SEXUALLY TRANSMITTED INFECTIONS (STIs)
These are communicable diseases that are usually transmitted through sexual contact between man and woman (heterosexual), and between sexual deviants. Other forms of transmission include vertically from mother to child in utero, during birth, or soon after birth; transfusion of contaminated blood; or via contaminated needles, syringes, specula, gloves,and skin piercing and cutting instruments. Injecting drug addicts who share needles are a high risk group. Clinical manifestations of these conditions depend on the offending organism and are numerous.
Accurate diagnosis and effective treatment of STI is essential and cos-effective HIV/AIDS prevention strategy.
Management
Give full course of appropriate drug therapy
Treat complications.
Follow up the patient.
Provide health education and counseling.
Manage the sexual contacts, including contact tracing, diagnosis, treatment, health education, and counseling.
Manage complications accordingly.
Follow the 4 C’s of STI management
Compliance with the full drug course follow-up.
Counseling on safer sexual behavior
Condoms: Ensure proper use.
Contact tracing, partner treatment and notification.
Patient Education
Avoid multiple or anonymous partners, prostitutes, or any other person with multiple sex partners.
Use Condoms correctly, e.g., avoid oil based lubricants, use a new condom for every sex act.
Avoid alcohol or drug abuse, which may lead to irresponsible sexual behavior.
GONORRHOEA AND URETHRAL DISCHARGE
Clinical Features
Discharge in anterior urethra with dysuria or urethra) discomfort. Caused by gonococcal infection in 90% of cases. The remaining 10% are non-gonococcal infections (NGIs) and are mainly due to Chlamydia trachomatis and to a lesser extent trichomonas or Herpes simplex. In 5-10%, there is a mixture of gonorrhea and NGI. In addition, infection of the glans (balanitis) or prepuce (posthitis) by Candida albicans can lead to discharge.
Gonorrhea: Abundant pus-like discharge, incubation period 3-10 days.
NGI: Mucoid or serous discharge, scanty, usually seen in morning, incubation 10-14 days.
Investigations
Diagnosis in male is usually clinical but if confirmation is required a urethral smear is done.
Gram stain showing pus cells and intracellular Gram-negative diplococci is 95% accurate
Management
Norfloxacin 800 mg STAT and Doxycycline 100mg BD for 7 days
Alternatively, IM Spectinomycin 2g STAT and Doxycycline 100mg BD for 7 days.
Practice abstinence
Avoid risky sexual practices like casual and multiple partners
Use condoms
Advice on counseling
GENITAL DISCHARGE IN THE FEMALE
Causes of vaginal discharge include Candida vulvovaginitis (monilia or thrush), trichomonas vaginitis, and bacterial vaginosis. Endocervical discharge can be caused by gonorrhea, chlamydia trachomatis, and mycoplasma hominis.
Management
Norfloxacin 800 mg STAT and Doxycycline 100mg BD for 7 days
Alternatively, IM Spectinomycin 2g STAT and Doxycycline 100mg BD for 7 days.
Practice abstinence
Avoid risky sexual practices like casual and multiple partners
Use condoms
Advice on counseling
CANDIDA VULVOVAGINITIS (MONILIA OR THRUSH)
Common infection of the vulva and vagina caused by a fungus called Candida albicans. It is not always transmitted by sexual intercourse. Predisposing factors are diabetes mellitus, systemic antibiotics, pregnancy, hormonal or injectable contraceptives and decreased host immunity.
Clinical Features
Vaginal discharge is creamy and thick (curd like). Associated with itching, burning and soreness during micturition and sexual intercourse. There is erythema, excoriation and fissure. Diagnosis is mainly clinical.
Investigations
Wet mount is prep[ared by putting a drop of the discharge onto a glass slide and adding a drop of saline or 10% potassium hydroxide (KOH) and covering with a cover slip. Examine under a low-power microscope. Candida albicans is identified by pseudohyphae and spores.
Management
Give clotrimazole pessaries 200mg OD for 3 days and clotrimazole cream.
Give fluconazole 200 mg STAT.
Treat partner with fluconazole 200 mg STAT and clotrimazole cream also.
Prevention
People who get recurrent infection should be given concurrent prophylactic treatment whenever broad-spectrum antibiotics are prescribed.
TRICOMONAS VAGINITIS
It is a common cause of vaginal discharge. Caused by Trichomonas vaginalis, a flagellated protozoan, and is mainly sexually transmitted.
Clinical Features
Symptoms depend on the severity of the infection and include a frothy, greenish yellow, foul-smelling discharge. Other features are vaginal soreness, dyspareunia and post-coital spotting. Infection usually involves the vulva, vagina, and cervix and may appear reddish and swollen. Diagnosis is mainly clinical.
Investigations
Wet mount preparation demonstrates flagellated protozoa.
Trichomonas may also be noted on urine microscopy or pap smear.
Management
Metronidazole 400mg TDS for 7 days. The same dose for the male partner. (Alcohol consumption to be avoided during treatment with metronidazole.)
Drug to be avoided during the first trimester of pregnancy. If possible, withhold treatment until the third month of pregnancy.
Clotrimazole 1 pessary intra-vaginally daily for 6 days.
BACTERIAL VAGINOSIS
Usually associated with Gardnerella vaginalis.
Clinical Features
Vaginal discharge greyish-white in nature with a characteristic fishy odour that increases in intensity after sexual intercourse. Not usually associated with soreness, irritation, pruritus burning sensation, or dyspareunia. Diagnosis is usually clinical.
Investigations
Wet mount preparation, which will show vaginal epithelial cells with adherent clusters of Gram-negative bacilli or coccobacilli (Clue Cells).
Whiff-test in which a drop of discharge is mixed with a drop of KOH, which gives a characteristic fishy odour.
Management
Treat both the patient and the male partner.
Give metronidazole 400mg TDS for 7 days (avoid alcohol).
Counsel on taking plenty of fluids.
CERVICITIS
About one third of all women presenting with vaginal discharge have cervicitis.
The commonest causes of endocervicitis are gonorrhea, chlamydia, trichomoniasis,and herpes simplex virus.
Clinical Features
Cloudy-yellow vaginal discharge that is non-irritating, non-odorous, and mucoid.
There may also be inter-menstrual or post-coital spotting or both. There may also be dyspareunia or pelvic discomfort or both. Cervical mucosa appears inflamed with focal hemorrhages. Cervix is friable and bleeds easily on touch. Vesicular herpetic lesions will be found on the vulva, vagina,and cervix. Abdominal and bimanual pelvic examination should be done to rule out pelvic inflammatory disease (PID)
Investigations
Wet mount preparation: Look for pus cells, trichomonas, and yeats.
Gram-stain of the discharge of endocervical swab (Neisseria gonorrhoeae: shows Gram-negative intracellular diplococci).
Culture for gonorrhea or chlamydia if available.
Pap smear after treatment.
Management
Norfloxacin 800 mg STAT then 400 mg BD for 7 days Ceftriaxone 250mg
Doxycycline 100mg BD.
Metronidazole 2g STAT.
DYSURIA IN THE FEMALE
Can result from urinary tract infection, vaginitis, or cervicitis. Treatment refer gonorrhea.
LOWER ABDOMINAL PAIN IN THE FEMALE
Clinical Features
Often due to pelvic inflammatory disease (PID). Must be differentiated from urinary tract infection, ectopic pregnancy, threatened abortion, appendicitis, and other causes of acute abdomen.
An abdominal and pelvic examination must be done on all cases of lower abdominal pain in women.
GENITAL ULCER DISEASE
This condition can present with a variety of features and have a variety of probable causes, from primary syphilis chancre to herpes to Granuloma inguinale. A thorough physical examination is required.
BUBOES OR SWOLLEN INGUINAL GLANDS
Buboes are enlarged lymph nodes in the groin. They may be associated with an ulcer in the genital area or on the lower limbs.
Clinical Features
Lymphogranuloma venereum: Several nodes matted together on one or both sides, usually without suppuration.
Chancroid tender fluctuant bubo that suppurates, leaving an undermined inguinal ulcer that should be aspirated before suppuration.
Investigations
Serology for syphilis should always be performed.
GENITAL WARTS
Clinical Features
Condyloma acuminatum (Human papillomavirus): Cauliflower-like warts. May be single or multiple on the vulva, vagina, perineal area, penis, urethra and sub-prepucial. Vaginal discharge, pain, and bleeding on coitus or touch may occur.
Molluscum contagiosum (Pox group virus): Umbilicated multiple papules with whitish, cheesy material being expressed when squeezed. Secondary infection and spread to other sites may occur.
Secondary syphilis should be ruled out when evaluating genital venereal warts.
Management
Carefully apply podophyllin 205 in tincture of benzoin to each wart, protecting the normal surrounding skin with petroleum jelly. Wash off the podophyllin thoroughly 1-4 hours later.
Repeat 1-2 times weekly. If there is no regression after 4 applications, use alternative treatment given below or refer.
Alternative treatments:Podophyllotoxin 0.5% electrosurgery, cryotherapy, 5-Fluorouracil, surgical removal, silver nitrate pencil application.
In pregnancy: Podophyllin should not be used during pregnancy, not in vaginal, cervical, internal urethral, anal, oral warts. Alternative regimens may be used, except 5-Fluorouracil and podophyllotoxin.