Genital Infections

Trichomoniasis

Trichomonas vaginalis is a sexually transmitted protozoan that infects squamous epithelium of the urogenital tract. Women are infected more than men and present with a thin, yellow-green, frothy malodorous discharge, pruritis, burning, dysuria, pelvic pain, dysuria, or dyspareunia. In men infection is generally asymptomatic but may cause urethral discharge or dysuria.

Trichomonas infection during pregnancy is associated premature delivery, early rupture of membranes, and low birth weight.

Antimicrobial

Metronidazole 500mg PO BID (preferred in pregnancy)

Alternative:

Metronidazole 2g PO single dose

Treat sexual partners presumptively with single dose metronidazole. Avoid sexual activity for 7 days after treatment initiation.

Comments and Duration of Therapy

Perform microscopy on wet mount of vaginal discharge to examine for motile trichomonads. Measure pH: in trichomonas infection this may be >4.5.

If diagnosis unable to be confirmed with bedside tests send bacterial swab for microscopy and culture, and send viral (dry) swab for multiplex PCR.

Test all patients for other sexually transmitted infections including HIV and syphilis.

Duration:

Metronidazole 2g: Give single dose.

Metronidazole 500mg: Treat for 7 days.

Test for cure with PCR after 2 weeks of treatment completion.

Gonorrhoea

Neisseria gonorrhoeae is a predominantly sexually transmitted infection. It presents as urethritis in men and cervicitis in women. It can also involve the throat (pharyngitis), rectum (proctitis) or cause conjunctivitis. Symptoms in women include dysuria, urinary frequency, and vaginal discharge. Symptoms in men include urethral discharge, dysuria, and urinary frequency. Infected patients may also be asymptomatic. Disseminated infection presents as bacteraemia, pustular skin rash and/or acute infective arthritis.

Antimicrobial

Ceftriaxone 500mg IV/IM single dose

PLUS

Azithromycin 1g PO single dose

For disseminated gonococcal infection:

See Septic Arthritis in Bone and Joint Infections chapter, confirmed Neisseria gonorrhoeae

For neonatal prophylaxis and treatment:

See Chapter 11: Paediatric Infections (Neonates, Infants and Children).

Test and treat all patient’s sexual partners for the preceding 60 days. Avoid sexual activity for 7 days after treatment initiation.

Comments and Duration of Therapy

Send first pass urine for PCR, swab vagina, male urethra, throat and/ or rectum (whichever is clinically indicated) with bacterial swab for culture, and swab with viral (dry) swab for PCR. If systemic infection suspected send blood culture.

Complications include urethral and labial abscesses, inflammation of the epididymis and testis, acute salpingitis, pelvic peritonitis, pelvic abscess, ectopic pregnancy, infertility, severe conjunctivitis, and iritis.

Test all patients for other sexually transmitted infections including HIV and syphilis.

Duration:

Treat with single dose only of both antibiotics.

Test for cure 2-3 weeks after completing treatment.

Chlamydia infection of ure- thra, endocervix or rectum.

Chlamydia trachomatis is an intracellular bacterium which can cause two sexually transmitted diseases in adults depending on the serotype.

In males Chlamydia presents with urethritis, or proctitis, and complications including epididymitis. In females, infection is often subclinical or non-specific. Complications include cervicitis, salpingitis and endometriosis. Chlamydia is major cause of female infertility worldwide.

Antimicrobial

Azithromycin 1g PO single dose

Alternative:

Doxycycline 100mg BID

If treating empirically, to cover the possibility of gonorrhoea infection ADD:

Ceftriaxone 500mg IV/IM single dose

Cefixime 400mg PO single dose

Test and treat all patient’s sexual partners for the preceding 60 days. Avoid sexual activity for 7 days after treatment initiation.

Comments and Duration of Therapy

Send first pass urine for PCR, swab vagina, male urethra, and/ or rectum (whichever is clinically indicated) with bacterial swab for culture, and swab with viral (dry) swab for PCR.

Test all patients for other sexually transmitted infections including HIV and syphilis.

Duration:

Azithromycin, Ceftriaxone, Cefixime: Give single dose

Doxycycline: Treat for 7 days

Test for cure 3 weeks after treatment initiation in patients who are pregnant, have PID, or have anorectal infection.

See Neonatal Chlamydia prophylaxis in Chapter 11: Paediatric Infections (Neonates, Infants and Children).

Chlamydia - Lymphogranuloma venereum (LGV).

This manifests as a transient painless genital ulcer followed by lymphadenopathy which ulcerates. Men who have sex with men will often present with symptoms of proctitis. LGV infection can be complicated by anal strictures and fistulas.

Antimicrobial

Doxycycline 100mg PO BID

Alternative:

Azithromycin 1g weekly

Test and treat all patient’s sexual partners. Avoid sexual activity until 3 weeks after treatment initiation.

Comments and Duration of Therapy

Swab ulcer, rectum, or aspirate (whichever is clinically indicated) with viral (dry) swab for PCR.

Test all patients for other sexually transmitted infections including HIV and syphilis.

Duration:

Treat for 21 days

Test for cure with PCR after 4 weeks of treatment completion in patients who remain symptomatic, pregnant patients, and patients treated with azithromycin.

Chancroid

A sexually transmitted ulcerative infection caused by Haemophilus ducreyi. This initially presents with painful vesicular papules, which rapidly developing into soft ulcers with undermined, ragged edges. Ulcers are haemorrhagic and sticky, and often secondarily infected. One to two weeks later, inguinal nodes become involved and a painful, matted, tethered ‘bubo’ occurs. A discharging sinus may develop and in time become a spreading ulcer. Lesions heal slowly and commonly relapse.

Antimicrobial

Azithromycin 1g PO single dose

Alternative:

Ceftriaxone 500 mg IV/IM single dose

Ciprofloxacin 500mg PO BID

STI pack (Cefixime 400mg PO and Azithromycin 1g PO) single dose

Treat all patient’s sexual partners in the 10 days preceding symptom onset regardless of symptoms. Avoid sexual activity until ulcer has healed.

Comments and Duration of Therapy

Haemophilus ducreyi is fastidious and difficult to culture, if this diagnosis is suspected contact laboratory for advice on how to collect a specimen. Note that a negative culture does not exclude this infection.

Test all patients for other sexually transmitted infections including HIV and syphilis.

Duration:

Azithromycin, Ceftriaxone: Give single dose

Ciprofloxacin: Treat for 3 days

If no evidence of clinical improvement within one week of treatment, consider alternative diagnosis.

Syphilis

A sexually transmitted infection caused the spirochete Treponema pallidum.

Early syphilis (< 2 years) Primary: Painless chancre. Sharply demarcated ulcer with indurated borders and clean base.

Secondary: Fever, systemic symptoms, lymphadenopathy, and non-pruritic rash (maculopapular, pustular, ulcerative, or mucosal lesions). CNS, GIT, ocular, renal, and musculoskeletal system involvement can also occur.

Early latent: Asymptomatic.

Late syphilis (>2years)

Progression from untreated early syphilis.

Late latent: Asymptomatic

Tertiary: Cardiovascular syphilis. Neurosyphilis. Gummatous disease with granulomas of skin, bones, and viscera. Patients should have a lumbar puncture to investigate for neurosyphilis.

Antimicrobial

Early syphilis:

Benzathine penicillin 2.4 million IU (1.8g) IM single dose

Alternative:

Procaine benzylpenicillin 2.5 million IU (1.5g) IM OD for 10 days

(not preferred) Doxycycline 100mg PO BID for 14 days

Late latent syphilis: and non-neurological tertiary syphilis

Benzathine penicillin 2.4 million IU (1.8g) IM weekly for 3 weeks.

Alternative:

Procaine benzylpenicillin 2.5 million IU (1.5g) IM OD for 15 days

(not preferred) Doxycycline 100mg PO BID for 28 days

In primary syphilis test and treat all patient’s sexual partners from the preceding 3 months, in secondary from the preceding 6 months, and in early latent syphilis from the preceding 12 months. In late syphilis screen and treat current sexual partners, and others according to sexual history.

Comments and Duration of Therapy

Confirming the diagnosis of syphilis requires a treponemal (TPPA, TPHA, EIA) AND a nontreponemal (RPR, VDRL) test. Treponemal tests are specific but remain positive lifelong regardless of treatment. Nontreponemal tests are not specific and can be falsely positive, but rise and fall with disease activity and can be used to monitor treatment response.

In primary syphilis treponemal tests may take 2 weeks, and nontreponemal tests 4 weeks to become reactive.

Following treatment, monitor response with a nontreponemal test at 3, 6 and 12 months, and in HIV patients at 18 and 24 months. Syphilis is considered treated if nontreponemal titre falls by at least fourfold. If this does not occur or titre increases, consider treatment failure or reinfection, and retreat. Also consider neurosyphilis as a cause for treatment failure.

In early and late syphilis if patient has CNS or eye involvement consider a lumbar puncture and treat as Neurosyphilis.

Test all patients for other sexually transmitted infections including HIV.

Neurosyphilis

Can occur at any stage of syphilis. In all patients with syphilis assess for cognitive dysfunction, motor or sensory loss, eye or auditory disturbances, cranial nerve palsies or symptoms or signs of meningitis. If present, treat as for Neurosyphilis.

Antimicrobial

Benzylpenicillin 4 million IU (2.4g) IV Q4H

Alternative (not preferred):

Ceftriaxone 2g IV OD

Comments and Duration of Therapy

Duration:

Treat for 14 days

Repeat lumbar puncture 6 months after completing treatment. If persistent leukocytosis, retreat.

Syphilis in Pregnancy

All pregnant women should be screened at first antenatal visit, during the 3rd trimester and at delivery. All pregnant women who are sexual contacts of patients with syphilis should be presumptively treated.

Antimicrobial

Early and late syphilis:

Benzathine penicillin 2.4 million IU (1.8g) IM weekly for 3 weeks.

Comments and Duration of Therapy

Repeat nontreponemal tests (RPR, VDRL) monthly following treatment for duration of pregnancy. Repeat treatment if titre is not falling by 6 weeks, or if sexual partner was not treated simultaneously.

All infants born to mothers with syphilis should be examined for evidence of congenital syphilis.

See Neonatal Syphilis prophylaxis/ treatment in Chapter 11: Paediatric Infections (Neonates, Infants and Children).

Genital Herpes simplex virus

Genital herpes is the most common cause of ulcerative genital disease worldwide. Most infections are caused by HSV-2, but HSV-1 genital infection is becoming a more common. Lesions present as vesicles, pustules, and erythematous ulcers. Associated symptoms include pruritis, pain, dysuria, tender inguinal lymphadenopathy, and systemic symptoms (headache, fever, malaise, myalgia). Primary infection may be severe or asymp- tomatic.

Antimicrobial

Primary infection:

Acyclovir 400mg PO TID

Recurrent infection:

Acyclovir 800mg PO TID

Suppressive therapy for recurrent infection in late pregnancy:

Acyclovir 400mg PO TID

Avoid sexual activity during outbreaks and for 1 to 2 days after. Use condoms.

Comments and Duration of Therapy

Antiviral therapy is not curative but shortens the duration of symptoms if given within 72 hours of symptom onset.

Test all patients for other sexually transmitted infections including HIV and syphilis. Genital HSV is an important risk factor for HIV acquisition and transmission.

Infants born to mothers with primary infection needed prophylactic therapy. See Neonatal Herpes Simplex Prophylaxis / Treatment in Paediatrics (Neonates, Infants and Children) chapter. If there are signs and symptoms of active infection delivery by cesarean section is indicated.

Duration:

Primary infection: Treat for 10 days

Recurrent infection: Treat for 2 days

Suppressive therapy for recurrent infection in late pregnancy: Start at 36 weeks. Continue until delivery.

See also Encephalitis in Chapter 4: Central Nervous System Infections, Dendritic corneal ulceration caused by Herpes Simplex virus in Chapter 7: Eye Infections, Neonatal Herpes simplex prophylaxis / treatment in Chapter 11: Paediatric Infections (Neonates, Infants and Children), and Herpes Simplex in Chapter 13: Skin and Soft Tissue Infections

Genital warts

Sexually transmitted infection caused by Human Papillomavirus (HPV). HPV infections are transmitted primarily through skin to skin, or skin to mucosa contact. Warts may be present on the vulva, vagina, penis, scrotum, urethral meatus, anus, and elsewhere on the perineum. The lesions may be well-defined papules, flat or filiform.

Antimicrobial

Podophyllin 0.5% solution topically to each wart BID (Contraindicated in pregnancy and breastfeeding mothers).

Comments and Duration of Therapy

Consider offering HPV vaccines to sexual partners if available. HPV vaccination protects against genital warts and HPV-associated cancers. HPV types that cause warts have not been associated with cancer.

Test all patients for other sexually transmitted infections including HIV and syphilis.

Duration:

Podophyllin: Apply for 3 days, cease for 4 days, then repeat this cycle weekly for 4-6 applications until warts disappear.

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