Syndromic management of

STI
Dr Mihiret Abiy (MD)
January, 2023
 Outline
• Session 1 • Session 2 • Session 3
• Definition • Genital ulcer • Followup visit for pts
• Diagnostic approaches • Vaginal discharge with STIs
to STI • Lower abdominal pain in • STI in children and
• Syndromic approach women adolescents
• STI syndromes • Inguinal bubo • Mgt of STIs not
• Urethral discharge in • Scrotal swelling presenting with typical
men syndromes
• Neonatal conjunctivitis
• Practical consideration
in managing STIs
• Partner management
2. GENITAL ULCERS SYNDROME

• Genital ulcer: • causes include:

• is an open sore or a break in the continuity • • Herpes simplex virus type 2
of the skin or mucous membrane of the • • Treponema pallidum (Syphilis)
genitalia as a result of sexually acquired • • Haemophilus ducreyi (Chancroid)
infections.
• • Chlamydia trachomatis serovars L1, L2, L3
• facilitates transmission of HIV more (LGV)
than other STIs • • Klebsiella granulomatis (Donovanosis)
• because it disrupts continuity of skin and
mucous membranes significantly.
• 1. Syphilis:
• Syphilis is a sexually transmitted • Transmission:
systemic disease • sexual contact (major)
• caused by a spirochete Treponema • Also by kissing or touching a person who
has active lesions on the lips, oral cavity,
pallidum breast or genitals
• has variable clinical manifestations. • to the fetus in utero
• average incubation period is 21 days • Thus syphilis can be classified as:
(ranging from 3 to 90 days). • congenital
• acquired
• Primary
• Secondary
• latent
• tertiary syphilis.
Clinical Manifestations: • Latent infections has no clinical
Primary syphilis: manifestation but are detected by
serologic testing.
• presents with an ulcer or chancer at the
site of infection.
• Secondary syphilis may show
generalized skin rash, mucocutaneous
lesions, lymphadenopathy, etc.
• tertiary syphilis may include visceral
organ damage such as cardiac,
ophthalmic, auditory abnormalities and
gummatous lesions.
Clinical Features of Acquired Syphilis by Stage of Infection

• Primary Syphilis • Chancer presents as common , generally bilateral, firm, non-

single painless or minimally painful fluctuant, non-tender without overlying
round or oval genital ulcer with clean erythema
base and firm indurated borders, little or • • Usually no systemic symptoms
no purulent exudates
• • Asymptomatic infections is common,
• • Most chancer appears on external probably due to unrecognized chancer
genitals, but intravaginal, cervical or
perianal lesions are also common, • • Atypical cases are common
sometimes oral chancers appear
• • Regional lymphadenopathy are
• Genital or perianal warty
outgrowths
• condylomata lata
• partly alopecia of scalp
• generalized
lymphadenopathy
• fever, malaise and
headache
• Occasionally, focal
neurological
manifestations
(especially cranial nerve
abnormalities and signs
of meningeal infection/
inflammation)
Tertiary Syphilis insufficiency
• angina pectoris
• Gummatous syphilis
• locally destructive granulomatous
lesions (gummas) of the skin, liver,
bones, or other organs
• Neurosyphilis
• Tabes dorsalis and dementia often
with paranoid features
• Latent meningovascular
parenchematous
• Optic atrophy
• General paresis
• Cardiovascular syphilis
• Aoritic aneurysm and aoritic valve
• Latent • By definition latent syphilis is
asymptomatic infection that follows
primary syphilis
• • Only detectable serologically
• • Subdivided into two stages
• • Early latent (infectious, less than one year)
• • Late latent (greater than one year, usually
noninfectious stages)
• 2. Genital Herpes: occasionally up to 3 weeks.
• Herpes virus 1 and 2 primarily affects • Primary infection: the virus ascends
oral and genital areas. peripheral sensory nerves and
• infection is caused by inoculation of the established in the root ganglia of the
virus onto a mucosa surface or through sensory or autonomic nerves evading
cracks in the skin, usually through close immune attack. Primary infection is
sexual contact. more severe than recrudescence but
may be asymptomatic.
• Latency and frequent recurrence
characterize genital herpes, producing a • Recurrent genital disease is due to
lifelong infection after the primary reactivation of the initial strain of virus
infection. from infected latent sacral root ganglia.
• incubation period is usually 2-10 days
for symptomatic initial herpes,
• First episode primary genital herpes is pustules, or painful erythematous
characterized by fever, headache, ulcers. The cervix and urethra are
malaise, and myalgia and manifested by involved in more than 80% of women
severe disease requiring with first episode infections.
hospitalization. Pain, itching, dysuria, • HSV2 is the leading cause of genital
vaginal and urethral discharge and ulcer and enhance the acquisition or
tender inguinal lymphadenopathy are transmission of HIV virus following
the predominant local symptoms. unprotected sex.
• Lesions largely involve the external
genitalia, skin, the urethra and cervix.
Lesions may present with varying
stages, including multiple vesicles,
• 3. Chancroid: • Lesions occur on the prepuce and
• caused by gram negative anaerobic frenulum in men and on the vulva,
bacillus called Haemophilus ducreyi. cervix and perianal area in women.
• incubation period is 3-7 days • Extra genital ulcers on the inner thighs,
breast and fingers have been reported.
• progressing from a small papule to
pustule and then to ulcer with soft
margins described as soft chancer.
• Multiple ulcers are commonly present
with painful inguinal lymphadenopathy.
• The ulcer edge is typically ragged and
undermined.
4. Lymphogranuloma venereum (LGV): • Characterized by inguinal lymphadenopathy
accompanied by systemic symptoms such as
• LGV is a sexually transmitted diseases fever, headache, myalgia, etc.
caused by L1, L2, L3 strain of Chlamydia
•
• Third stage refers to the complication
trachomatis.
of LGV and occurs years after the initial
• Incubation period ranges from 3-30 days infection:
after acquisition of infection.
•
ΞΞ Hypertrophic chronic granulomatous
• Initial infection can be urethral or enlargement with ulceration of the
cervical producing urethritis or cervicitis.
external genitalia (vulva, scrotum and
• • Primary lesion is a small papule or penis), rectal stricture, anogenitorectal
herpetiform ulcer that produces few or syndrome.
no symptoms and generally not noticed • ΞΞ Lymphatic obstruction leads to
and heals without leaving a scar. elephantiasis of the male or female
• • Secondary stage occurs after few days genitalia
or weeks of the primary lesion.
5. Granuloma inguinale (Donovanosis) • Multiple lesions may coalesce to form
• Granuloma inguinale is a chronic large ulcers.
progressive ulcerative disease of the • Subcutaneous spread of the infection is
genitalia caused by intracellular gram progressive and more destructive.
negative bacterium Klebsiella • Blockage of lymphatic vessels by
granulomatis scarred tissue will result in lymph
• Incubation period ranges from 1 to 4 edema and elephantiasis of the
weeks and may extend up to a year. external genitalia.
• Primary lesion is a small painless • Common sites of infections in men are
indurated papule/nodule which soon the prepuce, penile shaft and in female
ulcerates to form beefy red labia and fourchette. Lesions on the
granulomatous ulcer with rolled edges vaginal wall and cervix are rarely seen.
and bleeds easily on contact.
VAGINAL DISCHARGE SYNDROME (VDS)

• it is useful to distinguish between The first two cause cervicitis while the
noninfectious/physiological secretions last three cause vaginitis.
from STI related discharge. The common • In Ethiopia, Bacterial vaginosis is the
causes of vaginal discharge syndrome commonest cause of vaginal discharge
include: followed by Candida, Trichomonas,
• • Neisseria Gonorrhea Gonococcal and Chlamydia cervicitis.
• • Chlamydia trachomatis
• • Trichomonas vaginalis • Noninfectious vaginitis is usually due to
• • Gardnerella allergic reaction or irritation.
• • Candida albicans • Another common cause is atrophic
• The first three are sexually acquired and vaginitis due to estrogen deficiency.
the last two are endogenous infections.
• 1. Bacterial vaginosis (BV) • • Vulvar irritation (less common)
• Bacterial vaginosis (BV) is a clinical • • Dysuria or dyspareunia (rare)
syndrome resulting from replacement of • Physical findings in bacterial vaginosis
the natural vaginal flora (hydrogen may include the following:
peroxide producing Lactobacillus) by high
concentration of anaerobic bacteria • • Thin, homogeneous, malodorous, and
namely gardnerella, mycoplasma hominis, grayish white or yellowish vaginal
ureaplasma urealyticum, etc. discharge, which adheres to the vaginal
mucosa
• Typical symptoms:
• little or no evidence of inflammation of
• • Vaginal odor (the most common, and vaginal walls
often initial, symptom of BV); often
recognized only after sexual intercourse • • Normal-appearing labia, introitus, cervix,
and cervical discharge
• • Mildly to moderately increased vaginal
discharge • • In some case, evidence of cervicitis
• Risk factors that may predispose demonstrated to be of benefit. Therefore,
patients to Bacterial vaginosis: it is recommended that predisposing
• • Recent use of antiseptic/antibiotic factors mentioned above should be
vaginal preparation reduced or eliminated.
• • Decreased estrogen production of the
host
• • Presence of intrauterine device (IUD)
• • Frequent douching
• Bacterial vaginosis is an endogenous
reproductive infection. Treatment of
sexual partners has not been
• 2. Vulvovaginal Candidiasis (VVC) • Precipitating factors for the
• caused by Candida albicans and also acquisition of Candidiasis:
known as vaginal thrush. • • Medical conditions that compromise
• a common condition caused by a yeast the body’s immune system such as
infection in the vagina and surrounding (immunosuppression), diabetes
area. mellitus, pregnancy, and hormone
replacement therapy, etc.
• Candida lives harmlessly on the skin, in
the mouth, gut and vagina and is • • Taking antibiotics/chemotherapy –
normally kept under control by about 30 per cent of women will have
harmless bacteria. But sometimes thrush
conditions change and the yeast • • Use of chemical products that irritate
increases rapidly, causing symptoms of the vagina, such as vaginal douches or
discharge and irritation. bubble bath
• common among women of child • • Wearing tight clothing – this prevents
bearing age (30’s and 40’s), and in natural ventilation
those who are pregnant.
Sign and symptoms • Since candidiasis is usually not acquired
• Up to 20% asymptomatic through sexual intercourse, treatment
of sexual partner is not recommended.
• Typical manifestation includes:
• • Vulval itching, soreness and irritation
• • Redness of the vagina and vulva
• • Vaginal discharge, often white (like
cottage cheese) and this can be thick or
thin but is usually odorless
• • Pain or discomfort during sex or when
passing urine.
• About 75% of all women have at least
one episode of candidiasis in their
lifetime. Recurrent episodes may
indicate underlying immunodeficiency
or diabetes.
• 3. Trichomonas vaginalis (TV) strawberry appearance as a result may
• STI caused by flagellated protozoa known bleed easily when swabbed.
as T. vaginalis
• Incubation period rages from 1-4 weeks.
• About one fourth remain asymptomatic.
Some may produce recurrent attacks of
cystitis with dysuria and frequency, etc.
• Symptoms:
• offensive vaginal discharge and Vulval
itching
• Vulva becomes erythematous and
excoriated and vaginal walls are reddened.
• Frothy, greenish vaginal discharge with a
‘musty’ malodorous smell is characteristic.
• Rarely the cervix can be involved with a
Association with adverse pregnancy • Some patient may have concomitant
outcomes gonococcal or chlamydial infection in
• • Premature rupture of membranes addition to T. vaginalis which may modify
the clinical manifestations.
• • Preterm delivery and
• Due to the nonspecific clinical features
• • Low birth weight of vaginitis and the presence of mixed
• This association is particularly important infections, syndromic diagnosis and
in symptomatic women and hence, management is recommended.
impact of treating trichomoniasis in the • Sexual partners should be notified and
prevention of adverse outcomes of treated.
pregnancy.
• Patient should be advised against sexual
• frequently asymptomatic in men but is intercourse until both the index patient
increasingly recognized as a cause of and the partner (s) are treated.
symptomatic nongonococcal, non-
chlamydial urethritis.
• 4. Mucopurulent Cervicitis evaluation should be an essential part of
• mainly caused by N. gonorrhoeae and the physical examination of a patient
C.trachomatis. with vaginal discharge.
• The presence of purulent exudate from • Redness,
the cervical os • contact bleeding,
• Cervicitis is frequently asymptomatic. It • spotting and
may be detected on routine pelvic • endocervical discharge suggest diagnosis
physical examination or during of cervicitis.
evaluation of a patient with vaginal
discharge.
• Accordingly, cervical speculum
• Risk assessment - specific for use of • Number of risk factors have been shown
vaginal discharge flow-chart to be indicative of cervical infection.
• Using vaginal discharge as an entry point • • Multiple sexual partners in the last
to manage cervical infection is far from 3 months
ideal. While vaginal discharge is highly • • New sexual partner in the last 3
• indicative of vaginal infection, it is poorly months
predictive of cervical infection with • • Ever traded sex
gonorrhoea and/or chlamydia. • • Age below 25 year
• The flowchart may become more • The presences of one or more risk factors
predictive of cervical infection if a suggest cervicitis.
number of risk factors are included.
• Complications of Cervicitis and vaginitis
• • PID
• • Premature rupture of membrane
• • Pre-term Labor
• • Infertility
• • Chronic pelvic pain
• Recommended regimens for pregnant women
• Although metronidazole is not recommended for use in the first trimester of
pregnancy, treatment may be given where early treatment has the best chance of
preventing adverse pregnancy outcomes.
• In this instance a lower dose should be used

• • Metronidazole 200 or 250mg orally, 3 times per day for 7days , after
first trimester
• • Metronidazole 2gm orally, as a single dose, if treatment is
imperative during the first trimester of pregnancy
LOWER ABDOMINAL PAIN SYNDROME OR
PELVIC INFLAMMATORY DISEASES (LAPS/PID)

• Pelvic inflammatory disease (PID) is a • PID is a Polymicrobial inflammation caused

syndrome characterized by lower abdominal by infection that ascends from the vagina
pain syndrome. It is an inflammatory and cervix into the upper genital tract.
disorder of the upper female genital tract, • Causes: C. Trachomatis and Neisseria
involving the uterus, fallopian tubes, ovaries gonorrhoeae.
and adjacent pelvic structures. • Others include Gardnerella vaginalis,
• PID includes endometritis, salpingitis, tubo- Haemophilius influenzae, Mycoplasma and
ovarian abscess, oophoritis and pelvic anaerobes such as Peptococcus and Bacteroides
species.
peritonitis. Infection and inflammation may
spread to the abdomen, including
perihepatic structures.
• Risk Factor: • Use of an intrauterine device (IUD) for
• The classic high-risk patient is: contraception confers a relative risk of 2.0-
3.0 for the first 4 months following
• a menstruating woman insertion, but risk subsequently decreases
• younger than 25 years to baseline.
• Follow-up is recommended within the first
• who has multiple sex partners, month after IUD insertion.
• does not use contraception, and
• lives in an area with a high prevalence of
sexually transmitted disease (STD).
• Depending on the severity of the infection • Alternative causes of lower abdominal pain
(manifestation of patients with PID may be such as:
mild or severe with toxic symptoms like: • appendicitis, ectopic pregnancy, and
• fever, nausea, vomiting, and severe pelvic and cholecystitis, should be ruled out by proper
abdominal pain may occur. history and physical examination.
Women with PID usually present with: • PID become more probable when one or
more of the symptoms above combine with
• lower abdominal pain physical findings of:
• typically dull, aching or crampy, bilateral, and
constant. It begins a few days after the onset of • • Lower abdominal tenderness
the last menstrual period and tends to be • • Vaginal discharge
accentuated by motion, exercise, or coitus. • • Cervical motion tenderness
• vaginal discharge. • Over diagnosis and treatment nay be
• In approximately two third justified in order to prevent complications.
• Unanticipated vaginal bleeding, often
postcoital
• In one third.
• During history taking the service provider • • Check patient’s temperature.
should ask in detail for other symptoms • fever indicates infection
such as erratic bleeding, missed or overdue • • Palpate the abdomen for tenderness,
period, recent delivery, abortion or rebound tenderness, guarding and
miscarriage. You need to ask similar detection of a mass.
questions such as:
• • Guarding and rebound tenderness are
• • Are there any problems with your features of peritonitis or intra-abdominal
periods? abscess.

• • Do you have any vaginal bleeding not • • Check for abnormal vaginal bleeding.
related to normal menstruation? • possibility of an ectopic pregnancy or abortion.

• • Have you had a miscarriage, abortion or • • Finally, check for abnormal vaginal
delivery in the last six weeks discharge.
• When examining the patient:
• Complications of PID Seriously consider hospitalizing patients
• • Peritonitis and intra-abdominal abscess (Indications for Admission of patients) when:
• • Adhesion and intestinal obstruction • • The diagnosis is uncertain
• • Ectopic pregnancy • • Surgical emergencies such as
appendicitis and ectopic pregnancy cannot
• • Infertility be excluded
• • Chronic pelvic pain • • Pelvic abscess is suspected
• • Severe illness precludes management on
an outpatient basis
• • The patient is pregnant
• • Patient is unable to follow or tolerate an
outpatient regimen
• • Patient has failed to respond to
outpatient therapy
• • PID in HIV patients
• Recommended treatment for PID • However, failure to improve within 72
• Broad spectrum antibiotics to cover all hours after antibiotic treatment
pathogens are indicated because PID is indicates failure of medical treatment
Polymicrobial infection even with and the
setting of gonococcal or chlamydial • patient should be referred for surgical
infection. Empirical treatment should or gynecological evaluation and
be instituted as soon as diagnosis is treatment.
suspected.
• The vast majority of PID with or
without pelvic abscess to improve with
antibiotics alone and the fever usually
subsides in less than 72 hours.
SCROTAL SWELLING SYNDROME (SSS)

• cause of scrotal swelling can vary pseudomonas or mumps virus.

depending on the age of the patient. • Mumps epididymo-orchitis is usually noted
within a week of parotid gland
• younger than 35 years: N. gonorrhoea enlargement.
or C. trachomatis.
Complications of scrotal swelling
• older than 35 years: other caused by STIs
microorganisms or possibly TB if the
patient has not been involved in unsafe • • Epididymitis
sex. • • Infertility
• Other infectious causes: brucellosis, mumps, • • Impotence
onchocerciasis, W. bancrofti. However, these
conditions produce systemic disease and may • • Prostatitis
be associated with additional findings.
• pre-pubertal children: coliform,
 SCROTAL SWELLING SYNDROME (SSS)

• It is important to exclude other causes

of scrotal swelling that require urgent
referral for proper surgical evaluation
and treatment such as
• • Testicular torsion
• • Trauma
• • Tumor
• • Incarcerated inguinal hernia
• Steps in examining patients with scrotal • 6. Is there swelling in the inguinal area or
swelling: does the scrotal swelling increase when the
• 1. Inspect the scrotal sac and compare the patient raises intra-abdominal pressure
two sides for swelling of testis. Palpate and (straining as if passing stool)? This may
note any tenderness. point to a hernia and may require referral to
a surgical facility.
• 2. Determine the position of the testis in
the scrotal sac. Is it elevated or rotated? If
so , this is characteristic of testicular torsion.
• 3. Is there bruising of the scrotal skin which
could indicate trauma?
• 4. Is there an obvious urethral discharge? If
not, ask the patient to gently squeeze the
penis and milk the urethra in order to
express any discharge.
• 5. Is there evidence of any other STIs such
as an ulcer?
INGUINAL BUBO SYNDROME (IBS)

• Inguinal bubo: painful, often fluctuant, • The common STIs associated with
swelling of the lymph nodes in the inguinal bubo include:
inguinal region (groin). • • C. trachomatis (serovar L1; L2; and L3)
• It should be remembered that • • H. ducreyia
infections in the lower extremities or in
the perineum could produce swelling of • • C. granulomatis and
the inguinal lymph nodes, but strictly • • T. pallidum
speaking this regional enlargement
should not represent inguinal bubo.
 INGUINAL BUBO SYNDROME (IBS)

• When examining the patient, try and •

COMPLICATIONS
determine whether the swelling is really • • Fistula or sinus formation
a bubo or simply enlarged lymph nodes
or any other pathology which has •
• Multiple draining sinus
enlarged nodes in other sites. •
• Extensive ulceration of genitalia
• A bubo is usually painful, warm, tender
and fluctuant when palpated. •
• Extensive scarring
• There may be one large mass or a collection •
• Retroperitoneal lymphadenopathy
of smaller painful swellings.
•
• Chronic untreated LGV may result in
• Occasionally the bubo might have ruptured
and a sinus, discharging pus, will be lymphatic obstruction, elephantiasis of
present. the genitalia
• Examine eternal genitalia properly as well • • Rarely hematogenous dissemination
to lung, liver, spleen and bone.
NEONATAL CONJUNCTIVITIS SYNDROME (NNCS)

• Neonatal conjunctivitis (ophthalmia from the eye or sticky eyes.

neonatorum) is a purulent • For babies older than one month, the
conjunctivitis occurring in a baby less cause is unlikely to be STIs.
than one month of age.
CLINICAL MANIFESTATIONS
• transmitted by contact during delivery
or passage through the birth canal. • • Red and edematous conjunctiva
• Causes: gonorrhea and chlamydia. • • Edematous eye lid
• If caused by gonorrhea blindness often • • Discharge which may be purulent
follows.
• • Orbital cellulitis in more serious cases
• Newborn babies present with redness
and swelling of the eyelids, discharge
NEONATAL CONJUNCTIVITIS SYNDROME (NNCS)

COMPLICATIONS Prevention of Neonatal Conjunctivitis

• serious ophthalmic complications if it is • Prompt eye prophylaxis at delivery
not managed promptly. prevents gonococcal conjunctivitis.
• Some complications are: • All newly born babies should have
• • Pseudo membrane formation preventive therapy carried out as
follows.
• • Corneal edema • • As soon as the baby is born, carefully wipe
• • Thickened palpebral conjunctiva both eyes with dry, clean cotton wool
• • 1% tetracycline eye ointment into the
• • Corneal opacification infant’s eyes
• • Corneal perforation • Remember that the baby’s eyes are
• • Endophthalmitis usually swollen soon after birth and may
be difficult to open. Therefore eyes
• • Blindness should be opened and the eye ointment
placed in the lower conjunctivas sacs and
not on the eyelids.