Sexually Transmitted Infections
Digital Lecture Series : Chapter 6
Capt (Dr.) Sandeep Arora
Professor & Senior Advisor
Department of Dermatology
Army College of Medical Sciences
& Base Hospital Delhi Cantt
CONTENTS
 Introduction
 Viral STIs
 Scope of the problem
• Herpes genitalis
 Sexually Transmitted Infections
• Condyloma acuminata
 Approach to a case of STI
 Bacterial STIs
•
•
•
•
•
•
Syphilis
Chancroid
Lymphogranuloma venereum
Donovanosis
Gonococcal urethritis
Non Gonococcal Urethritis
 Other STIs
• Vaginitis
• Pediculosis
• Pelvic Inflammatory disease
 Syndromic approach to STIs
 MCQs
 Photo Quiz
Definition
Sexually Transmitted Infections are a group of communicable diseases that
are transmitted by sexual contact and caused by a wide range of bacterial,
viral, protozoal, fungal agents and ectoparasites.

STD stands for Sexually Transmitted Disease
The disease is clinically manifest e.g. primary syphilis

STI includes all sexually transmitted infections
The disease may not be clinically manifest e.g. Hepatitis B

For all practical purposes both these terms are used synonymously.
Scope of the problem
Sexually transmitted infections. Scope of the problem accessed at
http://www.who.int/mediacentre/factsheets/fs110/en/
Scope of the problem
More than one
million acquire
an STIs every
day
Every year 500
million acquire
one of the four
STIs
More than 500
million harbour
the Herpes
virus
STIs may be
asymptomatic
More than 290
million have
HPV infection
STIs increase
the risk of
acquiring HIV
infection
Increasing drug
resistance in STI
treatment
Long term
consequence in
form of mother
to child
transmission
Expansion of STIs
 List of pathogens which are sexually transmitted has expanded from
‘5 classical’ venereal diseases Syphilis
 Gonorrhoea
 Chancroid
 Donovanosis
 Lymphogranuloma venereum
 The total number of distinct sexually transmitted or transmissible
pathogens now exceeds 30.
 Shift to clinical syndromes associated with STIs.
Expanded Classification (Etiological)
Causative organism (Bacterial)
STI
Treponema pallidum
Syphilis
Haemophilus ducreyi
Chancroid
Calymmatobacterium granulomatis
Donovanosis
Numerous agents
Bacterial Vaginosis
Neisseria Gonorrhoea
Gonococcal uretheritis
Chlamydia trachomatis
Non Gonococcal Urethritis
Mycoplasma hominis
Non Gonococcal Urethritis
Ureaplasma urealyticum
Non Gonococcal Urethritis
Expanded Classification (Etiological)
Causative organism (Viral)
STI
Herpes simplex virus
Herpes genitalis
Hepatitis B, C
Hepatitis
Human Papilloma virus
Condylomata acuminata
Molluscum contagiosum virus
Molluscum contagiosum
Human Immunodeficiency Virus
AIDS
Expanded Classification (Etiological)
Causative organism (Protozoal)
STI
Entamoeba histolytica
Amoebiasis
Giardia lamblia
Giardiasis
Trichomonas vaginalis
Trichomoniasis
Causative organism (Fungal)
Candida species
STI
Vaginits, Balanoposthitis
Causative organism (Ectoparasites)
STI
Pthirus pubis
Pediculosis
Sarcoptes scabiei
Scabies
Diagnosis
History
 General history (Demography).
 Contact of a STD.
 Onset, character, periodicity, duration and relation to sexual
intercourse and urination.
 Ask for the 5 “P”.
The 5 Ps of STIs:
 Partners
 Practices
 Protection from STDs
 Past history of STDs
 Prevention of pregnancy
Presenting complaints
 Sores (either painful or painless)
 Blood in urine
 Burning sensation when urinating
 Rashes
 Itching
 Papules / pustules / ulcers
 Warts
 Unusual discharge
History
 Type of discharge.
 Past medical and STD history.
 Medications, allergies (emphasis antibiotics) and contraception.
 Past history of similar problems.
 Any STD in sexual partner(s).
 Last menstrual period.
 Vaccination history.
 Obstetric history (h/o abortions).
 Any history of injecting drug abuse, what drug, how often.
 Any history of tattooing or blood product exposure.
Sexual History
 Number of exposure (Single, multiple).
 Number of sexual partner(s).
 Date of last sexual exposure.
 Sex of partner(s) and history of male to male contact.
 Type of intercourse – oral, vaginal, anal.
 Protected / unprotected exposure.
History of HIV
 H/o Recurrent diarrhoea.
 H/o Fever.

H/o Loss of weight.

H/o Genital ulcer disease.

H/o Blood transfusion.

H/o Herpes zoster.
 H/o Opportunistic infections.
Examination
Inspect for :
Inspect for :
 Rashes
 Pubic hair for lice and nits
 Lumps
 Skin of the face, trunk, forearms,
palms and the oral mucosa
 Ulcers
 Discharge
 Odour
Palpate :
 Lymph Nodes
Examination
Inspection: Men
Inspection: Women
 Penis
 External genitalia
 External meatus
 Perineum
 Retracted foreskin
 Perianal area
 Perianal area
 Oral cavity
 Lymph nodes examination
 Lymph nodes examination
 Per rectal examination
 Speculum examination of vagina
and cervix
 Palpation of scrotum and
expression of any discharge from
the urethra.
 Proctoscopy
 Bimanual pelvic examination
Systemic Examination
 Cardiovascular
 Respiratory
 Gastrointestinal (Liver, spleen)
 Central Nervous
 Musculoskeletal
Bacterial Agents
Syphilis
‘One night with Venus, a lifetime with Mercury’.
 Caused by Treponema Pallidum.
 T. pallidum is a fine, motile, spiral organism measuring 6-20
millimicrons in length and 0.1 to 0.18 millimicrons in thickness with
characteristic motility.
 Transmission
 Contact with infectious, moist lesion(s), most commonly during oral,
anal or vaginal sex.
 Less common through casual skin-to-skin contact.
 Mother-to-child transmission.
 Cannot be spread by use of toilet seats, swimming pools, hot tubs,
shared clothing or eating utensils.
Transmission
 During early (primary and secondary) syphilis, efficiency of
transmission ~ 30%.
 Perinatal transmission can occur:
• at any time during pregnancy
• at any stage of the disease
 Syphilis can infect infants of untreated mothers. Chance of vertical
transmission by stage of infection:
• primary syphilis
= 50%
• early latent syphilis
= 40%
• late latent syphilis
= 10%
• tertiary syphilis
= 10%
Pathogenesis
Infection
Attachment to host cells
Corkscrew movement and travel to Lymph nodes
In perivascular lymphatics cause endarteritis obliterans
Loss of blood supply
Genital ulcer
Pathogenesis
 Primary stage
•
Multiplies at the site of inoculation & forms a chancre
 Secondary stage
•
Spread to local lymph nodes & then to the blood stream
 Secondary and latent stage
•
Can involve of many body organs (secondary and latent)
 Tertiary stage
•
infection/inflammation of the blood vessels in the central nervous
system and cardiovascular systems or poorly formed lesions
(gumma)
Syphilis Staging: Flowchart
Symptoms or Signs?
YES
1º (Ulcer)
2º (Rash, etc)
PRIMARY
SECONDARY
NO
LATENT
ANY EXPOSURE IN PAST YEAR?
Negative syphilis serology
Known contact to an early case of syphilis
Good history of typical signs/symptoms
YES
EARLY LATENT
NO
UNKNOWN
or LATE LATENT
Primary syphilis
 Stage from infection to the healing of the
chancre.
 Incubation period- 9-90 days.
 Single, painless, well defined ulcer with clean
looking granulation tissue on floor, Indurated.
 Hard chancre - heals with scar even without
treatment.
 Genital (90-95%): Coronal sulcus / glans /
frenulum / prepuce / shaft of penis in male and
cervix, labia, vulva, urethral orifice in females.
 Extra-genital (5-10%) : Commonest site is the
lips
Diagnostic Tests for Syphilis
 Darkfield / DFA-TP
 PCR
 VDRL/RPR Negative till one week after appearance of ulcer. Positive
by 4 weeks.
 FTA-abs / TPHA (MHA-TP)
 EIA
Syphilis Serology
Non-treponemal tests
Treponemal tests
 VDRL (Venereal Disease Research
Laboratory)
 TP-PA (Treponema Pallidum
Particle Agglutination)
 RPR (Rapid Plasma Reagin)
 FTA-abs (Fluorescent Treponemal
Antibody -Absorbed)
 TRUST (Toluidine Red Unheated
Serum Test)
 USR (Unheated Serum Reagin)
 EIA (Enzyme Immunoassay)
Secondary Syphilis
 6-8 weeks after appearance of primary chancre.
 Systemic disease; constitutional features like sore throat, malaise,
fever and joint pain may accompany the lesions.
 Usually occurs 3-6 weeks after primary chancre
• Rash (75-90%)
• Generalized lymph node swelling (70-90%)
• Constitutional symptoms (50-80%)
• Mucous patches (5-30%)
• Condyloma lata (5-25%)
• Patchy alopecia or hair loss (10-15%)
• Symptoms of neurosyphilis (1-2%)
• Less common : meningitis, hepatitis, arthritis, nephritis
Palmar Syphilide
Condyloma Lata
Diagnosis
 VDRL

•
Almost always positive
•
False negative (in some cases)
•
False positive (in some cases)
Specific tests : TPHA may remain reactive throughout life.
Latent syphilis
 Persistent seropositivity with clinical latency.
 Following resolution of primary or secondary stage latency occurs
and continues as such in 60-70% of patients.
 Less than 1 year : Early
 More than 1 year : Late
Tertiary Syphilis
 70% of untreated patients remain asymptomatic.
 30% of untreated patients progress to tertiary stage in 5-20 years.
Cutaneous :
Characteristic lesion is the Gumma
 A deep granulomatous process involving the epidermis secondarily.
 Causes punched out ulcerative lesions with white necrotic slough on
the floor.
 On lower leg, scalp, face, sternal area.
Tertiary Syphilis
Cardio-vascular :
Develops 20-30 years after infection - so in middle age; more in men
 Aortitis, aortic aneurysm, coronary ostial stenosis
Neurosyphilis
 Central nervous system invasion occurs early in infection in 30-40%
 Asymptomatic neurosyphilis can occur at any stage of syphilis.
 Early symptomatic forms (months to a few years)
•
Acute meningitis, Meningovascular (stuttering stroke)
 Late symptomatic forms (> 2 years)
•
General paresis, Tabes dorsalis
 CSF lymphocytosis, an elevated CSF protein level or a reactive VDRL
test would suggest neuro-syphilis and should be treated.
Diagnosis
 Clinical
 Laboratory
•
Cell count - Normal = 0-4 cells/mm3
Abnormal = >5 cells/mm3
•
Proteins
- Normal = up to 40 mg/100 ml
Abnormal = > 40 mg/100ml
•
VDRL
- Normal = Non reactive
Abnormal = Reactive
Syphilis treatment
Primary, Secondary, Early Latent (WHO/ CDC/ NACO)
Inj. Benzathine Penicillin G,
2.4 million units IM stat after test dose
Late Latent Syphilis (WHO/ CDC/ NACO)
Benzathine penicillin G 2.4 million units IM at one week intervals x 3
doses.
Neurosyphilis (NACO)
Aqueous crystalline / benzyl penicillin G, 18-24 million units daily
administered as 3-4 million units IV every 4 hours for 14 days.
Alternative regimen for penicillin allergic patients
 Doxycycline (100 mg) BD
 Erythromycin (500mg) QDS
 Tetracycline (500mg) QDS
Duration of treatment :
 Early syphilis : 15 days
 Late syphilis : 30 days
Syphilis - HIV Transmission and screening
 Syphilis increase HIV transmission.
 Genital ulcers  3 to 11-fold increased HIV acquisition.
 Telescoping of syphilis.
Syphilis Screening Guidelines
 Targeted screening of at risk populations
•
Patients with other STDs
•
Correctional settings
•
Drug treatment settings
•
HIV+
•
MSMs in outbreak areas or high risk
Management of Contacts
 Contacts to primary, secondary or early latent syphilis Persons
exposed within 90 days preceding the diagnosis in a sex partner
might be infected even if seronegative : Treat presumptively.
 Persons exposed >90 days before the diagnosis should be treated
presumptively if serologic tests are unavailable or follow up is
uncertain; if serologic tests are negative no treatment is needed.
Chancroid
 Also known as soft chancre.
 Acute, autoinoculable, STI caused by Hemophilus ducreyi.
 Males affected more commonly.
Etiology : Hemophilus ducreyi
 Pleomorphic gram negative facultative, anaerobic bacillus.
 “School of fish” or “rail road track” appearance (gram stain).
 Growth is best in Mueller Hinton agar supplemented with chocolate
horse blood.
Epidemiology
 10% of patients are co-infected with either HSV or T. pallidum.
 Males >> females.
 Occurs in sustained, urban outbreaks.
 Associated with female commercial sex workers and “sex-for-drugs”
trade.
Clinical features
 Incubation period : 3-7 days
 Sites : Frenulum, prepuce, coronal sulcus in male and vulva,
vestibule in females.
 Painful genital ulcers
 Non-indurated,
 Bleed on touch
 Yellow ragged edges
 Edema of prepuce
 Tender sometimes suppurative
inguinal lymphadenopathy (unilateral in majority).
Investigations and Treatment
 Microscopy:
Gram stain , Fluorescent labelled monoclonal antibody detection
 Serology : ELISA, Immuno dot technique
 Molecular techniques - PCR
 Histopathology
Treatment (NACO)
Azithromycin 1 gm orally single dose
or
Ceftriaxone 250 mg IM in a single dose
or
Ciprofloxacin 500 mg twice daily x 3 days
Lymphogranuloma Venereum (LGV)
Lymphogranuloma venereum is caused by Chlamydia trachomatis
serovars L1, L2 & L3.
Etiopathogenesis
 Chlamydia enters minute skin disruptions during intercourse
 Lymphotropic causing lymphangitis
 Lymph node necrosis and abscess formation
 Fistulae and sinus tracts
Life cycle
Infection
Clinical features
Primary
 Incubation Period : 3-12 days.
 Superficial ulceration, which looks like herpes, is temporary and
heals without scarring.
 It is usually transient and passes unnoticed.
Clinical features
Inguinal syndrome
 Most common manifestation
 Bubo
 Incubation period = 10-30 days
 More common in males
 Swelling in groin; unilateral in
majority
 Groove sign of Greenblatt
 Constitutional features
 Rarely suppurate
 Multiple sinuses
Genital syndrome
 Penile and scrotal elephantiasis.
 Penile or scrotal ulcerations.
 Ram-rod penis.
 Doughy tender swellings along
dorsal lymphatics of penis :
bubonuli.
 Females-elephantiasis of the vulva
and clitoris.
Anorectal syndrome
 Rectal strictures, Anal fissures
 Edematous rectal mucosa
 On proctoscopy - friable and
bleeding rectal mucosa
Penile Elephantiasis
Vulval Elephantiasis - Esthiomene
Investigations and Treatment
 Microscopy:
•
Giemsa stain for inclusion bodies
•
Direct immunofluorescence staining
•
ELISA rapid assays
 Serology:
•
Complement fixation test
•
Immunofluorescent antibody test
LGV (NACO)
 Recommended regimen : Doxycycline 100 mg twice daily for 15 days.
 Alternative regimen : Erythromycin base 500 mg four times daily for
15 days.
Donovanosis
 A chronic,destructive mildly contagious, granulomatous STI caused
by Calymmatobacterium granulomatis.
 Also known by various other names
•
ulcerating granuloma of the pudenda
•
granuloma genitoinguinale
•
granuloma venereum genitoinguinale
•
granuloma inguinale tropicum
 Incubation period : 8 - 80 days.
 The organism occurs inside large vacuolated histiocytes in the form
of “closed safety pin”.
Pathogenesis : Sites of trauma – nodular lesion ‘lumps under the skin’.
Clinical Variants of Donovanosis
 Classical or Fleshy exuberant type
 Sclerotic or Cicatricial type
 Destructive or Necrotic type
 Hypertrophic type
Investigations
Microscopy
 Giemsa or Leishman’s stain (crush smear) for Donovan bodies.
 Histopathology.
 Wright-Giemsa stain - demonstrates clusters of blue-to-black
organisms that resemble safety pins within the vacuoles of enlarged
macrophages.
Treatment
Doxycycline 100 mg twice daily
or
Erythromycin base / stearate 500 mg QDS for 14 days
or
Azithromycin 500 mg BD for 14 days
Treatment (CDC)
 Recommended Regimen
• Azithromycin 1 g orally once per week or 500 mg daily for at least
3 weeks and until all lesions have completely healed.
 Alternative Regimens
• Doxycycline 100 mg orally twice a day for at least 3 weeks and
until all lesions have completely healed OR
• Ciprofloxacin 750 mg orally twice a day for at least 3 weeks and
until all lesions have completely healed OR
• Erythromycin base 500 mg orally four times a day for at least 3
weeks and until all lesions have completely healed OR
• Trimethoprim-sulfamethoxazole (160 mg/800 mg) tablet orally
twice a day for at least 3 weeks and until all lesions have
completely healed.
Urethritis
 Characterized by urethral discharge, dysuria, meatal inflammation in
some cases with presence of polymorphs in urethral smear or
sediment in the first void urine.
•
Gonococcal
•
Nongonococcal
Gonococci
Etiology
 Amongst the first documented bacterial STD
 Word gonorrhea means “Flow of seed”
 Albert Neisser identified the organism in 1879
 Caused by N. Gonorrhea which is gram negative encapsulated
diplococcus bearing pili
Symptoms of Gonorrhea
 Appear 5-7 days or can take up to 30 days to appear.
 Sore or red throat if gonorrhea in the throat from oral sex.
 Rectal pain.
 Bloody and purulent anal discharge if acquired after anal sex.
Symptoms
Male symptoms
 Yellow or white drip / discharge from penis
 Burning or pain when urinating, Frequent urinating
 Swollen testicles
Female symptoms
 Symptoms may show up 2-21 days after having sex
 May notice a yellow or white discharge from the vagina
 May be a burning or pain when urinating
 Bleeding between periods, Heavier and more painful periods
 Cramps or pain in the lower abdomen, with nausea or fever.
Diagnosis of Gonorrhea
 Two glass urine test
 Smear examination
 Culture
 Fluorescent antibody test
 Serological tests
 Non-amplified DNA probe test
Nongonococcal Urethritis
Causative organisms :
 Chlamydia trachomatis
 Mycoplasma genitalium
 Ureaplasma urealyticum
 Adeno virus
 Others
Neisseria gonorrhoeae (NACO)
 Cefixime 400 mg oral stat dose OR
 Ceftriaxone 250 mg i.m OR
 Azithromycin 2g stat
PLUS Chlamydial therapy if infection not ruled out
Disseminated gonococcal infection
 Ceftriaxone 1 gm IM or IV Od for 7 days OR
 Cefixime 400 mg BD for 7 days
Non gonococcal urethritis (NACO)
 Azithromycin 1 gm in a single dose OR
 Doxycycline 100 mg bid x 7 days OR
 Erythromycin stearate 500 mg QDS for 7 days
Viral Agents
Herpes genitalis
 Organism - Herpes simplex virus (HSV-1, HSV-2)
 Incubation period : 2-20 days
 50% of neonates exposed to maternal HSV develop primary herpes
infection in 4-7 days of births
 Risk of neonatal transmission in women with recurrent
HSV-2 is <1%
Clinical features
 Symptoms usually show 2-20 days after contact.
 May be extremely painful or very mild.
 “Outbreaks” of blisters and ulcers.
 Primary and Recurrent episodes
 Initial infections produce systemic symptoms such as fever, malaise,
headache and myalgia.
 Pain, itching, dysuria, vaginal and urethral discharge are
predominant local symptoms.
 Once infected with HSV, people remain infected for life.
 Stress, bruising, chaffing, or a woman’s period may cause an onset
of the disease.
Herpes Genitalis
Investigations
 Microscopy :
•
Tzanck smear
 Serology :
•
Monoclonal antibodies to HSV 1 and 2
•
DNA hybridization

Molecular techniques - PCR

Histopathology

Culture
Genital Herpes (NACO)
 First Clinical Episode
Acyclovir 400 mg TDS OR
Acyclovir 200 mg 5 times a day
Duration : 7- 10 days
 Recurrence
Acyclovir 400 mg TDS x 5 days OR
Acyclovir 800 mg BD x 5 days
Condylomata acuminata (Genital wart)
 Very common STD.
 Incidence in India 3.2 - 21% but under reporting common.
 Human Papilloma virus.
 Incubation period - 4 months to 6 months.
 Risk factors
•
Multiple sexpartners
•
Frequency of sexual contact
•
Failure to use condom in male
•
Pregnancy
•
HIV infection
Genital Warts
 Growths that appear on the vagina or penis, near the anus, and
sometimes in the throat.
 They are caused by HPV and spread through sexual contact.
 The virus that causes genital warts is spread by vaginal or anal
intercourse and by oral sex.
 Warts may appear within several weeks after sex with a person who
has HPV; or they may take months or years to appear; or they may
never appear.
 A person can be infected and pass on the virus without knowing it.
Condylomata Acuminata
Diagnosis
 Histopathology
 Aceto-whitening : not recommended; predictive value not
established (Holmes)
 Pap smear : sensitivity poor; specificity very high
 HPV DNA detection studies
Treatment
Patient administered
Physician administered
Podofilox 0.5% solution or gel OR
Cryotherapy OR
Imiquimod 5% cream
Podophyllin resin 10-25%
(Not recommended for pregnant
women) OR
Trichloroacetic acid 80-90% OR
Surgical removal
Other STIs
Vaginitis
Etiology
 Candida albicans and other species of candida
 Trichomonas vaginalis
 Bacterial vaginosis
 Senile
Candidal vaginitis
 Pruritus
 Frequency of micturition
 Thick curdy white discharge
 Pre-menstrual flare
 Examination reveals thick
cheesy plaques
Trichomonal vaginitis
 Caused by Trichomonas vaginalis
 Green foamy vaginal discharge
 Severe pruritus
 Friable and punctate hemorrhages over the cervix - Strawberry
cervix.
Bacterial vaginosis
 Caused by a mixed flora - Gardnerella vaginalis, M.
Hominis and anaerobes.
 Causes grey, homogenous and odoriferous
discharge.
 Characteristic fishy odour.
 Pruritus not prominent.
Diagnosis:
 Clue cells : vaginal epithelial cells coated with
Gardnerella vaginalis (at least 20%).
 Whiff test : fishy odour on adding KOH.
Vulvovaginitis
Candidal vulvovaginitis
 Clotrimazole or Miconazole 100 mg od - 6 days Intravaginal OR
 Fluconazole 150 mg in a single dose OR
 Clotrimazole 500 mg vaginal pessary once
Trichomoniasis (NACO)
 Metronidazole 2 gm orally single dose OR
 Metronidazole 400 mg Bd for 7 days OR
 Tinidazole 2 gm stat
Bacterial Vaginosis (NACO)
 Metronidazole 400 mg BD for 7 days OR
 Metronidazole 2 gm orally as a single dose OR
 Tinidazole 2 gm as a single dose
Pediculosis Pubis
 Pubic lice, also called “crabs” because they look like crabs.
 Crabs are frequently the color and size of small freckles. These very
small lice (crabs) usually attack the pubic areas of the body.
 Found under arms, eyelashes, moustaches.
 Spread through direct physical contact. Close body contact with an
infected person.
 SYMPTOMS : A terrible, persisting itch in the genital, rectal area.
Pelvic Inflammatory Disease - Etiology
 STD - Gonorrhea, Chlamydia,
Bacterial vaginosis
 Primary :
•
Due to exogenous STD
organisms
•
Endogenous
 IUCD
 Douching
 Dilatation and curettage
 HIV infection
 Secondary :
•
Leading from primary cause
•
IUCD, MTP
Clinical Features
 Silent STD
 Mild and moderate symptoms:
 Severe PID : 10% of all cases
•
Severely ill
•
Most sexually active
•
Peritonitis
•
Lower abdominal
pain/cervical motion
tenderness
•
Purulent vaginal discharge
•
Fever/vomiting/chills
•
Perihepatitis
•
Fever
•
Tubo-ovarian mass
Diagnostic Criteria
Minimum Diagnostic Criteria
 Uterine/adnexal tenderness or cervical motion tenderness
Additional Diagnostic Criteria
 Oral temperature >38.30 C
 Elevated ESR
 Cervical CT or GC
 Elevated CRP
 WBCs/ saline microscopy
 Cervical discharge
Definitive Diagnostic Criteria
 Endometrial biopsy with histopathologic evidence of endometritis.
 Transvaginal sonography or MRI showing thick fluid-filled tubes.
 Laparoscopic abnormalities consistent with PID.
Syndromic Management to STIs
Syndromic Management
 Use of clinical algorithms based on an STD syndrome, the
constellation of patient symptoms and clinical signs, to determine
therapy.
 Antimicrobial agents are chosen to cover the major pathogens
responsible for the syndromes in a geographic area.
Essential Components
 Syndromic Diagnosis and Treatment
 Education on Risk reduction
 Condom Promotion
 Partner Notification
 Counselling
 Follow-up
(Each component is important for control. Any of the missed components
is a threat)
Advantages and Disadvantages
Advantages
 Simple, inexpensive, rapid and implemented on large scale.
 Requires minimum training and used by broad range of health providers.
 Allows for diagnosis and treatment in one visit.
Disadvantages
 Algorithm for vaginal discharge has limitations particularly in cases of
cervicitis (chlamydia/gonococci).
 Over diagnosis and over Rx (multiple antimicrobials for single infection).
 Selection of resistant pathogens.
 Does not address subclinical STI.
Urethral Discharge
Examine for Urethral Discharge: Milking of Urethra
Discharge seen
No Discharge seen
Rx for Gonorrhea and Chlamydia
Any other STI
F/u after 7 days
Cured
Use appropriate chart
Discharge persists
T/t regimen followed
Refer to higher care
regimen not followed
Repeat treatment &
Re-evaluate > 7 days
Genital Ulcer
No
Only vesicles present
No
GUD
Yes
Educate and counsel
Yes
Treat for Herpes
Treat for Syphilis if VDRL+
Treat for Chancroid and Syphilis
Treat for herpes if prevalence more than 30%
No
Ulcers healed
Yes
Educate and counsel
No
Ulcers
improving
Refer
Yes
Continue for 7 more days
Inguinal Bubo
Enlarged or painful inguinal lymph nodes
History & examine
No
Ulcer(s) present
Rx for LGV + Chancroid
As in genital
ulcer chart
14 Days
Responding to treatment
Yes
Yes
No
Refer to higher care centre
Presume cured
Painful scrotal swelling
No
Injury to scrotum
Swelling of scrotum?
Yes
Refer to higher care centre
No
Yes
Reassure
Testis rotated or
retracted
Yes
Refer immediately to
Higher care centre
No
Treat for gonorrhoea and chlamydia
After 14 days
Cured
No
Tenderness &
Swelling persisting
Yes
Refer to higher care centre
Vaginal Discharge / Itch / Burning
History
No
Vulvul erythema
Any other STI
Appropriate chart
Lower abdominal pain
High GC/CT prevalence
Lower abdominal pain chart
Yes
Treat for Gonococci/Chlamydia/
bacterial Vaginosis/Trichomonas
No
Treat for bacterial
Vaginosis
and Trichomonas
Educate
Yes
Yes
No
No
Yes
Vulvul edema / erythema
No
Educate
Treat for Candida
Lower Abdominal Pain
History & examine
 Missed period
 Recent delivery
 Guarding
No
Cervical motion tenderness
Lower abdominal tenderness
Yes
 Vaginal bleed
 Abdominal mass
Manage for PID. Review in 3 days
Yes
No
Surgical referral
Patient improved
Yes
Yes
Educate
Refer
Ophthalmia Neonatorum
Neonate with discharging eyes
History & examine
Yes
Conjunctivitis present
Treat baby for gonorrhoea and chlamydia.
Treat parents for the same
No
Reassure mother
Review if symptoms persist
Review baby in 2 days
Yes
Presume cured
Improved
No
Refer to higher care centre
MCQ’s
Q.1) A patient presented with a painless ulcer over the glans penis 4
weeks after an unprotected sexual exposure. Examination revealed
an no tenderness, indurated base which did not bleed on touch.
Inguinal lymphnodes were enlarged on both sides. What is the most
probable diagnosis?
A.
B.
C.
D.
Soft chancre
Primary chancre
Herpes genitalis
Donovanosis
MCQ’s
Q.2) A young male presented with foul smelling urethral discharge 7 days
after sexual exposure to his partner. Which bed side test will you prefer
to perform to assess the extent of infection?
A.
B.
C.
D.
Gram stain of discharge
Two glass urine test
Tzanck smear
Urethroscopy
MCQ’s
Q.3) A patient presented with history of recurrent multiple transient
erosions over the glans penis and the mucosal aspect of prepuce of
two days duration. No inguinal lymphadenopathy. History of similar
lesions in the sexual partner for the past three years. What is the
most probable diagnosis?
A.
B.
C.
D.
Multiple chancres
Herpes genitalis
Chancroid
Scabies
MCQ’s
Q.4) A patient presented with foul smelling greyish watery discharge per
vaginum. What is the most probable diagnosis?
A. Gonorrhea
B. Bacterial vaginosis
C. Candidiasis
D. Trichomoniasis
Q.5) Which of the following is not included in the syndromic approach to
a genital ulcer case?
A. Syphilis
B. Chancroid
C. Herpes
D. Donovanosis
Photo Quiz
This patient presented with a rapidly destructive painful ulcerative lesion
over the glans and prepuce for the past three weeks. He tested positive
for HIV. What is the most probable diagnosis?
A. Chancroid
B. Squamous cell carcinoma
C. Primary syphilis
D. LGV
Photo Quiz
This patient presented with itchy excoriated papular leasions on the
penile shaft, pubic regions and thighs for the past four months. What is
the most probable diagnosis?
A. Herpes genitalis
B. Scabies
C. Multiple hard chancres
D. Donovanosis
Thank You!