National STI Management
Guidelines of Pakistan
The National AIDS Control Programme
The Provincial AIDS Control Programmes
The World Health Organization
Basic Outline
and Concepts
Worldwide epidemiology of STIs
• 340 Million new infections annually
• Burden unevenly shared more by
developing countries
• Account for app 17% of health
expenses*
• HIV is an STI
• HIV-STI co-infections (with HSV-2, H.
ducreyi)
*World Bank. World Development Report: Investing in Health. 1993
Common Terms Used
• Provider and clinician are used
interchangeably
• This can under some circumstances
include non doctor providers
Epidemiology in Pakistan of STIs
• Very common among high risk groups
• Moderately common among bridge
groups
• Uncommon among general population
Care seeking for STIs in Pakistan
• Similar to other care in Pakistan: >70%
in the private sector
• Different providers see different types
of clients
• Syphilis testing and Tx is uncommon
• Partner management is rare
• Condom promotion is uncommon
Counseling and condom
promotion
• Condoms are the best prevention measure
• Counseling works
• Patient-provider interactions are the best
condom and risk behavior counseling
opportunities
• Free condom provision
• Discussing STI risk behaviors
Partner Management
• Patient>Partner>Patient
reinfection cycle
• Patient delivered medicines
• More important to focus on the
patient’s regular partner
Referrals
• Difficult STIs
• HPV/ warts
• Decide or pre-identify whom to
refer to
• Role of the provincial AIDS
Programs
The 4 Cs
Compliance, Counseling, Condoms
and Contact (Partner) Management
4 Cs: Compliance
STI patients must be encouraged to comply with their
prescribed treatment
• Instruct all patients to complete the full course of
treatment
• Disappearance of symptoms during treatment does
not mean that the patient is cured, full course of
treatment must be completed
• Without proper treatment, STIs may cause severe
complications
• Patient should avoid sexual contact during the treatment
and until partner has been treated
• Ensure a follow-up visit
4 Cs: Counseling for Prevention
Every patient presenting with STI symptoms must
receive and understand education messages tailored
for each patient regarding:
• STIs result from Sexual contact
• Information about safer sex practices and use of condom
• The mode of transmission of STIs, including HIV
• STI augments the risk of HIV transmission
• Offer HIV voluntary counseling and testing (VCT)
• Consider syphilis testing
4 Cs: Condom Use
To minimize the further transmission of
STIs, including HIV, it is essential to
educate all clients on the proper use of
condoms:
• Demonstrate to each patient how to use a
condom correctly
• Clinic should supply condoms to STI
patients
4 Cs: Contact (Partner)
Management
Patients must understand the importance of
partner management even if he/she is
asymptomatic:
• Risk of re-infection from asymptomatic partner
• Risk of complications for his/her partner
• Possible ways of partner management include:
• Providing additional treatment regimens for the
partner
• Encouraging partners to come to the clinic for
treatment
Reproductive Health Linkages
Two forms of linkages were identified in our
consultations
1. Gynecologists should act as the specialist to
whom either difficult infections or patients
with warts are sent to
2. All patients that are considered for STI
management in gynecology set up must be
considered for syphilis testing and if positive
for treatment.
3. All patients presenting for STIs are sexually
active. This is also an opportunity to discuss
family planning and if the method used is
condoms, they will provide dual protection
(against STIs and from pregnancy)
Risk Assessment of patients
• Some persons are at more risk
of STIs than others due to:
– Their behaviors
– Where they live
• STI algorithms (those for
women) work better with high
risk patients
What is Syndromic Management
• History-Exam-Lab paradigm
• History-Exam paradigm
• Limited laboratory support in most
areas
• Limited utility of labs when available
Benefits of Syndromic Approach
• Standardization of care
• Cost effectiveness
Limitations of the Syndromic
Approach
• Works better for male STIs
• No algorithms for anal symptoms
• Female algorithms work better in high
risk settings
• Syphilis management which requires
testing is not well addressed by these
guidelines
Syndromes discussed
1.
2.
3.
4.
5.
6.
Urethral Discharge
Genital Ulcer
Scrotal Swelling
Vaginal Discharge
Lower abdominal pain
Anal symptoms
STIs of interest
1.
2.
Human Immunodeficiency Virus (HIV)§
Neisseria gonorrhoeae (NG or GC – short for
GonoCocci)
3. Chlamydia trachomatis (CT)
4. Herpes simplex (HSV) (HSV-2)
5. Trichomonas vaginalis (TV)
6. Candida albicans
7. Bacterial Vaginosis (BV)1
8. Syphilis (Treponema pallidum)
9. Human Papilloma Virus (HPV)
10. Haemophilus ducreyi (Chancroid)2
11. Lymphogranuloma Venereum (LGV)2
1. Not actually an STI, included here as it causes symptoms in women
2. Uncommon in Pakistan and therefore will not be addressed in any depth
Basic Etiology (causative organisms)
of Syndromes
Syndrome
Urethral
discharge
Symptoms
• Urethral discharge
• Dysuria
• Frequent urination
Signs
Most common
causes
• Urethral discharge
• Gonorrhoea
• Chlamydia
Genital
ulcer
• Genital sore
• Genital ulcer
• Syphilis
• Chancroid
• Genital herpes
Scrotal
swelling
• Scrotal pain and swelling
• Scrotal swelling
• Gonorrhoea
• Chlamydia
• Lower abdominal pain
• Dyspareunia
•
•
•
•
• Gonorrhoea
• Chlamydia
• Mixed
anaerobes
Lower
abdominal
pain
Vaginal
discharge
Anal
Symptoms
•
•
•
•
Unusual vaginal discharge
Vaginal itching
Dysuria (pain on urination)
Dyspareunia (pain during
sexual intercourse)
• Anal Pain
• Anal Discharge
• Anal or peri-anal sores
Vaginal discharge
Lower abdominal
tenderness on palpation
Temperature >38°
• Abnormal vaginal
• discharge
VAGINITIS:
• Trichomoniasis
• Candidiasis
CERVICITIS:
• Gonorrhoea
• Chlamydia
• Anal tenderness
• Anal Discharge
• Anal or peri-anal Ulcers
• Gonorrhoea
• Chlamydia
• HSV-2
Issues of antibiotic resistance
• Empiric prescription of antibiotics
• Gonococcal resistance already a
problem
• Syndromic approach can help or
aggravate the problem
Evidence Behind the Guidelines
Urethral Discharge:
• Senstivity 87-99%
• Labs seldom add to sensitivity
• Labs slightly enhance specificity
for CT but not NG
Evidence Behind the Guidelines
Genital Ulcer:
• Senstivity: 72-100%
• More sensitive and specific
for HSV and Syphilis
• Labs add very little to
specificity
Evidence Behind the Guidelines
Vaginal Discharge:
• Senstivity: 73-93% when applied to
women presenting for STI care
• Senstivity: 29-86% when applied to
all women screened for STIs
• Only 10% of low risk women
actually have an STI
• Speculum does not add very much
to the reliability of the algorithm
(sens: ~30, spec: ~50)
Common Issues
• Protect yourself, wear gloves
Syphilitic
chancre of
fingers
Common Issues
• Protect yourself, wear gloves
• STIs require contact between 2
individuals, think of the partner
• Prevent future problems: promote
condoms
• Counseling when possible (remember the
4 Cs)
Referral
• Surgical Evaluations are usually emergent
• Pre-determine possible providers in your
area whom you will refer to
• Provincial AIDS Program recommends this
provider for ……
Common STIs
Gonorrhoea
• Causes
In men
In women
Urethritis
Cervicitis
Proctitis
Proctitis
Pharyngitis Pharyngitis
Urethritis
• Major complications: Men: Urethral Strictures
• Major complications: Women: PID
• Major complications: Disseminated
Gonorrhoea
Treatment of Gonorrhoea
Uncomplicated Anal/ Genital Infection
Ciprofloxacin 500 mg orally once only (Ciprofloxacin is contraindicated in pregnancy and for
children or adolescents)
OR
Cefixime 400 mg orally once only
OR
Ceftriaxone 125 mg intramuscularly (IM) once only
OR
Spectinomycin 2 gm intramuscularly (IM) once only
Disseminated Gonococcal infection
Ceftriaxone 1 gm intramuscular or intravenous once daily for 7 days
OR
Spectinomycin 2 gm intramuscularly twice daily for 7 days
Neonatal Ophthalmia
Ceftriaxone 50mg/ kg intramuscularly as a single dose
OR
Kanamycin 25 mg/ kg intramuscularly as a single dose
OR
Spectinomycin 25 mg/ kg intramuscularly as a single dose
Treatment of Chlamydia
Uncomplicated Anal/ Genital Infection
Doxycycline 100 mg orally twice daily for 7 days
(Not to be used for pregnant women, children or
adolescents)
OR
Azithromycin 1 gm orally once only
Alternative Regimens
Amoxycillin 500 mg orally 3 times a day for 7 days
OR
Erythromycin 500 mg 4 times a day for 7 days
OR
Ofloxacin 300 mg orally twice a day for 7 days
(Please note that all formulations of Ofloxacin in the market
have 200 mg, so 2 capsules or tablets will be required)
OR
Tetracycline 500 mg orally 4 times a day for 7 days
Chlamydia
• Usual presentation of Chlamydia are similar to
Gonorrhoea
• Chlamydia is also asymptomatic in many patients
• Common presentations of Chlamydia:
In men
• Conjunctivitis
• Urethritis
• Proctitis
• Epidydmitis
• Prostatitis
In women
• Conjunctivitis
• Cervicitis
• Proctitis
• Urethritis
• Endometritis
• Salpingitis
Complications of Chlamydia:
• Infertility
• Ectopic pregnancy
• Miscarriage
Syphilis
• One of the oldest diseases on man
• 4 stages: Primary, secondary, late latent
and tertiary
• Congenital syphilis in children born from
infected mothers
Primary Syphilis
•
•
•
•
Early infection
Lasts for 1-3 months
Lesion is called chancre
Occurs at the site of the entry of organism (usually
genitalia but can be anywhere)
• Multiple chancres can occur
• Not possible to accurately distinguish from HSV-2
Primary Syphilis
Primary syphilis on finger
Secondary Syphilis
• At this stage the organisms are multiplying and
disseminating in the body
• Manifestations can occurs all over the body
although most commonly happen in skin
• Lesions are macular, maculopapular, papular or
pustular
• Most commonly on palms and soles
• May become a painless, broad, moist, gray
white to erythematous highly infectious plaques
called condyloma lata
• May also cause arteritis
Secondary Syphilis
Clinical Manifestations of Secondary Syphilis
Plaques of Condyloma lata
Plaques of Condyloma lata
Skin
•Rash
•Macular
•Maculopapular
•Papular
•Pustular
•Condyloma latum
•Generalized lymphadenopathy
•Pruritus
Mouth and throat
•Mucous patches
•Erosions
•Ulcer (aphthous)
Genital lesions
•Chancre
•Chondyloma latum
•Mucous patch
Constitutional symptoms
•Fever of unknown origin
•Malaise
•Pharyngitis, laryngitis
•Anorexia, weight loss,
Arthralgias
Central nervous system
• Asymptomatic
• Symptomatic
• Headache
• Meningismus
• Meningitis
• Ocular
• Diplopia
• Decreased vision
• Otitic
• Tinnitus
• Vertigo
• Cranial nerve involvement (II–
VIII)
Renal
• Glomerulonephritis
• Nephrotic syndrome
Gastrointestinal
• Hepatitis
• Intestinal wall invasion
Arthritis, osteitis, and periostitis
Late Latent Syphilis
• This is the phase when the manifestations
of the primary and secondary syphilis are
over and yet the patient remains infected
• 10-25% of these individuals will go on to
develop tertiary syphilis
Tertiary Syphilis
• This is the late stage
• Involvement of CNS, eyes, cardiovascular
system in addition to late benign syphilis
(gumma)
Congenital syphilis
• Happens by infection of the baby in utero
• Many complications – most are serious
• We recommend that this condition must
always be referred to specialist care
Syphilis Testing
• 2 types of tests: Treponemal (VDRL, RPR) and Nontreponemal (FTA-ABS, TPHA)
• VDRL/RPR become positive earlier and may turn
negative in 3-5 years even when untreated
• FTA-ABS/TPHA take 2-3 months to turn positive and
remain positive for life
• VDRL/RPR turn negative in 1+ year after successful
treatment (may be upto 2 years)
• These patients will require follow up with the titer of
VDRL/RPR
• FTA-ABS/TPHA response to treatment is not known
Treatment of Syphilis
Early Syphilis (Primary, Secondary or Latent of less than 2 years duration)
Benzathine Penicillin 2.4 million IU intramuscularly once
Alternative Regimen
Procaine Benzyl Penicillin 1.2 million IU intramuscularly once daily for 10
days
Alternative Regimen (for Penicillin allergic patients and non-pregnant
patients)
Doxycycline 100 mg orally twice a day for 14 days
OR
Tetracycline 500 mg orally twice a day for 14 days
Alternative Regimen (for Penicillin allergic patients and pregnant patients)
Erythromycin 500 mg orally 4 times a day for 14 days
Treatment of Syphilis
Late Latent Syphilis (Infection of more than 2 years duration)
Benzathine Penicillin 2.4 million IU intramuscularly once a week for 2
consecutive weeks
Alternative Regimen
Procaine Benzyl Penicillin 1.2 million IU intramuscularly once daily for 20 days
Alternative Regimen for Penicillin allergic patients and non-pregnant
patients
Doxycycline 100 mg orally twice a day for 30 days
OR
Tetracycline 500 mg orally 4 times a day for 30 days
Alternative Regimen for Penicillin allergic patients and pregnant patients
Erythromycin 500 mg orally 4 times a day for 30 days
Treatment of Syphilis
Neurosyphilis
Aqueous Benzyl Penicillin 2-4 million IU by intravenous injection every 4
hours for 14 days (12-24 millions units a day for 14 days)
(Ideally it should be referred for admission) (or should we admit all)
OR
Procaine Benzyl Penicillin 1.2 million IU intramuscularly once daily plus
Probenecid 500 mg orally 4 times a day, both given for 10-14 days
(Although this regimen is meant for outpatient therapy, please ensure that
the patient will remain compliant with FULL treatment)
For Penicillin allergic non-pregnant patients
Doxycycline 200 mg orally twice a day for 30 days
OR
Tetracycline 500 mg orally 4 times a day for 30 days
Herpes Simplex type-2 (HSV-2)
• Common
• Mostly asymptomatic
• Manifests as blisters or ulcers and is
painful
• Treatment protocols divided as: first
episodes, recurrent episodes and those
requiring suppressive therapy
• Treatment suppresses symptoms but does
not cure infection
Treatment of Herpes Simplex type 2 (HSV-2)
Treatment of First Episode:
Acyclovir 400 mg 3 times a day for 7 days
Treatment of Recurrent Episodes:
Acyclovir 400 mg 3 times a day for 5 days
Suppressive therapy:
Acyclovir 400 mg twice a day continuously
Trichomonas Vaginalis
• Usually presents as a vaginal discharge
and vulvovaginal soreness or irritation
• Can also cause Dysuria or dyspareunia
(usually severe) and lower abdominal
discomfort
• Diagnosis is usually clinical
Treatment of Trichomonas Vaginalis
Metronidazole 2 gm orally once
OR
Tinidazole 2 gm orally once
Alternative regimen (also used for urethral infections)
Metronidazole 400 or 500 mg orally twice daily for 7 days
OR
Tinidazole 500 mg orally twice daily for 7 days
Bacterial Vaginosis
•
•
•
•
Commonest cause of vaginal discharge
Not an STI (does not effect males)
Represents alteration of the vaginal flora
Presents as a smelly discharge in lower
vagina and labia
• Discharge is grayish, thin, homogenous
and contains bubbles
Treatment of Bacterial Vaginosis
Metronidazole 2 gm orally once
OR
Clindamycin 2% vaginal cream, 5 gm intravaginally at bedtime for 7 days
OR
Metronidazole 0.75% gel, 5 gm intravaginally twice daily for 7 days
OR
Clindamycin 300 mg orally twice daily for 7 days
Treatment during Pregnancy
First Trimester (only if treatment is imperative): Metronidazole 2 gm orally once
2nd or 3rd trimesters: Metronidazole 200- 250 mg 3 times a day for 7 days
Alternative regimen
Metronidazole 2 gm orally once
OR
Clindamycin 300 mg orally twice daily for 7 days
OR
Metronidazole 0.75% gel, 5 gm intravaginally twice daily for 7 days
Candida
• Due to overgrowth of candida around labia and
surrounding areas
• Usually represents alteration of vaginal flora or other
causes and not an STI
• Diagnosis is clinical
• Dysuria
• Excoriations (redness with peeling of skin) in the
perivaginal area
• Shallow, radial, linear ulcerations
• Vaginal walls are red
• Discharge is thick, sticks to skin and has curds
• No smell
Treatment of Candida
Miconazole or clotrimazole 200 mg intarvaginally daily for 3
days
OR
Clotrimazole 500 mg intravaginallly once
OR
Fluconazole 150 mg orally once
Alternate Regimen
Nystatin 100,000 IU intarvaginally daily for 14 days
Venereal Warts
• Caused by viruses called the Human Papilloma Virus or
HPV
• Appear as skin tags
• Can be very small (barely visible) to several centimeters
• In men they are present around shaft of penis
• In women they are present around visible parts of the
vagina and clitoris although they can be anywhere on the
genitalia
• Peri-anal warts are present in those engaging in
receptive anal sex and may be inside anal canal
• Due to the danger of development of cancer, those
treated for warts must be referred to assessment of
cancer (Pap smear in women and follow up in men)
Treatment for Venereal Warts
Treatment is meant for external genitalia and vaginal. Please refer to
gynaecologic specialist for cervical warts
Consider sending patients with warts for gynaecological evaluation since the
causative agent of warts (human papilloma virus) increases the risk of cervical
cancer
Provider administered: Podophyllin 10-25% in compound of tincture or benzoin.
Apply carefully avoiding normal tissue. External genital genitalia should be washed
thoroughly in 1-4 hours. Allow the applied medicine to dry before removing speculum.
Repeat application weekly as needed.
OR
Cryotherapy (when available). Repeat after 1-2 weeks as needed
OR
Self applied by the patient: Podophyllin 0.5% twice daily for 3 days then no
treatment for 4 days. Follow this cycle for up to 4 times.
STI Syndromes
Urethral Discharge
•
•
•
•
Men mostly but women too
Gonorrhoea or Chlamydia or both
Emphasize confirming discharge
No discharge – other abnormality:
appropriate algorithm
• No discharge – no abnormality: reassure
Clinical case
• 25 year old man presents to the clinic, sits
down and is uncomfortable discussing his
complaints
• After some probing he admits some
difficulty related to penis and some
discomfort during urination
• He declines any extramarital sex activity
and continues to look uncomfortable
Learning point
• Many patients will not openly discuss their STI
related complaints
• Many may not accept extramarital sex
• Some may start with vague complaints and
come to their STI symptom only when
comfortable
• Confidence and Rapport building are crucial
for good STI history taking
• Examination of penis to confirm diagnosis of
urethral discharge is important
Urethral Discharge
Discharge
from Urethra
Expressing discharge from Urethra
TREATMENT OF GONORRHOEA
Uncomplicated Anal/ Genital Infection
URETHRAL DISCHARGE
Ciprofloxacin 500 mg orally once only
Yes
Patient
complains of
urethral
Discharge or
dysuria
No
Any
other
genital
disease
Discharge
confirmed?
(Ciprofloxacin is contraindicated in
pregnancy and for children or adolescents)
OR
Cefixime 400 mg orally once only
OR
Ceftriaxone 125 mg IM once only
No
Take history
and examine.
Milk urethra
if necessary
Use
appropriate
flow chart
 4 Cs
 Ask patient
to return in
7 days if
symptoms
persist
OR
Spectinomycin 2 gm IM once only
Disseminated Gonococcal infection
Ceftriaxone 1 gm IM or intravenous once daily for
7 days
OR
Spectinomycin 2 gm IM twice daily for 7 days
TREATMENT OF CHLAMYDIA
4 Cs:
1. Compliance Counseling
2.
3.
4.
Promote & provide
Condoms
Counseling for STI
prevention, HIV testing;
Educate and Reassure
patient
Partner (Contact) treatment
Yes
Treat for
Gonorrhoea and
Chlamydia
• 4 Cs
• Ask patient to return in
7 days if symptoms
persist
Uncomplicated Anal/ Genital Infection
Doxycycline 100 mg orally twice daily for 7 days
(Not to be used for pregnant women, children or
adolescents)
OR
Azithromycin 1 gm orally once only
Alternative Regimens
Amoxycillin 500 mg orally 3 times a day for 7
days
OR
Erythromycin 500 mg 4 times a day for 7 days
OR
Ofloxacin 400 mg orally twice a day for 7 days
OR
Tetracycline 500 mg orally 4 times a day for 7
days
Persistent or Recurrent Discharge
• Definition: Discharges that continue to
bother patient after 1 wk or more of
appropriate Tx
• Significance:
– Non-adherence
– Resistance (gonorrhoea)
– Re-infection
– Missed Diagnosis
• Re-infection may require probing history
about sexual relations
• Partner management issues
TREATMENT OF GONORRHOEA
Uncomplicated Anal/ Genital Infection
PERSISTENT URETHRAL DISCHARGE
Patient
complains of
urethral
Discharge or
dysuria
Yes
Any other
genital
disease
 4 Cs
 Ask patient to
return in 7
days if
symptoms
persist
No
Treat for
Trichomonas
No
Discharge
confirmed?
4 Cs:
1.Compliance
Counseling
2.Promote & provide
Condoms
3.Counseling for STI
prevention, HIV
testing; Educate and
Reassure patient
4.Partner (Contact)
treatment
Yes
Does
History
confirm reinfection or
poor
compliance
• 4 Cs
• Ask patient to
return in 7 days if
symptoms persist
Not
better
Yes
Repeat Urethral
Discharge
Treatment
Ciprofloxacin500 mg orally once only
(Ciprofloxacin is contraindicated in
pregnancy and for children or adolescents)
OR
Cefixime 400 mg orally once only
OR
No
Take history
and examine.
Milk urethra if
necessary
Use
appropriate
flow chart
Refer for
laboratory
tests and
Specialist
Care
Ceftriaxone125 mg IM once only
OR
Spectinomycin2 gm IM once only
TREATMENT OF CHLAMYDIA
Uncomplicated Anal/ Genital Infection
Doxycycline100 mg orally twice daily for 7 days
(Not to be used for pregnant women, children or
adolescents)
OR
Azithromycin1 gm orally once only
Alternative Regimens
Amoxycillin500 mg orally 3 times a day for 7
days
OR
Erythromycin500 mg 4 times a day for 7 days
OR
Ofloxacin400 mg orally twice a day for 7 days
OR
Tetracycline500 mg orally 4 times a day for 7
days
TREATMENT OF TRICHOMONAS
Metronidazole400 or 500 mg orally twice daily for 7
days
OR
Tinidazole500 mg orally twice daily for 7 days
Genital Ulcers
• Confirm with exam
• Critical distinction: Ulcer (sore) vs Vesicle
(blister)
• Clinically impossible to differentiate between
syphilis, HSV and chancroid in about ½ of ulcers
• Clinically relevant situation: Non healing
ulcers vs slow healing ulcers
• HIV/HSV co-infection and HIV transmission
Clinical Case
• 21 y/o man presents with severe pain on
penis for 3 days
• It is causing difficulty with urination
• On exam, there is a single ¼ cm ulcer on
the glans penis near the urethral meatus
Clinical Case
• 21 y/o woman presents with severe pain
around vagina for 3 days
• It is causing difficulty with urination
• On exam, there is a single ¼ cm ulcer
near the urethra
___________________________
Note: the ulcer may be on the labia, near or
on clitoris/ urethra or any where in the
genital area
Clinical points
• Ulcers range from barely visible to over a
centimeter in many of the patients
• They may be multiple
• Multiple ulcers may not all be together (ie
they may be in different parts of the
genitalia)
• They may occur around the anus
• In about half of the cases it is impossible
to distinguish between HSV and syphilis
Genital Ulcers
Vulvar ulcer - HSV
Vulvar ulcer –
Primary syphilis
Genital Ulcers
Penile ulcer - HSV
Peri-vaginal Primary
Herpes
Genital Ulcers
Penile ulcer – primary
syphilis
Penile Vesicles - HSV
GENITAL ULCERS
TREATMENT OF HSV-2
Refer for
laboratory
testing and
Specialist
treatment
Patient
complains of
genital ulcer
Treatment of First Episode:
Acyclovir 400 mg 3 times a day for 7
days
Treatment of Recurrent Episodes:
Take history
and examine
Only
vesicles
present
Acyclovir 400 mg 3 times a day for 5
Yes
 Treat for HSV
 Test and Treat for
syphilis
 4 Cs
 Ask patient to
return in 7 days if
symptoms persist
No
Sore or
ulcer
present
Yes
 Treat for syphilis
AND HSV
 4 Cs
 Ask patient to
return in 7 days if
symptoms persist
days
No
Suppressive therapy:
Ulcer(s)
improving
Acyclovir 400 mg twice a day
continuously
Yes
No
Ulcer(s)
healed
Continue
treatment
for
another 7
days
Yes
TREATMENT OF SYPHILIS is
complicated and detailed. Please refer
to separate sheet
4 Cs:
1. Compliance Counseling
2.
3.
No
 4 Cs
 Reassure
4.
Promote & provide
Condoms
Counseling for STI
prevention, HIV testing;
Educate and Reassure
patient
Partner (Contact)
treatment
Scrotal Swelling
• Critical decision: Infectious or Non-infectious
• History important for prior trauma
• Examination is important to distinguish rotation,
elevation or rotation of testes
• Infectious causes are usually GC/ CT
• Non-infectious causes are usually surgical
• Surgical problems require (usually emergent)
referral
• Remind patients that scrotal swellings
particularly that are due to past trauma may take
a long time to resolve….
Clinical Case
• 19 y/o man presents with scrotal discomfort
• There was a history of difficulty urination and
perhaps some urethral discharge about 3 weeks
ago
• There is a history of penetrative sex with a Hijra
in the past several weeks
• On exam the left side of scrotum is slightly
swollen and slightly tender just under the base
of penis
Clinical points
• It is absolutely essential to distinguish
infection from surgical causes of scrotal
swelling – when in doubt refer for surgical
care
TREATMENT OF GONORRHOEA
Uncomplicated Anal/ Genital Infection
SCROTAL SWELLING
Ciprofloxacin 500 mg orally once only
(Ciprofloxacin is contraindicated in
pregnancy and for children or adolescents)
OR
Patient
complains
of Scrotal
Swelling
No
History and
examination
Swelling/
Pain
Confirmed
4 Cs:
1. Compliance Counseling
2.
3.
4.
Promote & provide
Condoms
Counseling for STI
prevention, HIV testing;
Educate and Reassure
patient
Partner (Contact) treatment
Yes
 Reassure
patient
 Provide
analgesics if
needed
 4 Cs
Testes
rotated or
elevated or
history of
trauma
Cefixime 400 mg orally once only
Treat for
Gonorrhoea and
Chlamydia
OR
Ceftriaxone 125 mg IM once only
OR
Spectinomycin 2 gm IM once only
No
• 4 Cs
• Ask patient to
return in 7 days if
symptoms persist
Disseminated Gonococcal infection
Ceftriaxone 1 gm IM or intravenous once daily for
7 days
OR
Spectinomycin 2 gm IM twice daily for 7 days
TREATMENT OF CHLAMYDIA
Yes
Refer for
surgical
evaluation
Uncomplicated Anal/ Genital Infection
Doxycycline 100 mg orally twice daily for 7 days
(Not to be used for pregnant women, children or
adolescents)
OR
Azithromycin 1 gm orally once only
Alternative Regimens
Amoxycillin 500 mg orally 3 times a day for 7
days
OR
Erythromycin 500 mg 4 times a day for 7 days
OR
Ofloxacin 400 mg orally twice a day for 7 days
OR
Tetracycline 500 mg orally 4 times a day for 7
days
Anal Symptoms
• Main concerns:
–
–
–
–
–
Discharge
Ulcers
Warts
Hemorrhoids
Rectal Fissures
• Proctoscopy increases diagnosis for most common
causes
• Warts a concern for future development of cancer
• Occasionally HSV can also cause anal discharges,
Discharges not responding to GC/CT Tx may be tried on
HSV-2 Tx
Clinical case
• A 29 y/o man presents with anal
discomfort for one week
• On probing, he admits to occasionally
selling anal sex, last being about 2 weeks
ago
• On exam there is anal ulcers
Clinical Case
• A 35 y/o married man presents with soiling of
underwear for a week
• The soiling is foul smelling and has caused
embarassment for him at his office
• He denies any extramarital sex
• After some rapport building he admits to having
sex with a male colleague but insists that he
(your patient) only penetrated
• On exam there is purulent anal discharge
Clinical Case
• A 36 y/o disshevelled man presents with severe pain
during defecation
• After rapport building he admits to using injected
drugs
• On exam he has a stage 3 hemorrhoid (prolapses
with minimal pressure) that has some ulceration and
scarring on the mucosa
____________________
Learning point: Many IDUs sell anal sex for drugs.
Advanced hemorrhoids are not uncommon among
IDUs and are a result of repeated anal trauma
Anal Fissures may develop from this trauma as well
Anal Symptoms
Courtesy CDC, USA
Anal Warts
Anal Fissure
TREATMENT OF GONORRHOEA
Uncomplicated Anal/ Genital
Infection
ANAL SYMPTOMS
Discharge
Confirm
on exam
Discharge
Confirmed
Yes
Treat for
Gonorrhoea and
Chlamydia
No
Ulcers or
blisters
seen
Pain
Cefixime 400 mg orally once only
Ceftriaxone 125 mg IM once only
No
Examination
(use
proctoscope
if cause not
seen on
inspection)
only
OR
OR
No
abnormality
Anal
symptoms
Ciprofloxacin 500 mg orally once
Warts
OR
Supportive/
symptomatic
care
Spectinomycin 2 gm IM once only
Disseminated Gonococcal
infection
Ceftriaxone 1 gm IM or
intravenous once daily for 7 days
OR
Spectinomycin 2 gm IM twice
Yes
Treat for HSV-2
Test and treat
for Syphilis
Wart removal/
needs
observation for
cancer
daily for 7 days
TREATMENT OF
CHLAMYDIA
Uncomplicated Anal/ Genital
Infection
Doxycycline 100 mg orally
twice daily for 7 days
OR
Azithromycin 1 gm orally
once only
Alternative Regimens
Amoxycillin 500 mg orally 3
times a day for 7 days
OR
Erythromycin 500 mg 4
times a day for 7 days
OR
Ofloxacin 400 mg orally twice
a day for 7 days
OR
Tetracycline 500 mg orally 4
times a day for 7 days
TREATMENT OF HSV-2
Treatment of First Episode:
Acyclovir 400 mg 3 times a day for 7 days
Treatment of Recurrent Episodes:
Acyclovir 400 mg 3 times a day for 5 days
Suppressive therapy:
Acyclovir 400 mg twice a day continuously
4 Cs:
1.Compliance Counseling
2.Promote & provide Condoms
3.Counseling for STI
prevention, HIV testing;
Educate and Reassure
patient
4.Partner (Contact) treatment
Hemorrhoids
(piles) seen
Treat for
Hemorrhoids
(piles)
Rectal
Fissures
Refer for
Surgical
evaluation
TREATMENT FOR WARTS
Treatment is meant for external genitalia and vaginal. Please refer to
gynaecologic specialist for cervical warts
Provider administered: Podophyllin 10-25% in compound of tincture
or benzoin. Apply carefully avoiding normal tissue. External genital
genitalia should be washed thoroughly in 1-4 hours. Allow the applied
medicine to dry before removing speculum. Repeat application weekly as
needed.
OR
Cryotherapy (when available). Repeat after 1-2 weeks as needed
Vaginal Discharge
• Vaginal Discharge is a common complaint among
women
• Critical point: Do not treat women that don’t present
with this complaint (ie Vaginal discharge is not the
reason why they came to see you)
• Critical point: Assessment of risk
• High risk > Treat for cervicitis otherwise for vaginitis
• Speculum exam does not improve Dx
• HSV-2 can also cause rare discharge. Treatment nonresponders must be re-assessed for risk and for HSV-2
Tx
• Asking about amount of discharge or smell may help
distinguish cervicits from vaginits
Vaginal Discharge: Causes
Vaginitis
Cervicitis
Caused by Trichomoniasis
(TV), Candidiasis and
Bacterial Vaginosis
Caused by Gonorrhoea and
Chlamydia
Most common cause of
vaginal discharge
Less common cause of
vaginal discharge
Easy to diagnose
Difficult to diagnose
No complications
Major complications
Treatment of partner
unnecessary, except for TV
Need to treat partner
Clinical Case
• 21 y/o married mother of 2 children
presents with a sore throat
• On a comprehensive review of systems
she admits to having a vaginal discharge
• On exam there is a scant vaginal
discharge
• Clinical point: This is likely physiological
discharge and should not be treated
Clinical Case
• A 22 y/o mother of 1 child presents with vaginal
discharge
• She describes some scant odor to the discharge
which also itches
• On rapport building she admits that she
occasionally has sex with a neighbor for money
to make ends meet
• Clinical point: This is likely Cervicitis. Note that
the critical point is the assessment of risk
Clinical Case
• 34 y/o somewhat obese woman presents with
vaginal itching and discomfort
• One further questioning she also admits noticing
a vaginal discharge
• On rapport building there is no history of risky
sex behavior
• Clinical point: this is likely Candidiasis, this
woman may have diabetes although having
diabetes is not necessary for candidiasis
Treat for
Gonorrhoea
and Chlamydia
VAGINAL DISCHARGE
Patient complains of
vaginal discharge,
vulval itching or
burning
No
Yes
History,
examination
and
Risk
assessment*
High NG/CT
prevalence in
community or
high individual
risk profile
Lower
abdominal
pain
Yes
TREATMENT OF GONORRHOEA
Uncomplicated Anal/ Genital
Infection
Ciprofloxacin 500 mg orally once
only
OR
Cefixime 400 mg orally once only
OR
Ceftriaxone 125 mg IM once only
No
OR
Spectinomycin 2 gm IM once
only
Yes
Treat for BV/
Trichomonas
Use Lower
Abdominal pain
flowchart
Abnormal
discharge
or vulval
erythema
Disseminated Gonococcal
infection
Ceftriaxone 1 gm IM or
intravenous once daily for 7 days
OR
Spectinomycin 2 gm IM twice
daily for 7 days
No
Use Appropriate
flowchart
*Risk factors assessed
should include:
 Personal sexual history
(including extramarital sex)
 High risk group
membership
 Community factors such as
STI prevalence in
community.
Vulval edema/curd-like
discharge, erythema,
excoriations present
No
No
Yes
 Reassure patient
 Provide analgesics
if needed
 4 Cs
Treat for
Candida
4 Cs:
1.Compliance Counseling
2.Promote & provide Condoms
3.Counseling for STI prevention, HIV
testing; Educate and Reassure
patient
4.Partner (Contact) treatment
Uncomplicated Anal/ Genital
Infection
Doxycycline 100 mg orally
twice daily for 7 days
OR
Azithromycin 1 gm orally once
only
Alternative Regimens
Amoxycillin 500 mg orally 3
times a day for 7 days
OR
Erythromycin 500 mg 4 times
a day for 7 days
OR
Ofloxacin 400 mg orally twice
a day for 7 days
OR
Tetracycline 500 mg orally 4
times a day for 7 days
TREATMENT OF BACTERIAL VAGINOSIS
Metronidazole 2 gm orally once (also treats Trichomonas)
OR
Yes
Any other
genital
disease
TREATMENT OF CHLAMYDIA
TREATMENT OF CANDIDA
Miconazole or clotrimazole 200 mg intarvaginally daily for 3 days
OR
Clotrimazole 500 mg intravaginallly once
OR
Fluconazole 150 mg orally once
Alternate Regimen
Nystatin 100,000 IU intarvaginally daily for 14 days
Clindamycin 2% vaginal cream, 5 gm intravaginally at bedtime for 7
days
OR
Metronidazole 0.75% gel, 5 gm intravaginally twice daily for 7 days
OR
Clindamycin 300 mg orally twice daily for 7 days
Treatment during Pregnancy
First Trimester (only if treatment is imperative): Metronidazole 2 gm
orally once
2nd or 3rd trimesters: Metronidazole 200- 250 mg 3 times a day for 7
days
Alternative regimen
Metronidazole 2 gm orally once
OR
Clindamycin 300 mg orally twice daily for 7 days
OR
Metronidazole 0.75% gel, 5 gm intravaginally twice daily for 7 days
Lower Abdominal Pain
• Main concerns:
– PID (infectious)
– Retained placenta/ dead fetus/ other products of
conception
• Critical finding: Cervical Motion Tenderness
• Prompt referral for non-responders is critical
• Hospitalization important for serious patients
Clinical Case
• 32 y/o woman presents with lower abdominal
pain for past 4 days
• She denies any history of risky sex (was asked
properly, with respect and tact)
• She did have increase in vaginal discharge 3
weeks ago (she usually notices some discharge
every month) but was busy helping her husband
with some essential house work before he
started another truck trip to Afghanistan
• On exam there is cervical motion tenderness
• Clinical point: This is likely PID
Clinical Case
• A 28 y/o woman presents with lower abdominal
pain for 6 months - on and off
• Her abdominal pain is not related to meals and
she does not have diarrhea (if anything she
often does not need to go to bathroom for 2-3
days)
• There is no risky sex behavior
• She lives in a household of 14 people and her
husband is the only bread earner
• There is no cervical motion tenderness
• Clinical point: This is unlikely to be infectious
Lower Abdominal Pain
Criteria for hospitalization:
• Pregnant patient
• Cannot exclude surgical emergencies (ie
appendicitis)
• Severe illness: Nausea and vomiting or Fever
>39oC,
• Severe pain (enough to interfere with daily life)
• No response to oral medicines
• Unable to take or can not tolerate oral medicines
• Evidence of a tubo-ovarian abscess
OUTPATIENT TREATMENT OF LOWER
ABDOMINAL PAIN
LOWER ABDOMINAL PAIN
Ceftriaxone 125 mg IM once only
OR
Appropriate
surgical or
gynecological
referral
Patient complains of
lower abdominal pain
History and
examination (including
gynecological exam)
Any of the following
present:
 Missed or overdue
period
 Recent delivery/
abortion/ miscarriage
 Adnominal guarding
and/or rebound
tenderness
 Abnormal vaginal
bleeding
 Abdominal mass
 intrauterine device
Spectinomycin 2 gm IM once only
PLUS
Doxycycline 100 mg orally twice daily for 7 days
Yes
No
Cervical
motion
tenderness
or lower
abdominal
tenderness
and vaginal
discharge
No
Yes
OR
Any other
illness
found
Appropriate
management
Refer or
Specialist
care
• Manage for
PID
• 4 Cs
• Review in 5
days
No
Patient
improved
Yes
4 Cs:
1.Compliance Counseling
2.Promote & provide
Condoms
3.Counseling for STI
prevention, HIV testing;
Educate and Reassure
patient
4.Partner (Contact) treatment
Tetracycline 500 mg orally 4 times a day for 7 days
(both Doxycylcine and Tetracycline are
contraindicated for pregnant women)
PLUS
Metronidazole 400 mg orally twice daily for 14 days
ALL PATIENTS NOT
IMPROVING WITH
OUTPATIENT THERAPY
MUST BE ADMITTED FOR
FURTHER TREATMENT
Continue until treatment
completed




Reassure patient
Provide analgesics if needed
4 Cs
Ask patient to return as
needed
Common side
effects of
medicines used
Acyclovir:
Rare side effects in patients treated short-term with
acyclovir are nausea, vomiting, and headache. Long-term
treatment has the additional potential for rash and diarrhea.
Azithromycin:
Azithromycin is generally well tolerated. The most common
side effects are diarrhea or loose stools, nausea,
abdominal pain, and vomiting, each of which may occur in
fewer than one in twenty persons who receive
Azithromycin. Rarer side effects include abnormal liver
tests, allergic reactions, and nervousness.
Ceftriaxone:
If administering Ceftriaxone into a muscle, it may be mixed
with Lidocaine (Xylocaine, Lignocaine) to reduce pain at
the injection site. Milder symptoms are: Diarrhea, stomach
pain, upset stomach, vomiting. More severe symptoms
include: unusual bleeding or bruising, difficulty breathing,
itching, rash, hives, sore mouth or throat.
Cefixime:
Cefixime is generally well tolerated and side effects are
usually transient. Reported side effects include diarrhea,
pseudomembranous colitis (can occur even after cefixime
is stopped) nausea, abdominal pain, vomiting, skin rash,
fever, joint pain and arthritis, abnormal liver tests, vaginitis,
itching, headaches, and dizziness.
Clindamycin:
Mild diarrhea or stomach upset may occur. If any of these effects
persist or worsen, they should be observed carefully. Although unlikely,
vaginal pain/itching/discharge may occur or worsen. These symptoms
may be due to a new vaginal infection (e.g., yeast/fungal infection,
trichomonas infection). This medication may infrequently cause a
fungal infection in another part of the body (e.g., oral thrush). This may
manifest as a change in vaginal discharge, white patches in your
mouth, or other new symptoms. Many people using this medication do
not have serious side effects. Serious side effects include: pain on
urination, lower back pain, menstrual problems, abnormal vaginal
bleeding. A very small amount of this medication may be absorbed into
bloodstream and may rarely cause a severe intestinal condition
(pseudomembranous colitis) due to a resistant bacterium. This
condition may occur while receiving therapy or even weeks after
treatment has stopped. Do not use anti-diarrhea products or narcotic
pain medications if you suspect that the patient has this condition
because these products may make them worse. Major signs of
pseudomembranous colitis are persistent diarrhea, abdominal or
stomach pain/cramping, or blood/mucus in stool. A very serious allergic
reaction to this drug is unlikely, but requires immediate medical
attention if it occurs. Symptoms of a serious allergic reaction may
include: rash, itching, swelling, severe dizziness, trouble breathing.
Fluconazole:
Up to 25% develop side effects from this medication. Headaches, nausea,
abdominal pain, diarrhea or dizziness are common. Severe skin rash may
occur but is uncommon.
Miconazole:
Irritation and burning have been reported by patients using topical or vaginal
miconazole
Clotrimazole:
The most commonly noted side effects associated with clotrimazole are local
redness, stinging, blistering, peeling, swelling, itching, hives, or burning at the
area of application. All of these are quite unusual, however.
Tinidazole:
Tinidazole may cause side effects. Consider stopping it if any of these
symptoms are severe or do not go away: sharp, unpleasant metallic taste,
upset stomach, vomiting, loss of appetite, constipation, stomach pain or
cramps, headache, tiredness or weakness, dizziness. Some side effects can be
serious. The following symptoms are uncommon, but require that the medicine
must be stopped immediately: seizures, numbness or tingling of hands or feet,
rash, hives, swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles,
or lower legs, hoarseness, difficulty swallowing or breathing
Nystatin:
diarrhea, nausea, gas, or vomiting as until the body adjusts to the medication. If
these symptoms persist or get worse consider stopping the medicine.
Doxycycline:
Doxycycline is generally well-tolerated. The most common side effects
are diarrhea or loose stools, nausea, abdominal pain, and vomiting.
Tetracyclines, such as doxycycline, may cause tooth discoloration if
used in persons below 8 years of age. Exaggerated sunburn can occur
with tetracyclines; therefore, sunlight should be minimized during
treatment.
Tetracycline:
Tetracycline is generally well-tolerated. The most common side effects
are diarrhea or loose stools, nausea, abdominal pain, and vomiting.
Tetracyclines may cause discoloration of teeth if used in patients below
8 years of age. Exaggerated sunburn can occur with tetracyclines;
therefore, sunlight should be minimized during treatment
Metronidazole:
Metronidazole is generally well tolerated with appropriate use. Serious
side effects of metronidazole are rare; and include seizures and
damage of nerves resulting in numbness and tingling of extremities
(peripheral neuropathy). Metronidazole should be stopped if these
symptoms appear. Minor side effects include nausea, headaches, loss
of appetite, a metallic taste, and rarely a rash.
Ciprofloxacin:
Nausea, vomiting, diarrhea, abdominal pain, rash,
headache, and restlessness. Rare allergic reactions have
been described, such as hives and anaphylaxis (shock)
Levofloxacin:
The most frequently reported side events are nausea or
vomiting, diarrhea, headache, and constipation. Less
common side effects include difficulty sleeping, dizziness,
abdominal pain, rash, abdominal gas, and itching.
Ofloxacin:
The most frequent side effects include nausea, vomiting,
diarrhea, insomnia, headache, dizziness, itching, and
vaginitis in women. Rare allergic reactions have been
described, such as hives and anaphylaxis (shock).
Symptoms of nervous system stimulation, such as anxiety,
euphoria, and hallucinations have rarely been reported.
Penicillin:
This medication may cause mild diarrhea, stomach upset,
nausea, vomiting or irritation at injection site during the first
few days. If this irritation worsens or persist for more than a
few days, stop the medicine. Medicine should be stopped if
patient develops: watery diarrhea, stomach cramps, fever,
unusual bleeding or bruising, yellowing of the eyes or skin,
unusual tiredness or weakness. In the unlikely event of an
allergic reaction to this drug, appropriate care for
anaphylaxis should be provided. Symptoms of an allergic
reaction include: wheezing, difficulty breathing, skin rash,
hives, itching.
Podophyllin
Swelling, pain, burning, itching, peeling skin, small sores,
or headache may occur. Most serious side effect is
bleeding.