, that these signs and symptoms only point to certain diagnoses. The caregiver should ALWAYS seek to establish the definitive diagnosis whenever possible as stated above. This may necessitate a speculum examination. 

Common STI syndromes:

  • Genital ulcer disease (GUD)
  • Urethral discharge (UD)
  • Genito-urinary symptoms in women (GUS)
  • Lower abdominal pain (women) (LAP)
  • Enlarged inguinal lymph nodes (bubo)
  • Balanitis/balanoposthitis

 

GENITAL ULCER DISEASE (GUD)

Common Causes:

Genital herpes, Chancroid and Syphilis may be present concurrently.

Genital herpes is the most prevalent amongst the three. Treat patients with GUD for the above three infections

GENERAL MANAGEMENT/TREATMENT

  • Give Ciprofloxacin 500mg PO stat for 3 days and
  • Give Benzathine penicillin 2.4 MU IM stat
  • Give Acyclovir 400mg 8 hourly for 7 - 10 days
  • Tell patient to return for follow-up care in 7-10 days, see below

Note: Acyclovir is indicated only in symptomatic GUD clients. If genital herpes infection is suspected and this is the first episode, treat with Acyclovir for 7-10 days. If it is a recurrent genital herpes infection, lower the dose frequency to twice a day and treat for a shorter duration – 3 days. 

Offer analgesia if indicated, particularly in GUD with pain.

If patient allergic to penicillin/Ciprofloxacin and pregnant or lactating:

  • Give Erythromycin 500mg 6 hourly for 15 days plus
  • Give Acyclovir 400 mg 6 hourly for 7 – 10 days

Infants born to mothers treated for GUD with Erythromycin alone:

  • Give Benzathine Penicillin 500,000 IU/kg as a single dose

Follow-up care of GUD

  • Inform the patient to return 7-10 days after starting treatment.
  • If the ulcers have not healed or are getting worse, repeat GUD treatment if there is evidence of noncompliance.
  • If the client complied fully and there is no improvement:
    • Give Azithromycin 2g stat.
    • Review in further 7-10 days
    • If no improvement after 14 days, refer for specialist opinion (patient may need a tissue biopsy)
    • If improved, follow patient's progress until completely healed
    • No further antibiotics are required at this time
  • If the ulcers have improved but not completely healed:
    • Repeat chancroid treatment Ciprofloxacin 500mg single dose  
    • Review in further 7-10 days  
    • Subsequent action as above
  • If the ulcers have completely healed:
    • Reinforce counselling and patient education
    • Promote/provide condom

ABNORMAL VAGINAL DISCHARGE (AVD)

  • Causes: Vaginal infection, cervical infection, endometrial infection/pelvic inflammatory disease (PID)
  • Common causes of vaginal infections: Trichomonas vaginalis, candida albicans and bacterial vaginosis.
  • Common Causes of cervical infections: Neisseria gonorrhoeae and chlamydia trachomatis.

Note: Vaginal discharge is normal during and after sexual activity; at various points throughout the menstrual period; and during pregnancy and lactation.

Note: it is mandatory to perform a pelvic examination which includes a speculum examination for all women presenting with abnormal vaginal discharge.

GENERAL MANAGEMENT

  • Do risk assessment to identify women at risk of cervical infection
  • Treat all women with vaginal discharge and a positive risk assessment for gonococcus and Chlamydia infection, plus trichomoniasis and
    • If the discharge is white and curd-like also treat for candidiasis.
  • Treat all women with vaginal discharge and a negative risk assessment for trichomoniasis and bacterial vaginosis
    • If the discharge is white and curd-like, also treat for candidiasis.

TREATMENT

If vaginal discharge is present and the risk assessment is positive:

  • Give Gentamycin 240mg IM stat plus
  • Give Doxycycline 100mg 12 hourly for 7 days, plus
  • Give Metronidazole 2g orally single dose

If the discharge is white or curd-like add 1 Clotrimazole pessary 500mg inserted intra- vaginally stat

If vaginal discharge is present and risk assessment is negative: Give Metronidazole 2g orally single dose stat ONLY

If the discharge is white or curd-like add 1 Clotrimazole pessary 500mg inserted intra- vaginally stat

If no discharge is found and risk assessment is positive:

  • Give Gentamycin 240mg IM stat plus
  • Give Doxycycline 100mg 12 hourly for 7 days

If no discharge is found and risk assessment is negative:

  • Reassure client, counsel, educate and provide condoms.
  • Advise client to come back if symptoms persist.
  • Offer HIV testing after providing information and counselling
  • Offer cervical cancer screening

Note: Examination of GUS in women should never be omitted only for convenience of the health worker.

 

LOWER ABDOMINAL PAIN IN WOMEN (LAP)

It may be a serious condition 

Notes:

  • Not every woman with lower abdominal pain has PID.
  • Be sure to exclude any conditions which require immediate surgical or gynaecological treatment

Associated Signs and symptoms

  • Fever, abnormal vaginal discharge, cervical motion tenderness, and often adnexal tenderness or masses on bimanual examination.
  • Signs and symptoms of acute illness requiring immediate gynaecological/surgical attention
    • Missed or overdue or delayed period; delivery or miscarriage; abnormal uterine bleeding; abdominal guarding or rebound tenderness; active vaginal bleeding.

General Management

If the patient has a missed/overdue period or abnormal vaginal bleeding:

Check vital signs

  • Do a urine pregnancy test
  • Offer analgesia
  • Consider admission and/or referral if necessary

When referring, ensure patient's general condition is stable

  • If the patient is very ill, bleeding heavily or in shock:
    • Set up an IV drip and commence resuscitation
  • If the patient does not have missed/overdue period or abnormal vaginal bleeding but does have any of the following:
    • Recent delivery; Recent/suspected miscarriage; Rebound tenderness; Abdominal guarding
      • If at the health centre Give first dose of treatment for PID.
      • Refer immediately for hospital admission after resuscitating the patient should this be required.
      • Treatment if at the hospital, Admit if the patient: is obviously sick; is pregnant; vomits oral medication or if adequate followup care cannot be provided.

If the patient does not have missed/overdue period  or  abnormal  vaginal  bleeding  and does not have any  of  the  signs/symptoms listed above but does have cervical excitation tenderness or fever:

  • Give Gentamycin 240mg IM stat,
  • Give Doxycycline 100mg 12 hourly and
  • Give Metronidazole 400mg 8 hourly for 10 days.
  • Remove IUCD if any and offer other means of contraception
  • Treat partner for gonococcal and chlamydial infection as described above
  • Review patient after 72 hours:
    • If improved, complete 10-day course of treatment for PID
    • If not improved, refer for gynaecological or surgical consultation
    • If the patient does not have missed/overdue period or abnormal vaginal  bleeding  and does not have any of  the  signs/symptoms  listed above, and does not have cervical motion tenderness or fever;
    • Determine whether the patient has any other genitourinary complaint/syndrome and manage as per appropriate syndrome;  
    • Ask her to return if the abdominal pain persists.

 

PELVIC INFLAMMATORY DISEASES (PID)

SIGNS AND SYMPTOMS

A triad of lower abdominal pain, abnormal vital signs (particularly fever and tachycardia) and peritonism (guarding or rebound tenderness with cervical motion and adnexal tenderness)

Patients additionally have positive risk screen and abnormal vaginal discharge

Other additional factors are;

  • Failure to respond to syndromic treatment regime within 72 hours
  • Presence of tender pelvic mass which may be an abscess or an ectopic pregnancy
  • History or suspicion of recent induced abortion, delivery or miscarriage
  • Active vaginal bleeding
  • Missed, overdue or delayed period
  • Pregnancy
  • Heavy menstrual bleeding
  • Vomiting

 Note: The patient should be admitted

TREATMENT

  • If deranged vital signs, dehydration etc:
    • Give IV fluids
    • Offer analgesia
    • Parenteral antibiotics
    • 1st line
      • Ceftriaxone 2g IV daily
      • Metronidazole 500mg IV 8 hourly
    • Alternatively
      • Gentamicin 240mg IV daily
      • Metronidazole 500mg IV 8 hourly
      • Ampicillin 1g IV 8 hourly
  • When improved and able to swallow switch to oral antibiotics:
    • Doxycycline 100mg 12 hourly and
    • Metronidazole 400mg 8 hourly for 10 days
    • Analgesic
  • If pain is severe:
    • Give Pethidine 100 mg IM then PRN

Notes:

  • Post abortal sepsis and puerperal sepsis may present as acute PID. If these are recognized, the following must be done:
    • Admit and treat with parenteral antibiotic therapy. 
    • If retained products of conception suspected, evacuate the uterus within 12 hours of antibiotic therapy regardless of the patient's temperature.
    • Provide supportive care such as blood transfusion, iv fluids and closely monitor vital signs.

ENLARGED INGUINAL NODES (BUBO)

  • Both chancroid and lymphogranuloma venereum (LGV) can cause bubo.
  • Exclude the following conditions which may also cause enlarged inguinal lymph nodes: septic skin lesions on thigh, foot, leg, toes, buttock, anus, perineum, scrotum, penis, labia, vulva and vagina, systemic infections. e.g., Hepatitis B, HIV, infectious mononucleosis, syphilis, TB, bubonic plague, cat scratch fever, trypanosomiasis, lymphoma, leukemia, Kaposi's sarcoma.
  • Exclude other conditions which may cause groin swelling unrelated to enlarged lymph nodes including inguinal hernia, lipoma, a boil in overlying skin.
  • Confirm presence of bubo by careful examination

Note: All patients with bubo should be carefully examined for signs of other STIs

Treatment

  • If bubo present and genital ulcer present, treat as for genital ulcer disease
  • If bubo present, and painful, fluctuant or recent onset (under 2 weeks) and no genital ulcer present: treat patient and partner for LGV
  • Give Doxycycline 100mg 12 hourly with food for 14 days. If pregnant/ lactating, give Erythromycin 500mg 6 hourly for 14 days
  • If bubo fluctuant, aspirate through adjacent normal skin (do not incise)
  • If enlarged inguinal lymph   node   present, but not painful, fluctuant or of recent onset (under 2 weeks) and no genital ulcer present: look for other causes of inguinal swelling:
    • e.g., generalized lymphadenopathy (rule out secondary syphilis and HIV), hernia, tumour.
  • Refer for biopsy if indicated
  • If bubo not present but other signs of STI found, treat accordingly
  • If bubo not present and other signs of STI not found, reassure, educate/counsel the patient
  • Promote/provide condoms