Sexually Transmitted

Infections (STIs)

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 The term "sexually transmitted
diseases" is used to denote
disorders spread principally by
intimate contact (usually means
sexual intercourse)

Introduction
Many sexually transmitted
diseases (STDs) can be acquired
by transplacental spread, by
passage through the birth canal,
and via lactation during the
neonatal period.

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 • STI
o Infections acquired through sexual
intercourse
o may be symptomatic or
asymptomatic
• STD
Introduction…. o Symptomatic disease acquired
through sexual intercourse
• STI is most used because it
applies to both symptomatic and
asymptomatic infections

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Interaction Between HIV and
STIs
• Significant interaction exists between HIV and STIs
• Affect similar populations
• Have a similar route of transmission
• HIV affects the treatment and management of STI’s
• STI’s affect the management of HIV

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 Diagnostic
approaches
• Globally, service
providers use one of the
following three
diagnostic approaches:
o Etiologic
o Clinical and
o Syndromic approach.

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 Etiologic

• This is done by
identifying the
causative agent(s)
using laboratory tests
and giving treatment
targeting to the
pathogen identified

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 Clinical

• Uses clinical experience to

identify symptoms which are
typical for a specific STI, then
giving treatment targeted, to
the suspected pathogen(s)

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 Syndromic

• Identification of
clinical syndrome and
giving treatment
targeting all the
locally known
pathogens which can
cause the syndrome

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Syndromic…
• Syndromic approach is called “Comprehensive
approach” because in addition to the provision of
treatment it includes:
o education of the patient
o condom supply
o counseling
o partner notification and
o management and HIV testing and counseling (HTC).

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Syndromic…
• Advantages
o Simple, rapid and inexpensive
o Complete HIV care offered at first visit
o Patients are treated for possible mixed infections
o Accessible to a broad range of health workers
o Avoids unnecessary referrals to hospitals
• Disadvantages
o Over-treatment
o Asymptomatic infections are missed

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Syndromic…
• The commonly encountered STI syndromes are:
o Urethral discharge in men
o Genital ulcer
o Vaginal discharge
o Lower abdominal pain in women
o Inguinal bubo
o Scrotal swelling
o Neonatal conjunctivitis.

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 Flow Charts
Each flow-chart is made up of a series
of three steps.
• The clinical problem: is what the
patient complains of
• The decision that needs to be
taken: requires further information,
(history taking or examining).
• The action that needs to be carried
out: This is the box that instructs
the service provider on what action
to take.

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 The diagnosis of STIs relies on
proper history taking and physical
examination.

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Syndromic diagnosis relies on
identification of symptoms and
Assessment signs
of a Patient Needs elaboration on the chief
with STIs complaints of the patient in order

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to determine the syndrome.

Age, sex, and marital status are

important components of the
history.
13
History Taking
Presenting symptoms

Previous diagnosis of STI

Sexual history

Symptoms and diagnosis in sexual partner

Past general medical history

Current medications

Risk factors for the acquisition of HIV and STIs

In females: obstetric, menstrual history, and use of contraceptives

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Talking about STIs with Patients

Important to understand
the patient’s perspective on Patients would like their
talking about sex with a medical provider to be
medical provider
• Embarrassed • Nonjudgmental
• Nervous • Respectful
• Guilty • Maintain privacy and
• Shame, fear confidentiality

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History to each specific syndrome
Urethral discharge or burning sensation on urination
in men: Onset, history of unprotected casual sex, the
amount of discharge.

Vaginal discharge: change of color, amount and odor

of vaginal discharge, history of STI in the partner,
multiple sexual partners and change in sexual partner.

Genital ulcer in men and women: The onset, history of

recurrence, presence of pain, location and whether the
ulcer is single or multiple.

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History to each specific syndrome
Lower abdominal pain in women: The onset, type of pain, radiation,
severity, presence of vaginal discharge, last menstrual period, and
systemic symptoms like fever, nausea and vomiting.
Scrotal swelling: The onset, presence of pain, history of trauma and
history of concomitant urethral discharge.

Inguinal Bubo: Presence of pain, ulceration, discharges and the

locations of the swelling.

Neonatal conjunctivitis; onset, presence of unilateral or bilateral eye

discharge, sticky eyes and swollen eyelids

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Examination in women
Examination in women should proceed as follows:
• General examination:
o Inspection any rash, sores, warts and discoloration
o Palpation to determine the presence of enlargement of
lymph nodes in the anterior and posterior cervical
region, sub mental, suboccipital, axillary and
epitrochlear areas.
• Examination of the oral cavity
o ulcers, candidiasis, leukoplakia, gingivitis.

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Examination…
• Examination of the abdomen:
o Inspection for any obvious lumps.
o Palpation for the size of the liver and spleen and the
presence of any masses, tenderness, guarding and
rebound tenderness are noted.
• Examination of the inguinal and femoral triangle
lymph nodes: should be palpated to check for
lymphadenopathy or lymphadenitis.

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Examination…
• Examination of the vulva: The the vulva should be
visually inspected for any lesions and the Bartholins
glands should be milked for discharge.
• Examination of the anus and perineum: The anal
area should be visually inspected for any lesions.

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Examination…
• Speculum examination: to visualize the cervix; and
visualize vaginal mucosa as it falls into place.
• Digital bimanual examination: help to enlist
cervical tenderness/excitation or adnexal masses

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GENITAL ULCER
SYNDROME
• Genital ulcer is an open sore or a break in the
continuity of the skin or mucous membrane of the
genitalia as a result of sexually acquired infections.
• Commonly genital ulcer is caused by bacteria and
viruses.
• Genital ulcer facilitates transmission of HIV more
than other sexually transmitted infections because
it disrupts continuity of skins and mucous
membranes significantly.

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GENITAL ULCER
SYNDROME
• Most cases of genital herpes are caused by HSV-2.
• According to the validation study conducted in
2001 HSV2 alone was the leading cause of genital
ulcer syndrome in both males and females
constituting 44% and 76% of the cases respectively.
• Treponema pallidum (syphilis), Haemophilus
ducreyi (chancroid) and Chlamydia trachomatis are
also causative

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GENITAL ULCER
SYNDROME
CLINICAL MANIFESTATION
• Common clinical manifestations of genital ulcer are:
o Constitutional symptoms such as fever, headache,
malaise and muscular pain
o Recurrent painful vesicles and irritations
o Shallow and non-indurated tender ulcers

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GENITAL ULCER
SYNDROME
• Common sites in women are vulva, perineum,
vagina and cervix and can cause occasionally severe
vulvo- vaginitis and necrotizing cervicitis
• Painless indurated ulcer(Chancre)
• Regional lymph adenopathy

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GENITAL ULCER
SYNDROME
COMPLICATIONS OF GENITAL ULCER SYNDROME
• Locally destructive granulomatous lesions occur
(Gummas) on the skin, liver, bones, or other organs
• Tabes dorsalis and dementia, often with paranoid
features
• Latent meningovascular parenchymatous
• Optic atrophy
• General paresis
• Aortic aneurysm and aortic valve insufficiency
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GENITAL ULCER
SYNDROME
COMPLICATIONS….
• Asymptomatic aortitis
• Angina pectoris
• Recurrent disease
• Aseptic meningitis
• Encephalitis
• Extra genital lesions

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GENITAL ULCER
SYNDROME
TREATMENT OF GENITAL ULCER SYNDROME
1. Treatment for Non- Vesicular Genital Ulcer
o Benzathine penicillin 2.4 million units IM stat /Doxycycline(in penicillin
allergy) 100mg bid for 14 days plus
o Ciprofloxacin 500mg bid orally for 3 days /Erythromycin 500mg tab qid
for 7 days plus
o Acyclovir 400mg tid orally for 10 days (or 200mg five times per day of
10 day)
2. Treatment for Vesicular, multiple or recurrent genital ulcer
o Acyclovir 200 mg five times per day for 10 days Or Acyclovir 400 mg
tid for 7 days
3. Treatment for recurrent infection:
o Acyclovir 400 mg tid for 7 days

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 3
0

Think, Pair &

Share

A 22-year-old married
woman presented with a
compliant of ulcer around
the labia majora.

Which history are you

going to ask this woman?
Haweni A.

04/15/2022
 3
1

Think, Pair &

Share
On history she revealed that the
ulcer starts back to 1 week for the
first time and is accompanied by
pain and no abnormal v.discharge.

What physical examination are

you going to perform for this
woman?
Haweni A.

04/15/2022
 3
2

Think, Pair &

Share
Physical examination revealed
that the ulcer is non-vesicular
and singular, there is no
abnormal vaginal discharge.

What is the possible

management for this
woman?
Haweni A.

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Think, Pair & Share
• Benzathine penicillin 2.4 million units IM stat /Doxycycline(in penicillin
allergy) 100mg bid for 14 days plus
• Ciprofloxacin 500mg bid orally for 3 days /Erythromycin 500mg tab qid
for 7 days plus
• Acyclovir 400mg tid orally for 10 days (or 200mg five times per day of
10 day)
• Educate
• Counsel
• Promote and provide condoms
• Offer HTC
• Partner treatment
• Ask the patient to return in 7 days

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VAGINAL DISCHARGE
SYNDROME
• Abnormal vaginal discharge which is STI
related is abnormal in color, odor and
amount.
• In another word abnormal vaginal
discharge is there when a women
notices a change in color, odor and
amount accompanied by pruritus.

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VAGINAL DISCHARGE
SYNDROME
ETIOLOGY OF VAGINAL DISCHARGE SYNDROME
• The most common causes of vaginal discharge syndrome are
o Neisseria gonorrhea
o Chlamydia trachomatis
o Trichomonas vaginalis
o Gardnerella vaginalis (Polymicrobial)
o Candida albicans

• Bacterial vaginosis (Gardnerella vaginalis) is the leading cause

of vaginal discharge in Ethiopia followed by candidiasis,
trichomoniasis, gonococcal and chlamydia cervicitis in that
order.

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VAGINAL DISCHARGE
SYNDROME
CLINICAL MANIFESTATIONS
The discharge can be
• Thin, homogenous whitish discharge with fishy
odor
• Thick, profuse, malodorous, yellow-green, frothy
itchy
• Purulent exudate from the cervical Os
• White , thick and curd like discharge coating the
walls of the vagina

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VAGINAL DISCHARGE
SYNDROME
• Physical examination may reveal dry congestion of
the vulva with discharge.
• There can be signs of cervicitis during speculum
examination which are redness and contact
bleeding from the cervix, spotting and endo cervical
discharge.
• Risk Assessment
• While vaginal discharge is highly indicative of
vaginal infection, it is poorly predictive of cervical
infection with gonorrhoea and/or chlamydia.
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VAGINAL DISCHARGE
SYNDROME
• The following are the common risk factors for
development of vaginal discharge syndrome
secondary to cervicitis:
o Multiple sexual partners in the last 3 month
o New sexual partner in the last 3 month
o Ever traded sex
o Age below 25 years
• The presences of one or more risk factor suggest
cervicitis.

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COMPLICATIONS
• Pelvic Inflammatory • Chorioamnionitis
Disease (PID) • Post-partum
• Peritonitis and intra- endometritis
abdominal abscess • Pre-term labor
• Adhesions and • Low birth weight
intestinal obstruction
• Infertility
• Ectopic pregnancy
• Chronic pelvic pain
• Premature Rupture of
Membrane (PROM)

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VAGINAL DISCHARGE
SYNDROME
TREATMENT OF VAGINAL DISCHARGE SYNDROME
• Risk Assessment Positive
o Ceftriaxone 250mg IM stat/Spectinomycin 2 gm IM stat Plus
o Azithromycin 1gm po stat/Doxycycline 100 mg po bid for 7 days
Plus
o Metronidazole 500 mg bid for 7 days
o If discharge is white or curd-like add Clotrimazole vaginal pessary
200 mg at bed time for 3 days
• Note: The preferred regimen is
o Ceftriaxone 250mg IM stat plus
o Azithromycin 1gm po stat plus
o Metronidazole 500 mg bid for 7days

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VAGINAL DISCHARGE
SYNDROME
• Risk Assessment Negative
oMetronidazole 500 mg bid for 7 days
oIf discharge is white or curd-like add
Clotrimazole vaginal pessary 200 mg
at bed time for 3 days

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LOWER ABDOMINAL PAIN/PELVIC
INFLAMMATORY DISEASE (PID)
• Pelvic inflammatory disease (PID) refers to a clinical
syndrome resulting from ascending infection from
the cervix and/or vagina.
• PID comprises a spectrum of inflammatory
disorders of the upper female genital tract,
including any combination of endometritis,
salpingitis, tubo-ovarian abscess and pelvic
peritonitis.

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LOWER ABDOMINAL….
• The vast majority of PID with or without pelvic
abscess improves with antibiotics alone and the
fever usually subsides in less than 72 hours.
• However, failure to improve within 72 hours after
antibiotic treatment indicates failure of medical
treatment and the patient should be referred for
surgical evaluation and treatment.

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LOWER ABDOMINAL….
ETIOLOGY
• PID is frequently poly-microbial. The commonest pathogens
associated with PID, which are transmitted sexually, are
o C. trachomatis and N. gonorrhoea.
• Other causes which may or may not be transmitted sexually
include:
o Mycoplasma genitalium
o Bacteroides species
o E. coli
o H. influenza
o Streptococcus

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LOWER ABDOMINAL….
CLINICAL MANIFESTATION
• Lower abdominal pain
• Abnormal vaginal discharge
• Inter-menstrual or post coital bleeding
• Dysuria
• Backache
• Fever, nausea and vomiting
• Cervical excitation tenderness
• Adnexal tenderness
• Rebound tenderness
• Adnexal mass

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LOWER ABDOMINAL….
COMPLICATIONS OF LOWER ABDOMINAL PAIN
SYNDROME
• Peritonitis and intra-abdominal abscess
• Adhesions and intestinal obstruction
• Ectopic pregnancy
• Infertility
• Chronic pelvic pain
• Recurrent PID

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LOWER ABDOMINAL….
TREATMENT OF LOWER ABDOMINAL PAIN SYNDROME
• For outpatient
o Ceftriaxone 250 mg IM stat /Spectinomycin 2gm i.m stat Plus
o Azithromycin 1gm po stat/Doxycycline 100 mg po b.i.d for 14
days Plus
o Metronidazole 500 mg po b.i.d for 14 days
• Admit if there is no improvement within 72 hours
Note : The preferred regimen is
o Ceftriaxone 250mg IM stat plus
o Azithromycin 1gm po stat plus
o Metronidazole 500 mg bid for 14 days

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LOWER ABDOMINAL….
• For inpatient
o Ceftriaxone 250 mg i.m/i.v /Spectinomycin 2 gm i.m bid
Plus
o Azithromycin 1gm po daily /Doxycycline 100 mg po b.i.d
for 14 days Plus
o Metronidazole 500 mg po b.i.d for 14 days

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LOWER ABDOMINAL….
INDICATION FOR INPATIENT TREATMENT
• The diagnosis is uncertain
• Surgical emergencies such as appendicitis and ectopic
pregnancy cannot be exclude
• Pelvic abscess is suspected
• Severe illness precludes management on an outpatient basis
• The patient is pregnant
• The patient is unable to follow or tolerate an outpatient
regimen
• Patient has failed to respond to outpatient therapy.
• PID in HIV patients
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STI Prevention
• Counsel for risk reduction and educate
• Provide HIV testing and counseling
• Contact tracing whenever possible
• Diagnosis and treatment of active STIs
• Screening of risk groups, pregnant women and their
partners for asymptomatic STI and offering
treatment
• Supply and counsel about use of condoms
• Counsel about use and efficacy of spermicides
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 Transmission issues
Prevention • Effective treatment of chlamydia and/or
gonorrhea may reduce HIV transmission
Counseling • Abstain from sexual intercourse until
partners are treated and for seven days after
single dose therapy or until completion of a
seven day regimen

Nature of the infection

• Chlamydia is commonly asymptomatic in
men & women
• Gonorrhea is usually asymptomatic in
women
• Both easily transmitted during asymptomatic
phase
• Both have serious adverse effects on
women’s reproductive health if untreated

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Contents of counseling for STI
patients

Assessing the patient’s Other personal risk

Personal sexual behavior
risk level factors

Any barriers the patient

perceives to changing
Patient’s Protective
Partners Sexual Behavior behavior( gender ,cultur
Behavior
e ,religion and
socioeconomic)

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 Help patients re-examine long-standing
Help habits and situation that are putting
them at risk

The aim of Prevent Prevent further transmission to others

risk reduction
counseling Remain
Remain free of infection in the
and future

education Promote
Promote partner notification,
treatment and education

Adherence Promote treatment adherence

Enhance
Enhance coping with the STI and its
social consequences

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Key Points
• STIs are among the most common cause of illness in the
world
• Emergence and spread of HIV infection and AIDS has major
impact on the management and control of STIs
• STIs increase the acquisition and transmission of HIV
• HIV infection alters the clinical features and response to
therapy of STIs
• The syndromic approach to the management of STIs:
• Recommended by WHO
• Simple, rapid and inexpensive
• Leads to unnecessary over-treatment

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 Thank you
04/15/2022

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