PocketGuide: STDs and Family Planning - Diagnosis and Treatment

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STDs and Family Planning

Diagnosis and Treatment

Vaginal/Urethral Discharge | Genital Ulcers and Buboes | Lower Abdominal Pain | Acute Scrotal Pain/Swollen Scrotum

Vaginal/Urethral Discharge Bacterial Vaginosis \| Yeast \| Trichomoniasis \| Gonorrhea \| Chlamydia
GTI	Bacterial vaginosis
CLINICAL FINDINGS (signs/symptoms)	Vaginal discharge with fishy odor, grayish in color Not necessarily sexually transmitted
DIAGNOSIS	> 20% "clue cells" (vaginal epithelial cells covered with bacteria) on saline wet mount (or Gram stain); elevated vaginal pH (> 5) and positive "whiff" test for fishy smell
TREATMENT¹	Metronidazole, 400–500 mg orally, twice a day for 7 days Metronidazole, 2 g orally, single dose For pregnant women requiring treatment: Clindamycin, 300 mg orally, twice a day for 7 days

GTI	Yeast (candidiasis)
CLINICAL FINDINGS (signs/symptoms)	Women Curd-like vaginal discharge, whitish in color Moderate to intense vaginal or vulvar itching (pruritus) Men Itchy penile irritation (balanitis) Frequently not sexually transmitted
DIAGNOSIS	Presumptive diagnosis by symptoms; confirmed by microscopic examination of saline or KOH wet mount preparation
TREATMENT¹	Women Vaginal: antifungal inserted into the vagina as directed (e.g., 2 Nystatin suppositories, each containing 100,000 units each night for 14 nights; Miconazole, 200 mg, each night for 3 nights) Vulvar: antifungal cream, ointment or lotion applied to vulva twice a day for 10 days Alternatively, paint vagina with 1% aqueous solution of gentian violet. Client should be encouraged to continue treatment for at least 1 week. In men with candida balanitis, topical application of a gentian violet solution or nystatin cream is advised.

GTI	Trichomoniasis
CLINICAL FINDINGS (signs/symptoms)	May produce few symptoms in either sex Women Often will have a frothy (bubbly), foul-smelling, greenish vaginal discharge Intense pruritus (itching) Men may have a urethral discharge.
DIAGNOSIS	In both sexes, diagnosis is made easily by observing microscopically the whipping motion (flagellating) of the parasite on saline wet mount.
TREATMENT¹	Metronidazole, 2 g, single oral dose (8x250 mg tablets) Alternatives: Metronidazole, 400–500 mg orally, twice a day for 7 days Occasionally, retreatment may be necessary after 14 days, especially in males. The cure rate is 82–88% but can be increased to 95% if both partners are treated simultaneously.

GTI	Gonorrhea ("clap" or "drip")
CLINICAL FINDINGS (signs/symptoms)	Women Purulent (containing mucopus) vaginal discharge Pain (or burning) on passing urine (dysuria) Inflamed (red and tender) urethra 70% of women are asymptomatic in initial stages. If left untreated, can result in: infection of the pelvic organs (PID), infertility due to tubal blockage, or increased risk of ectopic pregnancy (tubal scarring). Men Pain (or burning) on passing urine (dysuria) Purulent (containing mucopus) urethral discharge (drip) If left untreated, can result in: infection of the epididymis (coiled tube leading from the testis to the spermatic cord), urethral abscess or narrowing (stricture), or infertility (blockage of the epididymis).
DIAGNOSIS	Women 40–60% positive Gram-negative intracellular diplococci (GNIDs) on Gram stain of cervical smear Men Up to 98% positive GNIDs microscopically on Gram stain of urethral smear
TREATMENT¹	*Oral Regimens* Ciprofloxacin, 500 mg, single oral dose Cefixime, 400 mg, single oral dose Alternatives: Trimethoprim, 80 mg/ sulfamethoxazole, 400 mg, 10 tablets a day for 3 days Intramuscular Regimens Ceftriaxone, 250 mg Spectinomycin, 2 g Alternative: Kanamycin, 2 g

GTI	Chlamydia
CLINICAL FINDINGS (signs/symptoms)	Women Produces few symptoms, even with upper genital tract infection ("silent PID"); on examination, purulent vaginal or cervical discharge, frequently a "beefy" red cervix which is friable (bleeds easily) Men Most frequent cause (50%) of nongonococcal urethritis (NGU)
DIAGNOSIS	Presumptive diagnosis based on mucopus and/or friable (easily bleeding) cervix and negative GNIDs Definitive diagnosis by serologic tests or culture
TREATMENT¹	Doxycycline, 100 mg orally, twice a day for 7 days, or Tetracycline, 500 mg orally, 4 times a day for 7 days As an alternative and in pregnancy: Erythromycin, 500 mg orally, 4 times a day for 7 days^a Sulfafurazole, 500 mg orally, 4 times a day for 10 days

Genital Ulcers and Buboes Chancroid \| Syphilis \| Lymphogranuloma Venereum \| Granuloma Inguinale \| Genital Herpes \| Genital Warts
GTI	Chancroid (soft chancre)
CLINICAL FINDINGS (signs/symptoms)	Painful, "dirty" ulcers located anywhere on the external genitalia In 25–60% of cases, an enlarged lymph node (bubo) develops in the groin. Most common cause of genital ulcers in many parts of the world
DIAGNOSIS	Presumptive diagnosis often rests on clinical features (syphilitic chancres usually are not painful) and a negative darkfield (microscopic) examination or serology (RPR or VDRL). Confirmation sometimes can be made if the causative bacteria are seen (Gram-negative coccobacilli in chains—the so-called "school of fish").
TREATMENT¹	Erythromycin, 500 mg orally, 3 times a day for 7 days Alternatives: Oral Regimens: Ciprofloxacin, 500 mg, single oral dose Trimethoprim, 80 mg/ sulfamethoxazole, 400 mg, 2 tablets twice a day for 7 days Intramuscular Regimens: Ceftriaxone, 250 mg by IM injection, single dose Spectinomycin, 2 g by IM injection, single dose

GTI	Syphilis
CLINICAL FINDINGS (signs/symptoms)	Occurs in 2 forms—early (primary and secondary) and late. Early syphilis Initially, painless ulcer (chancre): in women on the external genitalia (labia), in men on the penis; and enlarged rubbery lymph nodes Later (several months): non-itchy body rash Both types of lesions disappear spontaneously. Late syphilis develops in about 25% of untreated cases and is often fatal due to involvement of the heart, great vessels and brain.
DIAGNOSIS	Definitive diagnosis made by darkfield microscopy of secretions from a primary or secondary lesion or serology (RPR or VDRL) in equivocal cases or when there are no signs or symptoms (latent stage).
TREATMENT¹	Early: Benzathine penicillin G, 2.4 million units, at a single session by IM injection Alternative: Aqueous procaine benzathine penicillin G, 1.2 mIU daily, by IM injection, for 10 days In clients allergic to penicillin: Tetracycline, 500 mg orally, 4 times a day for 15 days Doxycycline, 100 mg orally, twice a day for 15 days Late: Benzathine penicillin G, 2.4 mIU, by IM injection once a week for 3 weeks Alternative: Aqueous procaine benzathine penicillin G, 1.2 mIU daily, by IM injection, for 20 days

GTI	Lymphogranuloma venereum (LGV)
CLINICAL FINDINGS (signs/symptoms)	Small, usually painless papules (like pimples) on the penis or vulva, followed by buboes in the groin which ultimately break down forming many fistulae (draining openings) If untreated, the lymphatic system may become blocked, producing elephantiasis (swelling of the genitals or extremities).
DIAGNOSIS	Clinical findings may not be helpful. Microscopic diagnosis rests on seeing inclusion bodies in white cells (PMNs) of bubo aspirate.
TREATMENT¹	Doxycycline, 100 mg orally, twice a day for 14 days Tetracycline, 500 mg orally, 4 times a day for 14 days Alternatives: Erythromycin, 500 mg orally, 4 times a day for 14 days Sulfadiazine, 1 g orally, 4 times a day for 14 days Some patients may require longer treatment.

GTI	Granuloma inguinale (Donovanosis)
CLINICAL FINDINGS (signs/symptoms)	An uncommon cause of ulcerative GTIs Typically, the infected person develops lumps under the skin which break down to form "beefy" red, painless ulcers.
DIAGNOSIS	Diagnosis rests on identifying "Donovan bodies" inside the cell in Giemsa-stained smear from the groin or perineal buboes.
TREATMENT¹	Trimethoprim, 80 mg/ sulfamethoxazole, 400 mg, 2 tablets orally, twice a day for 14 days Alternative: Tetracycline, 500 mg orally, 4 times a day for 10 days

GTI	Genital herpes
CLINICAL FINDINGS (signs/symptoms)	Multiple, painful, shallow ulcers which clear in 2 to 4 weeks (first attack) and may be accompanied by watery vaginal discharge in women; recurrent (multiple bouts) more than 50% of the time
DIAGNOSIS	Presumptive diagnosis by signs and symptoms and, often, by exclusion
TREATMENT¹	Acyclovir, 200 mg orally, 5 times a day for 7 days Client Instructions: Keep lesions clean. Wash affected sites with soap and water and dry carefully. Avoid sexual contact while lesions are present. Use a condom (male or female) after lesions are healed. If lesions become secondarily infected, treat for 5 days with trimethoprim, 80 mg/ sulfamethoxazole, 400 mg, 2 tablets orally twice a day.

GTI	Genital warts (condyloma acuminata)
CLINICAL FINDINGS (signs/symptoms)	Single or multiple soft, painless, "cauliflower" growths which appear around the anus, vulvo-vaginal area, penis, urethra and perineum
DIAGNOSIS	Presumptive diagnosis by signs and symptoms. Exclude syphilis by darkfield examination or serology.
TREATMENT¹	Preferred treatment, if available: Cryotherapy with liquid nitrogen, solid carbon dioxide or cryoprobe Treat warts on the penile shaft or perivulval skin (since they will not respond to podophyllin) with glacial trichloracetic acid (TCA 75% solution). Treat recurrences as above, making sure that partner(s) is examined. Alternatively, apply podophyllin solution (10–25%) carefully to warts, leave on for 1–4 hours and then wash. Repeat treatment weekly. Podophyllin should not be used during pregnancy and should not be applied to lesions on the cervix or inside the urethra.

Lower Abdominal Pain Pelvic Inflammatory Disease
GTI	Pelvic inflammatory disease (PID)
CLINICAL FINDINGS (signs/symptoms)	Acute: lower abdominal tenderness, cervical motion tenderness (CMT) on pelvic examination and one or more of the following: purulent (containing mucopus) vaginal/cervical discharge, temperature > 38EC, GNIDs on cervical smear, or presence of a pelvic mass.
DIAGNOSIS	GNIDs on cervical smear
TREATMENT¹	For acute PID, treat for gonorrhea (Ceftriaxone), chlamydia (Doxycycline) and anaerobic infections (Metronidazole) as follows: Ceftriaxone, 250 mg by IM injection, plus Doxycycline, 100 mg orally, twice a day for 14 days, plus Metronidazole, 400–500 mg orally, twice a day for 14 days If client does not improve with this treatment, refer her to a higher level health care facility.

Acute Scrotal Pain and/or Swollen Scrotum Epididymitis Orchitis (sexually acquired) \| Epididymitis Orchitis (not sexually acquired)
GTI	Epididymitis/Orchitis (sexually acquired)
CLINICAL FINDINGS (signs/symptoms)	Acute: Severe pain in one or both testes, sudden swelling of the testes
DIAGNOSIS	May include urethral discharge (or past history)
TREATMENT¹	Ceftriaxone, 250 mg IM, single dose, plus Doxycycline, 100 mg orally, twice a day for 10 days, or Alternative: Ofloxacin, 300 mg orally, twice a day for 10 days If acute, treat for gonorrhea and chlamydia.

GTI	Epididymitis/Orchitis (not sexually acquired)
CLINICAL FINDINGS (signs/symptoms)	Acute: Severe pain in one or both testes, sudden swelling of the testes
DIAGNOSIS	May include urethral discharge (or past history)
TREATMENT¹	If urinary tract infection with Gram-negative bacilli such as E. coli or pseudomonas species, treat with trimethoprim and sulphamethoxazole as follows: Trimethoprim, 80 mg/ sulfamethoxazole, 400 mg, 2 tablets twice a day for 10 days

¹Treatment regimens are based on: World Health Organization. 1994. Management of Sexually Transmitted Diseases. WHO: Geneva, Switzerland.

^{a Only erythromycin ethylsuccinate and not the estolate form can be
used by pregnant women.

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