STIs Flashcards
STIs
Please read from STG okay
Forget what ever tryouts have written here.
Sexually Transmitted Infections in Adults
Sexually Transmitted Infections (STIs) result in several clinical syndromes caused by organisms that can be acquired and transmitted through sexual activity.
They cause acute morbidity in adults and may result in long-term complications such as urethral stricture, infertility, ectopic pregnancy, anal fistula, cervical cancer, foetal wastage, prematurity, low birth weight, ophthalmia neonatorum and congenital syphilis. Their control is the cornerstone in improving reproductive health and reducing Human Immunodeficiency Virus (HIV) infections.
Comprehensive management of STI is important and comprises prompt and effective case detection and treatment. However, owing to the lack of laboratory equipment and manpower in primary care facilities where most patients first present, an accurate diagnosis is often not possible. Also with most STIs, one cannot usually tell which organism is causing the infection from the history and physical examination alone. Multiple infections also occur, with each needing to be treated. Failure to treat one infection adequately may result in the development of serious complications.
It is therefore more practical in managing STIs to base treatment on a ‘syndromic diagnosis’, which identifies all STIs that could cause a particular symptom or sign and provide treatment for each of them simultaneously.
The common clinical syndromes associated with STIs include urethral discharge in males, persistent/recurrent urethral discharge, vaginal discharge, lower abdominal pain, genital ulcer, scrotal swellings, inguinal lymphadenopathy (buboes), ano-rectal syndromes (ano-rectal discharge, ulcers and vesicles), and genital warts. Scabies and pediculosis pubis may also be transmitted by sexual contact.
In dealing with patients with STI, privacy and confidentiality, especially with the history taking and examination, are paramount.
Education and counselling of STI patients and concurrent management of their partners provide additional opportunities to reduce the risk of STI in the community.
(See section on ‘Sexually Transmitted Diseases in Children’ for STIs
in children)
163� STI-related Urethral Discharge in Males
163� STI-related Urethral Discharge in Males
Causes
y Neisseria gonorrhoea (Gonococcal urethrits)
y Chlamydia trachomatis (Non-gonococcal urethritis)
164. Mycoplasma genitalum
Symptoms
y Urethral discharge
y Dysuria or discomfort on urination
Signs
y Urethral discharge Note 16-1
Gentle milking of the urethra may reveal the discharge if it is not initially visible.
In uncircumcised males, check that the discharge is coming from the urethral opening and not from the glans penis.
Investigations
y Urethral swab culture and sensitivity (if available)
Treatment
Treatment objectives
y To treat gonorrhoea and chlamydia urethritis simultaneously y To prevent further transmission to sexual partners.
y To treat both partners simultaneously as much as possible
y To prevent development of complications and sequelae
y To reduce risk of HIV infection Non-pharmacological treatment
y None
Pharmacological Treatment
Evidence Rating: [C]
A. For Gonorrhoea
y Ceftriaxone, IM, 250 mg stat Or
y Cefixime, oral, 400 mg stat Or
y Ciprofloxacin, oral, 500 mg stat And
B� For Chlamydia and Mycoplasma:
y Doxycycline, oral, 100 mg 12 hourly for 7 days Or
y Tetracycline, oral, 500 mg 6 hourly for 7 days Or
y Erythromycin, oral, 500 mg 6 hourly for 7 days Or
y Azithromycin, oral, 1 g stat.
STI-related Persistent or Recurrent Urethral Discharge
STI-related Persistent or Recurrent Urethral Discharge
This may occur due to drug resistance, poor treatment compliance or re-infection following treatment for an STI. In some cases persistence of urethral discharge may be due to infection with Trichomonas vaginalis.
Causes
y Neisseria gonorrhoeae, Chlamydia trachomatis or Mycoplasma genitalum following drug resistance, poor compliance or re-infection after treatment
y Trichomonasvaginalis Treatment
Treatment objectives
y To re-treat for gonococcal or non-gonococcal urethritis if suspected to be due to previous poor treatment compliance or re-infection
y To treat infection with Trichomonas vaginalis
y To prevent transmission to sexual partners
y To treat both partners simultaneously as much as possible y To prevent development of complications and sequelae
y To reduce risk of HIV infection
Non-pharmacological treatment
y None
Pharmacological Treatment
Evidence Rating: [C]
A. For Gonorrhoea, Chlamydia, Mycoplasma
Repeat treatment for urethral discharge
B� For Trichomonas vaginalis
y Metronidazole, oral, 400 mg 12 hourly for 7 days
Or
y Metronidazole, oral, 2 g stat. Or
y T inidazole, oral, 2 g stat. Or
y Secnidazole, oral, 2 g stat.
Referral Criteria
Refer all cases of treatment failure to a health facility where microbiological culture and antimicrobial sensitivity tests can be done on the urethral discharge.
STI-related Vaginal Discharge
Risk Assessment— STG page 446
STI-related Vaginal Discharge
While a vaginal discharge is a notable clinical feature of an STI, not all forms of vaginal discharge are abnormal or indicative of an STI. A vaginal discharge may be associated with a physiological state such as menses or pregnancy, or with the presence or use of foreign substances and chemicals in the vagina.
A careful risk assessment (See note below) of women with a vaginal discharge may help identify STIs and non-STIs and selection of appropriate treatment regimens based on the most likely aetiology of the vaginal discharge. Other considerations for selecting treatment include pregnancy status and patient discomfort.
Causes
y Neisseria gonorrhoea
y Chlamydiatrachomatis
y Trichomonas vaginalis (green or yellow, smelly, bubbly or frothy
discharge associated with itching)
y Herpes simplex virus (following first episode of infection)
Symptoms
y Vaginal discharge - change in colour, odour, consistency or amount y Vulval swelling
y Pain on urination
y Lower abdominal or back pain
Signs
y Vaginal discharge
y Vulval swelling
y Vulval erythema
y Lower abdominal tenderness
y Cervical excitation tenderness
y Cervical mucopus or erosions (on speculum examination)
Investigations
y Highvaginalswabformicroscopy,cultureandsensitivity(ifavailable) Treatment
Treatment objectives
y Toidentifyandtreatnon-STIvaginitis(especiallycandidiasis,whichis frequently diagnosed in women being evaluated for STIs)
y To assess STI risk and treat STI-related infections appropriately y To prevent complications and sequelae
To treat both partners simultaneously as much as possible
Non-pharmacological treatment
y None for STI-related discharge Pharmacological Treatment
Evidence Rating: [C]
Treatment for trichomoniasis and bacterial vaginosis
y Metronidazole, oral, 2 g stat. (contraindicated during the 1st trimes- ter of pregnancy)
Or
y Metronidazole, oral, 400 mg 8 hourly for 5 days (contraindicated during the 1st trimester of pregnancy)
Or
y Secnidazole, oral, 2 g stat. (contraindicated during the 1st trimester of pregnancy)
Or
y Tinidazole, oral, 2 g stat. (contraindicated during the 1st trimester of pregnancy)
Or
y Clindamycin cream (2%), topical (preferred in pregnancy) And
B� Treatment for candidiasis
y Miconazole vaginal tablets, 200 mg inserted into vagina at night for 3 days
y Or
y Clotrimazole, vaginal tablets, 200 mg inserted into vagina at night
y Clotrimazole cream, apply 12 hourly (for vulval irritation) C� Treatment for gonorrhoea
for 3 days y And
y Ceftriaxone, IM, 250 mg stat.
Or
y Ciprofloxacin, oral, 500 mg stat. (avoid in pregnant and lactating mothers)
And
y Doxycycline,oral,100mg12hourlyfor7days(avoidinpregnantand lactating mothers)
Or
y Tetracycline, oral, 500 mg 6 hourly for 7 days (avoid in pregnant and lactating mothers)
Or
y Cefixime, oral, 400 mg stat Or
y Erythromycin, oral, 500 mg 6 hourly for 7 days Or
y Azithromycin, oral, 2 g stat.
Referral Criteria
Refer all cases of recurrent vaginal discharge and/or treatment failures to a health facility where speculum examination can be carried out and microbiological culture and antimicrobial sensitivity tests can be done on the vaginal discharge.
STI-related Lower Abdominal Pain in Women
STI-related Lower Abdominal Pain in Women
Causes
y Neisseria gonorrhoea
y Chlamydiatrachomatis
y Anaerobic bacteria (often relating to recurrent infections)
Symptoms
y Lower abdominal pain
y Pain with sexual intercourse (dyspareunia) y Vaginal discharge
y Dysuria or urethral discomfort
y Fever
Signs
y Lower abdominal tenderness
y Vaginal discharge
y Tenderness on moving the cervix (cervical excitation) on bimanual
vaginal examination y Adnexal tenderness y Adnexal masses
Investigations
y High vaginal swab culture and sensitivity
y Pelvic ultrasound
Treatment
Treatment objectives
y Totreatforgonorrhoea,chlamydiaandanaerobicbacterialinfection y To relieve pain and inflammation
Non-pharmacological treatment
y Remove IUD, if present, 3 days after initiation of drug therapy Pharmacological Treatment
Evidence Rating: [C]
A. Out-Patients
y Cefixime, oral, 400 mg stat. Or
y Ciprofloxacin, oral, 500 mg 12 hourly for 3 days
And
y Doxycycline, oral, 100 mg 12 hourly for 14 days And
y Metronidazole, oral, 400 mg 12 hourly for 14 days
B� In-Patients
y Ceftriaxone, IM, 250 mg daily for 3 days And
y Doxycycline, oral, 100 mg 12 hourly for 17 days And
y Metronidazole, oral, 400 mg 12 hourly for 17 days
STI-related Genital Ulcer
STI-related Genital Ulcer
Causes
y Herpes simplex
y Treponema pallidum (syphilis)
y Haemophilus ducreyi (chancroid)
y Calymmatobacterium granulomatis (granuloma inguinale)
Symptoms
y Genital ulcer (painful or painless)
y Urethral discharge
y Inguinal swelling (lymphadenopathy)
Signs
y Inguinal lymphadenopathy y Herpes simplex
y Multiple, recurrent vesicular lesions (Herpes simplex) y Syphilitic ulcers
y Often single, painless and indurated lesions with a clear base and well-defined edges
y Occasionally multiple, painful, non-indurated or have a puru-
lent base
y Discrete, firm, painless, inguinal lymphadenopathy a week after
the primary lesion
y Primary ulcer usually heals within six weeks, usually without
leaving a scar. y Chancroid
y Painful with undermined ragged edges
y The base is covered with a purulent exudate and easily bleeds
to touch
y Several ulcers may coalesce to form serpiginous lesions
y Lymphadenopathy is usually unilateral and may become fluc-
tuant
y Granuloma inguinale
y Begins with a small papule that progresses into an enlarging granulomatous ulcer with trauma
y Edges are well defined
y Healing is not spontaneous and is accompanied by extensive
scarring
Investigations
y VDRL (if available) y TPHA (if available)
Treatment
Treatment objectives
y To treat small ulcers and vesicles, especially if recurrent for Herpes simplex
y To direct initial management of all ulcers at herpes simplex, syphilis and chancroid concurrently
Non-pharmacological Treatment
y Keep lesions dry and clean Pharmacological Treatment
Evidence Rating: [C]
y Aciclovir, oral, 200 mg 4-6 hourly for 7-10 days (5 doses daily) Or
A. For Herpes simplex
y Aciclovir, oral, 400 mg 8 hourly for 7-10 days For individuals with herpes and HIV co-infection
y Aciclovir, oral, 400 mg 8 hourly for 7-10 days Or
y Aciclovir, oral, 800 mg 12 hourly for 7-10 days Episodic therapy for recurrent episodes
y Aciclovir, oral, 400 mg 8 hourly for 5 days Or
y Aciclovir, oral, 800 mg 12 hourly for 5 days
Or
y Aciclovir, oral, 800 mg 8 hourly for 2 days
Suppressive therapy in HIV infected individuals
y Aciclovir, oral, 400-800 mg 8-12 hourly for 2-6 years
B� For Syphilis
y Benzathine Penicillin G, IM, 1.2 MU in each buttock (total dose 2.4 MU) stat.
Or
y Procaine Penicillin Aqueous, IM (by deep injection), 1.2 MU daily for 10 days
For persons allergic to penicillin
y Doxycycline, oral, 100 mg 12 hourly for 14 days Or
y Tetracycline, oral, 500 mg 6 hourly for 14 days For pregnant women allergic to penicillin
y Erythromycin, oral, 500 mg 6 hourly for 14 days Or
y Azithromycin, oral, 500 mg daily for 10 days
C� For Chancroid
y Ceftriaxone, IM, 250 mg stat. Or
y Azithromycin, oral, 1 g stat. Or
y Ciprofloxacin, oral, 500 mg 12 hourly for 3 days Or
y Erythromycin, oral, 500 mg 6 hourly for 7 days
STI-related Scrotal Swelling
STI-related Scrotal Swelling
Causes
y Chlamydiatrachomatis
y Neisseria gonorrhoea
y Treponema pallidum (very rarely)
Symptoms
y Scrotal swelling
y Scrotal pain
y Urethral discharge y Dysuria
y Frequency of micturition y Fever
Signs
y Scrotal swelling, oedema and/or erythema y Scrotal tenderness
y Urethral discharge
y Fever
Investigations
y Urethral swab for culture
y Urine culture and sensitivity
y Ultrasound scan of the scrotum
Treatment
Treatment objectives
y To provide pain relief
y To identify and treat STI and non-STI related causes appropriately y To treat for gonorrhea and chlamydia simultaneously
Non-pharmacological treatment
y Bed rest
y Scrotal support until inflammation and fever subside
Pharmacological Treatment
Evidence Rating: [C]
A. For Gonorrhoea
y Ceftriaxone, IM, 250 mg stat. Or
y Cefixime, oral, 400 mg stat.
y Ciprofloxacin, oral, 500 mg stat.
And
B� For Chlamydia
y Doxycycline, oral, 100 mg 12 hourly for 7 days Or
y Tetracycline, oral, 500 mg 6 hourly for 7 days Or
y Azithromycin, oral, 1 g stat. Or
y Erythromycin, oral, 500 mg 6 hourly for 7 days
STI-related Inguinal Bubo
STI-related Inguinal Bubo
Causes
y Chlamydia trachomatis (Lymphogranuloma venereum) y Haemophilus ducreyi (Chancroid)
Symptoms
y Painful or painless inguinal swelling(s)
Signs
y Inguinal swellings:
y unilateral or bilateral y tender or non-tender
y fluctuant
y suppurating y Genital ulcer
Investigations
y No investigations required, in view of the syndromic approach y Recommended in managing STIs
Treatment
Treatment objectives
y To relieve pain
y To relieve the swelling
y Totreattheinfectionoflymphogranulomavenereumandchancroid
concurrently
Non-pharmacological treatment
y Aspiration of fluctuant buboes using a wide bore needle through adjacent healthy skin every second or third day. An incision and drainage should not be attempted. If buboes persist, the patient should be referred.
y Sequelae such as strictures and/or fistula may require surgery.
Pharmacological treatment
A. For Lymphogranuloma Venereum (LGV) andChancroid
Evidence Rating: [C]
Doxycycline, oral, 100 mg 12 hourly for 21 days
Or
Azithromycin, oral, 1 g stat.
Or
Erythromycin, oral, 500 mg 6 hourly for 14 days
