Syndromic STIs: Vaginal Discharge Diagnosis

• Study notes on the diagnosis and management of syndromic STIs.

Vaginal Discharge Syndrome

• For patients presenting with vaginal discharge, vulva itching/burning, take a history, examine the patient (external, speculum & bimanual), and assess risk factors.
• Risk factors include age less than 21 years, patient complaining of yellow discharge, and the partner having urethral discharge.
• If the patient has lower abdominal tenderness, cervical motion tenderness, the response is YES, refer to the flowchart for lower abdominal pain.
• If the patient has cervical mucus or erosions and risk assessment is positive, treatment should cover CT/GC/TV/BV (Chlamydia trachomatis/Neisseria gonorrhoeae/Trichomonas vaginalis/Bacterial vaginosis).
• Treatment includes Azithromycin 1g stat PO (by mouth), Ceftriaxone 250mg IM (intramuscular) stat, and Metronidazole 2g stat.
• Ask the patient to return in 7 days and issue contact slips.
• If the patient has vulvar erythema, excoriations, or curd-like discharge, treatment is for Candida: Clotrimazole pessaries 100mg nocte (at night) for 6 nights.
• Ask the patient to return in 7 days.
• If the patient is still symptomatic after 7 days, but no vulvar presentation, perform a wet mount and gram stain microscopy of the vaginal specimen, or take a high vaginal swab and send it to the laboratory.
• If motile trichomonas is present, treat for T. vaginalis with Metronidazole 2g stat.
• If clue cells are seen plus pH > 4.5 and KOH is positive, treat for B. vaginosis with Metronidazole 2g stat.
• If budding yeasts or pseudohyphae are seen, treat for Candida albicans with Clotrimazole pessaries.
• If there are no abnormal findings and the patient has persistent symptoms, refer to higher level of care.
• Always educate and counsel patients.
• Educate and counsel patients to promote condom use, and provide condoms; treat partners and offer HIV testing and counselling, ask patients to return in 7 days and review.
• Reinforce health promotion package for all patients.

Health Promotion for all Patients

• Educate, ensure compliance and risk reduction counselling.
• Promote abstinence during the course of treatment.
• Stress the importance of partner treatment and issue one contact slip for each sexual partner, follow up partner treatment during review visits.
• Provide HIV counselling and testing; for negative results, repeat test after 3 months.
• Offer SMC (safe male circumcision) to uncircumcised partners.
• Provide cervical cancer screening during follow-up visits.
• Promote and demonstrate correct and consistent condom use and provide condoms.

Lower Abdominal Pain

• For patients with lower abdominal pain, take a history (including gynaecological) and perform an examination (abdominal and vaginal), including a bimanual examination.
• Offer an HIV test and follow the RHT (reproductive health triage) flow chart.
• If the patient has, recent delivery/abortion/miscarriage, missed period/overdue period, abdominal guarding and/or rebound tenderness, abnormal vaginal bleeding, or an abdominal mass, refer to the higher level.
• Refer the patient urgently for surgical or gynaecological opinion and assessment; before referral, set up an IV line and apply resuscitative measures if necessary and do pregnancy tests, and give analgesia.
• If the patient has cervical mucopus or yellow discharge, cervical excitation tenderness, or temperature > 38°C, manage for PID (pelvic inflammatory disease)
• Manage for PID with Ceftriaxone 250mg IM stat, Azithromycin 1g weekly for 2 weeks, and Metronidazole 2g weekly for 2 weeks.
• Provide a health promotion package, offer HIV counselling and testing, and ask the patient to return in 3 days.
• If the patient improves after 3 days of treatment, continue treatment until completed and reinforce the health promotion package.
• If the patient does not improve after 3 days of treatment, and there are any other illness found, manage following appropriate flow chart.
• If there are no other illnesses found, admit the patient for IV antibiotics or refer to higher level.

Major Etiologies of Lower Abdominal Pains

• Chlamydia (caused by C. trichomatis.).
• Gonorrhoea (caused by N. gonorrhoeae.).

Genital Ulcer Disease (GUD)

• For patients presenting with a sore or ulcer on the genital area, take a history, examine, and offer an HIV test (follow RHT flowchart).
• Major aetiologies include herpes simplex virus type 2 (HSV), syphilis (T. pallidum), and chancroid (H. ducreyi).
• If vesicles are present, treat for herpes with Acyclovir 400mg TID (three times a day) for 7 days.
• If no vesicles are present and an ulcer is found on the genitals, treat for syphilis, chancroid, and herpes with:
  • Benzathine penicillin 2.4 million units IU IM stat
  • Ceftriaxone 250mg IM stat
  • Acyclovir 400mg TID for 7 days
  • Provide a health promotion package, consider RPR/VDRL (syphilis tests), ask the patient to return in 7 days, give health promotion, and issue a contact slip.
• If the ulcer heals, and other STIs are not present, reinforce health promotion package.
• If the ulcer improves but has not healed, re-evaluate for re-infection or poor treatment adherence.
• If re-infection or poor treatment adherence are likely, re-treat; if not, refer to a high level of care.
• If the ulcer is completely healed, and other STIs are not present, reinforce health promotion package.

Major Aetiologies of Genital Ulcer Disease

• Herpes Simplex Virus type 2 (caused by HSV).
• Syphilis (caused by T. Pallidum).
• Chancroid (caused by H. Ducreyi).

Inguinal Bubo

• For patients complaining of swelling in the groin with or without pain, take a history, examine, and offer an HIV test (follow RHT flowchart).
• Major aetiologies include chancroid (H. ducreyi) and lymphogranuloma venereum (C. trachomatis).
• Treat for the following -Treat for LGV/Chancroid (Lymphogranuloma venereum):
  • For LGV/Chancroid use Ceftriaxone 250mg IM stat, Azithromycin 1g PO (by mouth) weekly for 3 weeks, aspirate Bubo if fluctuant (as needed) then Provide health promotion package.
  • Ask patient to return in 21 days.
• Signs of other STIs present, treat as follows.
• Bubo has improved.
• Then it is re-infection or poor treatment.
  • Likely treat the correct way.
    • Not likely Doxycycline 100mg PO BID for 21 days then Aspirate Bubo if fluctuant (every 3 days)
• And then ask patient to return in 7 days.
• Bubo has not improved.
• Refer to additional resources. -Reinforce health promotion package for all patients.

Major Aetiologies of Inguinal Bubo

• Chancroid (caused by H. Ducreyi).
• Lymphogranuloma venereum (caused by C. trachomatis).

STI Screening for Pregnant Women

• Pregnant woman at her first antenatal care visit; take history and examine.
• Explain the need for syphilis screening and provide HIV testing and counselling.
• No STI present: Provide health promotion package to a pregnant woman and partner.
• STI present follow flow chart, HIV test positive, repeat HIB test every 3 months and refer to PMTCT.
• History of Treatment being RPR positive and titre less than or equal to last test result and higher: No records available, treat for Syphilis.
  • Treat for Syphilis and Benzathine penicillin 2.4 IU IM weekly for 3 weeks then provide health promotion package.
• Treat mother with, Azithromycin 1 g weekly for three weeks or Erythromycin 500mg QID for 21 days then contact should be treated as early Syphilitic case(s) after examination.
• Review after 3 months for patients, and if no more than 10 days of therapy missed the entire course will be restarted.
• Patient with RPR/VDRL Titre less or equal to last test result continue to Reinforce Health promotion package and discharge patient.
• And in patient with Higher Re-infection has occurred consider syphillis confirmatory test and Review HIV status and bio markers.

Congenital Syphilis

• For infants born to RPR (Rapid Plasma Reagin) positive mothers, or unknown RPR, perform a physical exam and collect blood for RPR.
• If Infant is not symptomatic, and RPR results are available treat as less likely Syphilis, or as congenital Syphilis with Titer quantification with its mother.

Molluscum Contagiosum

• Common viral infection identified by raised umbilicated papule or nodules.
• Treat with Excisional curettage.
• Or use Podophyllotoxin 0.5% to the lesion BD for 3 days, or Imiquimod 5% cream, or Cryotherapy with liquid nitrogen.
• Refer clients with generalized lesion for HIV testing if unknown.

Genital Scabies

• Infestation of the top layer of skin caused by a parasite.
• Benzyl Benzoate (BB) 25% lotion to be applied all over the body below the neck after bath for two consecutive nights.
• Patients should bathe 24 hours after the second application.
• Transmitted by sexual or non-sexual contact with an infected person, or spread by direct prolonged skin-skin contact with a scabies infested person.

Anorectal Infections

• Management Algorithm for Ano-Rectal Infections are not the low sensitivity.
• Microscopy and patient with passive/receptive anal sex in last 6 months and/or anal symptoms.
• Unprotected sex in last 6 months and Partner with STI, or Multi sex partners and Anal pain or perineal pain.

Genital Warts

• Patient with Complain of painless growths in the genital area and take history, examine, and offer HIV test.
• Genital warts should recommend regimen and follow patients after 3 months.
• No improvements refer patient to higher level.