52 STI Syndromes

52.1 Urethral Discharge in Men/Causes of Urethritis in Men

  • Gonnorhoea
  • Chylamdia
  • Trichomonas
  • Mycoplasma genitalium

Test: Gram stain of pus Gonnorhoea - Gram negative pairs

Chlamydia test is done through antigen detection test (~70% sensitive). Gold standard is an expensive PCR test

Complications of gonnorhoea:

  • Urethral Stricture
  • Epididymoorchitis

Treating gonnorhoea:

  • Ceftriaxone 250mg IM. Plus Azithromycin 1g PO

Treating chlymdia

  • Doxycycline
  • Or Azithromycin

We know that ceftriaxone resistance is increasing to gonnohroea. But we’ve next to no data for Africa. We also know that ciprofloxacin resistance is also appearing. And Azithromycin.

So if you’ve a patient with the syndrome of urethritis, then you’ll treat for both gon and chyl. You’ll also test for HIV. You’ll also ask them to return in 7 days if he’s got symptoms. You’ll provide condom use etc.

52.2 Lower Abdominal Pain in Women/Cervical Discharge/Pelvic Inflammatory Disease

  • Cervical Gonnorhoea
  • Cervical Chylamdia

Symptoms may be increased discharge, but up to 50% are asymptomatic.

But these spread up to the endometrium and can cause pelvic inflammatory disease. Can cause adhesions and infertility, and ectopic pregnancy. And perihepatitis.

Gram stain is not v good. Patients can do self administered test if PCR available.

Treat for both diseases. Ceftriaxone (one off) plus doxycycline (2 weeks) plus metronidazole (2 weeks)

Other fears. Congenital gonococcal opthalmic disease, can be potentially blinding. Can be prevented through giving tetracycline eye ointment at delivery. The studies showing this are over 20 years old, so are these antibiotics still effective? Not known.s

52.3 Vaginal Discharge

  • Trichomonas
  • Bacterial Vaginosis (Not an STI)
  • Candida (not an STI)
  • Gonnorhoea (not a vaginal infection)
  • Chylamdia (not a vaginal infection)

Speculum exam: will determine candida

Discharge: Wet scan will show trichomonas (have tails and swim about)

Diagnosing BV? Normal flora is lactobacilli. BV has loads of gram positive cocci

Treat candidiasis: with clotrimazole pessary/oral fluconazole Treat Trich: Single oral metronidazole Treat BV: Longer metronidazole

Do you treat someone with vaginal discharge for gon/chly. If they’ve got abdominal pain yes. If they’ve got a positive risk assessment, or pus coming from cervix, then treat for everything.

52.4 Syndromic Approach Advantage

  • Problem orientated
  • Sensitive
  • Treatment given quickly
  • Cheap
  • Standardised treatment

52.5 Syndromic Approach Disadvantages

  • Overtreatment
  • Not as good for women
  • Doesn’t treat asymptomatic infections
  • Side Effects
  • DIfficulties with partner notification

52.6 Genital Ulcers

  • Chancroid
  • Donovanosis
  • LGV
  • Syphilis
  • Herpes

But clinical diagnosis is not very good, they can all look like each other!

52.6.1 Genital Herpes

Blistering and painful ulceration. Heal within 4-5 days

Symptoms are self limiting, unless they’re immunocompromised

52.6.2 Syphilis

Primary Chancre

Test serologically: VDRL and RPR (but both these are non treponemal and can give false positives). So follow that up with a treponemal test. The disadvantage of treponemal test is once positive always positive.

RPR = Rapid Plasma Reagin.

Rapid Treponemal Antibody Test. Do not distinguish between current and past infections.

You can do a dual pathology test (HIV plus Syphilis).

Treat with benzyl penicillin G 2.4 million units IM (for primary secondary and early latent). For late latent maybe give 3 doses a week apart. But probably only give once

52.6.3 Chancroid

The “soft sore” of chancroid versus the “hard sore” of syphilis.

Haemophilus ducreyi. Grows only in highly selective medium at lower temperature in culture.

Asymptomatic infection is rare. Mainly seen only amongst sex workers and their clients.

No commercial PCR test available.

About 50% will have painful inguinal lymphadenopathy. You can also get perianal chancroid

Treat with azithromycin 1 gram stat.

Chancroid cases are reducing.

52.6.4 LGV

Caused by chlamydia trachomatis

Can cause transient genital ulcer or proctitis.

Sexondary infection can cause lymphadenopathy and severe proctitis and eventually fibrosis, lympheodema, rectal stricture.

Diagnosis, no commercial test, serology and PCR not really available.

Treat with 2 weeks of doxycycline 100mg bd.

52.6.5 Donovanosis (granuloma inguinale)

Painless ulcers caused by a klebsiella infection.

Test with blahhhhhhhhhhhhh

Add from slides.

52.6.6 Treatment

You would follow the Genital Ulcer flow chart, basically you would treat for the three common causes.

  • Syphilis
  • Herpes
  • Chancroid