A collection of disorders, several of which are better regarded as syndromes for more effective management using a syndromic approach
Prevention of STIs
General preventive measures include:
• Give health education about STIs (very important)
♦ Provide specific education on the need for early reporting and compliance with treatment
• Ensure notification and treatment of sexual partners
♦ Counsel patient on risk reduction, eg. practice of safe sex by using condoms, remaining faithful to one sexual partner, personal hygiene
♦ Provide condoms
♦ If necessary and possible, schedule return visits
14.2.1 URETHRAL DISCHARGE SYNDROME (MALE)
Causes
A number of diseases, usually spread by sexual intercourse, produce similar manifestations in the male and may be difficult to distinguish clinically:
• Gonorrhoea: caused by the bacterium Neisseria gonorrhoea
• Trichomoniasis: caused by the protozoan Trichomonas vaginalis
• Non-gonococcal urethritis: caused by virus-like bacteria Mycoplasma and Chlamydia trachomatis
Clinical features
• Patients complain of mucus or pus appearing at the tip of the penis or staining of underwear
• Burning pain on passing urine (dysuria)
• Examination may show a scanty or profuse discharge
Investigations
Pus swab: Gram stain, C&S
Blood: screening tests for syphilis
Examine patient carefully to confirm discharge
Retract prepuce to exclude presence of ulcer
Treatment (patients and partners)
HC2
ciprofloxacin 500mg single dose plus doxycycline 100mg every 12 hours for 7 days
If partner is pregnant:
Give erythomycin 500mg every 6 hours for 7 days plus cotrimoxazole 2.4g (5 tabs) every 12 hours for 3 days
If discharge or dysuria persists and partners treated:
Exclude presence of ulcers under prepuce
Repeat doxycycline 100mg every 12 hours for 7 days
Also give metronidazole 2g single dose
If discharge or dysuria persists and partners not treated:
Start the initial treatment all over again
If discharge still persists:
Refer for specialist management
Prevention
• See p257
14.2.2 ABNORMAL VAGINAL DISCHARGE SYNDROME
Often the first evidence of genital infection, although absence of abnormal vaginal discharge does not mean absence of infection
Causes
• Can be a variety and often mixture of organisms
• Bacterial vaginosis
Clinical features
• In all cases: abnormal increase of vaginal discharge - normal discharge is small in quantity and white to colourless
• Gonorrhoea produces a thin mucoid slightly yellow pus discharge with no smell
• Trichomoniasis causes a greenish-yellow discharge with small bubbles and a fishy smell and itching of the vulva
• Candida albicans causes a very itchy, thick white discharge like sour milk
• Mycoplasma, chlamydia may cause a non-itchy, thin, colourless discharge
Differential diagnosis
• Cancer of the cervix especially in older women with many children (multiparous) - causes a blood-stained smelly discharge
Investigations
Speculum examination especially in older multiparous women
Pus swab: microscopy, Gram stain, C&S
Blood: syphilis tests (RPR/VDRL)
Treatment
HC2
a) If there is lower abdominal tenderness:
Treat as 14.2.3 Lower abdominal pain syndrome, p261
b) If there is no lower abdominal tenderness but there is itching, erythema or excoriations:
Insert one nystatin pessary 100,000 IU into the vagina at night for 14 days or insert one clotrimazole pessary 500mg HC4 single dose at night for 1 night
plus metronidazole 2g single dose
If discharge or dysuria persists:
Give doxycycline 100mg every 12 hours for 7 days
plus ciprofloxacin 500mg stat
If discharge or dysuria still persists and partners not treated:
Repeat doxycyline and ciprofloxacin
If discharge or dysuria still persists and partners treated:
Refer for specialist management
c) If there is no lower abdominal tenderness and no itching, erythema or excoriations:
ciprofloxacin 500mg stat
plus doxycycline 100mg every 12 hours for 7 days
plus metronidazole 2g single dose
If discharge or dysuria persists and partners not treated:
Repeat the above 3-drug treatment
If discharge or dysuria persists and partners treated or if discharge still persists after the repeat course above:
Refer for further management
In pregnancy:
Give erythromycin 500mg every 6 hours for 7 days
plus cotrimoxazole 2.4g (5 tabs) every 12 hours for 3 days
Do not give cotrimoxazole in the 1st trimester or after 36 weeks
Do not give ciprofloxacin, chloramphenicol, doxycycline or tetracycline
Postpone giving metronidazole until after 1st trimester
Child: (7-day course)
cotrimoxazole 24mg/kg every 12 hours or erythromycin 12.5mg/kg every 6 hours
plus
metronidazole 12.5mg/kg every 8 hours
Prevention
• See p257
14.2.3 LOWER ABDOMINAL PAIN SYNDROME (FEMALE) / PELVIC INFLAMMATORY DISEASE (PID) SYNDROME
Causes
• Infection of the uterus, tubes and ovaries by N. gonorrhoea, Chlamydia and anaerobes
Differential diagnosis
• Ectopic pregnancy
• Puerperal sepsis
• Ovulation pain
Investigations
Take history, check if period overdue
If possible examine the patient bimanually - for pregnancy, bleeding, recent delivery or abortion
Check for severe pain, vomiting or rebound tenderness
Treatment
HC2
If any of the above signs and symptoms are found:
Refer quickly for further management
If none of the above signs and symptoms are found:
Give ciprofloxacin 500mg every 12 hours for 3 days
plus
doxycycline 100mg every 12 hours for 10 days
plus
metronidazole 400mg every 12 hours for 10 days
If there is an IUCD:
Remove it 2-4 days after commencing treatment
If no improvement within 7 days:
Refer for specialist management
Prevention
• See p257
14.2.4 GENITAL ULCER DISEASE (GUD) SYNDROME
Causes
A number of conditions may produce genital sores in men and women
• Syphilis: caused by Treponema pallidum bacteria
• Genital herpes: caused by Herpes simplex virus
• Granuloma inguinale: caused by Donovania granulomatis
• Chancroid: caused by Haemophilis ducreyi
Clinical features
• Primary syphilis: the ulcer is at first painless and may be on the fold between the large and small lips of the vulva (labia majora and labia minora) or on the labia themselves or on the penis
• Secondary syphilis: multiple, painless ulcers on the penis or vulva
• Herpes: small, multiple, usually painful blisters, vesicles or ulcers
• Granuloma inguinale: an irregular ulcer which increases in size and may cover a large area
• Chancroid: multiple, large, irregular ulcers with enlarged painful suppurating lymph nodes
Differential diagnosis
• Cancer of the penis in elderly men
• Cancer of the vulva in women >50 yrs
Investigations
Swab: for microscopy
Blood: for VDRL/TPR
Treatment
HC2
a) If blisters or vesicles are present:
aciclovir 200mg every 5 hours for 5 days
Perform RPR test
If positive, give benzathine penicillin 2.4 MU IM single dose (half into each buttock)
Use alternative regime below in penicillin-allergic patients
Advise on genital hygiene
If blisters or vesicles persist:
Repeat aciclovir as above
b) If blisters or vesicles are absent:
ciprofloxacin 500mg every 12 hours for 3 days
plus benzathine penicillin 2.4 MU IM single dose (half into each buttock)
Use alternative regime below in pregnant or penicillin-allergic patients
If ulcer persists for >10 days and partners were treated:
erythromycin 500mg every 6 hours for 7 days
If ulcer persists for >10 days and partners were not treated:
Repeat the above course of ciprofloxacin and benzathine penicillin
If the ulcer still persists:
Refer for specialist management
Alternative regime if patient is pregnant or allergic to penicillin:
erythomycin 500mg every 6 hours for 14 days
Note
♦ Genital ulcers may appear together with enlarged and fluctuating inguinal lymph nodes (buboes) which should be aspirated through normal skin and never incised
14.2.5 INGUINAL SWELLING (Bubo)
Found in many sexually transmitted conditions affecting the female and male genitals
Causes
• Lymphogranuloma venereum (LGV)
• Grauloma inguinale (GI)
• Chancroid
Clinical features
• Excessively swollen inguinal glands
• Pain, tenderness
• Swellings may become fluctuant if pus forms
Differential diagnosis
• Other causes of swollen inguinal lymph nodes, eg. leg ulcer
Management
HC2
Aspirate using wide-bored needle through healthy skin - do not incise
doxycycline 100mg every 12 hours for 10 days
plus ciprofloxacin 500mg every 12 hours for 3 days
14.2.6 WARTS
Cause
• Viral infection
Clinical features
• Usually light coloured umbilicated papules with irregular rough surface found on the face and genital areas
Differential diagnosis
• Rashes
• Eruptive skin lesions
Management
HC4
Apply podophyllum resin paint 15% to the warts 1-3 times weekly
- apply precisely on the lesion avoiding normal skin
- wash off with water 2-4 hours after each application
Treat underlying infection & advise on personal hygiene
If no improvement after 3 applications:
Refer for surgery
Warning
Podophyllum resin paint (podophyllin paint): protect normal skin with Vaseline® before application
Prevention
• See p257
