STI Booklet Final

SEXUALLY TRANSMITTED
INFECTIONS
The Republic of Ghana
Guidelines for Management
National AIDS/STI Control Programme

Ministry of Health, Accra, Ghana
SEXUALLY TRANSMITTED
INFECTIONS
GUIDELINES FOR MANAGEMENT

Ministry of Health
Accra, Ghana
May 2013
Contents
Acronyms 6
Foreword 7-8
Sexually Transmitted Infections
Acknowledgement 9 - 10
1.0 Introduction 11 - 13
2.0 Prevention of Sexually Transmitted Infections 14 - 19

Education and Counselling 14
Approaches to STI Prevention 15
Partner Management 16
Surveillance 18
3.0 History Taking and Physical Examination 20 - 24

History 20
Physical Examination 22
2 4.0 Urethral Discharge in Males 25 - 28

Definition 25
Public Health Importance 25
Aetiology 25
Management 26
Urethral Discharge - Treatment Regimen 28
5.0 Persistent/ Recurrent Urethral Discharge 29 - 31

Persistent Urethral Discharge Treatment Regimen 31
6.0 Vaginal Discharge 32 - 37

Definition 32
Public health Importance 32
Aetiology 32
Management 33
Vaginal Discharge - Treatment Regimen 36
7.0 Lower Abdominal Pain 38 - 4
Definition 38
Aetiology 38
Management 39
Lower Abdominal Pain Treatment (Out-Patients) 42
Lower Abdominal Pain Treatment (In-Patients) 42
8.0 Genital Ulcer 43 - 47

Definition 43
Aetiology 43
Management 44
Genital Ulcer Treatment Regimen 46
9.0 Scrotal Swelling 48 - 51

Definition 48
Aetiology 48
Management 48
Scrotal Swelling - Treatment Regimen 51
3
10.0 Inguinal Bubo 52 - 54
Definition 52
Aetiology 52
Management 52
Inguinal Bubo - Treatment Regimen 54
11.0 Ano-rectal Related Syndromes 55 - 58

Definition 55
Aetiology 55
Management 55
A. Ano-rectal Discharge 58
B. Ano-rectal Ulcers/Vesicles 59
Guidelines For Management

12.0 Genital Warts 61 - 63
Definition 61
Aetiology 61
Management 61
Genital Warts - Treatment Regimen 62
Prevention 63
13.0 Scabies 64 - 65
Definition 64
Public health importance 64
Aetiology 64
Management 64
Scabies -Treatment Regimen 64
14.0 Pediculosis Pubis (Pubic Lice) 66 - 67

Definition 66
Aetiology 66
Management 66
Pediculosis Pubis - Treatment Regimen 67
15.0 Sexually Transmitted Infections in Children 68

4
A. Neonatal Conjunctivitis (Opthalmia Neonatorum) 70 - 72
Definition 69
Aetiology 69
Management 69
Prophylaxis of ophthalmia neonatorum 70
Neonatal Conjunctivitis Treatment Regimen 72
B. Management of specific STI & STI syndromes in children 74 - 84

Management of Urethral Discharge Syndrome In Children 74
Management of Vaginal Discharge Syndrome in Children 75
Management of Lower Abdominal Pain Syndrome in Children 77
Management of Genital Ulcer Syndrome in Children 78
Management of Ano-Rectal Related Syndromes in Children 80
Management of Genital Warts in Children 83
Management of Scabies and Pubic Lice in Children 83
Management of specific STI & STI syndromes in children 88
Annexes
Ghana Health Service/Ministry of Health 85 - 86
One STI Sentinel Surveillance Report Form
87
Two GHS/MOH Sexually Transmitted Infections (STI)
Quarterly Reporting Format
Figures
1. Urethral Discharge In Males flowchart 27
2. Persistent Urethral Discharge In Males Flow Chart 30 5
3. Vaginal Discharge Flowchart (without Speculum) 34
4. Vaginal Discharge Flow Chart

(with Speculum And Bimanual Examination) 35
5. Lower Abdominal Pain Flowchart 41
6. Genital Ulcer Flow Chart 45
7. Scrotal Swelling Flowchart 50
8. Inguinal Bubo Flowchart 53
9: Anorectal Infections Flow Chart 57
10. Neonatal Conjunctivitis Flowchart 71

Acronyms
AIDS Acquired Immune Deficiency Syndrome
CHAG Christian Health Association of Ghana

EML Essential Medicines List
GUD Genital Ulcer Disease
HCW Health Care Worker
HIV Human Immunodeficiency Virus
HPV Human Papilloma Virus
HSV Herpes Simplex Virus
HTC HIV Testing and Counselling
IDSR Integrated Disease Surveillance and Response
IUCD Intra Uterine Contraceptive Device
6 LGV Lymphogranulomavenereum
MSM Men who have Sex with Men
NACP National AIDS/STI Control Programme
NGU Non-gonococcal Urethritis
PEP Post Exposure Prophylaxis
PID Pelvic Inflammatory Disease
STG Standard Treatment Guidelines
STI Sexually Transmitted Infections
USAID United State Agency for International Development
WHO World Health Organisation
Foreword
S exually Transmitted Infections (STIs) are a major public health
problem and their control is the cornerstone for improving
reproductive health and reducing HIV infections.
Comprehensive management of STIs is important and comprises

prompt case detection and effective treatment. The benefits of
management include individual benefits, in addition to reduction of
the period of infectiveness and reduction in incidence and
prevalence of STI in the population. Education and counselling,
which are part of management, also provide opportunity to reduce
further risk of STI and HIV infection. In addition, since partner
management is incorporated into treatment it affords the
opportunity to treat asymptomatic clients. The syndromicapproach
seeks to include all of these aspects in its comprehensive
management.
In March 1993 the National AIDS/STI Control Programme (NACP) 7

developed technical guidelines for the management of STI. These
guidelines used algorithms for the management of urethral
discharge, vaginal discharge, genital ulcers and lower abdominal
pain similar to the syndromic approach to treating STIs
recommended by the World Health Organisation. In 2001 the STI
guidelines were reviewed again and the syndrome of recurrent
urethral discharge and other STI-related conditions were added. In
2008 revisions were mainly focused on new drug regimens and
treatment of STI following an update of the national essential
medicines list.
This edition incorporates new developments and recommendations

from the World Health Organization (WHO) and an expanded
scope to include management for ano-rectal related syndromes.

There is in addition a new section entirely devoted to a wider
scope of sexually transmitted infections in children, unlike the
previous editions which only focused on neonatal conjunctivitis.
It is expected that these guidelines will be adapted to develop

training manuals for capacity building for all healthcare workers
(HCWs). To enhance the use of these guidelines, specific

management algorithms must be reproduced in poster form for
easy utilization by service providers. It is hoped that these
guidelines will improve the quality of STI management in all health
facilities including the public, private, Christian Health Association
of Ghana (CHAG) and other quasi government health institutions
and contribute to the reduction of transmission of STI including
HIV.
The support of the President’s Emergency Plan for AIDS Relief

(PEPFAR) through the United State Agency for International
Development (USAID), the Global Fund for AIDS, TB and Malaria,
and WHO towards the revision of these guidelines is
acknowledged.
8
Dr. Ebenezer Appiah-Denkyerah

Director-General
Ghana Health Service
Acknowledgement
T his current revision of the National Guidelines for
Management of Sexually Transmitted Infections has been
made possible by the contribution, inputs and expertise of the
underlisted experts which constituted the review team. I wish to
on behalf of the National AIDS/STI Control Programme of the
Ghana Health Service express my appreciation to the review team
for work so expertly done. The National AIDS/STI Control
Programme further acknowledges the support of United States
Agency for International Development (USAID) under the terms
of GHH- 1-03-07-0043-00-HIV/AIDS Preventions for Most At
Risk Populations (MARP) and People Living with HIV (PLHIV) in
Ghana for supporting the process of revision.
Dr. S. B. Ofori
Regional HIV/STI Coordinator, Eastern Region
Dr. Ronald Sowa

Regional HIV/STI Coordinator, Western Region
9
Dr. Thomas Agyarko-Poku

Regional HIV/STI Coordinator, Ashanti Region
Dr. Afua Asabea Amoabeng Nti

University Hospital, Legon Accra
Dr. Anthony Ashinyo

Nkwanta South District Hospital, Nkwanta, Volta Region
Dr. Kimberly Green

FHI360 , Ghana
Mrs. Nana Fosua Clement

FHI 360, Ghana

Dr. Doris Macharia
FHI 360, South Africa
Dr. Henry Narh Nagai

Country Director, FHI360 Ghana.
Ms. Caroline Adonadaga

Ms. Winifred N. O. Armah-Attoh

Mrs. Angelina Kodua Nyanor

Dr. Stephen Ayisi Addo

Dr. Bernard Tei Dornoo

Dr. Nii Akwei Addo

10 Programme Manager, National AIDS/STI Control Programme
Dr. Nii Akwei Addo

Programme Manager
Chapter 1.0
Introduction
T he term Sexually Transmitted Infection (STI) refers to a variety
of clinical syndromes caused by pathogens that can be
acquired and transmitted through sexual activity. STIs are common
in many parts of the world. STIs are not only a cause of acute
morbidity in adults but may result in complications with sequelae
such as infertility, ectopic pregnancy, urethral stricture, cervical
cancer, congenital syphilis, foetal wastage, low birth weight,
prematurity, anal fistula and Ophthalmia neonatorum.
Due to their frequency of occurrence and potential for morbidity,

STIs are in their own right a public health priority. The prevalence
of Human Immunodeficiency Virus (HIV), as well as various sexual
practices, have increased the importance of STIs. STI facilitate the
acquisition and transmission of HIV. Adequate management of
STIs therefore have an important bearing on HIV and AIDS
epidemic.
11
The main goals of STI control are:
• Interrupting the transmission of sexually acquired infections;

• Preventing development of complications and sequelae; and
• Reducing the risk of HIV infection.
These goals can be achieved through:
• Primary prevention directed at reducing the incidence

of disease; and
• Secondary prevention, directed at reducing the prevalence
by shortening the duration of disease and as a result
preventing probable complications or sequelae.

Primary prevention activities are essentially the same for HIV and
other STIs. These include:
• Promotion of safer sexual behaviour and practices;

• Provision of condoms at affordable prices; and
• Correct and consistent use of condoms during sexual
intercourse.
Secondary prevention activities are:
• Promotion of health care seeking behaviour directed

particularly towards those at increased risk of acquiring
STIs; and
• The provision of accessible, effective and acceptable
services, which offer diagnosis and effective treatment for
STI clients and their partners.
Effective client management remains the cornerstone for

controlling STI. Providers have generally used two approaches to
12 diagnosing STI: aetiological and clinical diagnosis.
Aetiological diagnosis is often regarded as the ideal approach in

medicine. It enables service providers to make precise diagnoses
and treat their patients with equal precision. However, in the
diagnosis and treatment of STI, the aetiological approach presents
a number of challenges. Many of the primary care facilities where
the majority of patients are seen do not have the laboratory
equipment and manpower required. Where they are available
these laboratory tests are expensive and time-consuming.
Clinical diagnosis is identifying the STI causing the symptoms

based on clinical experience. However even experienced STI
service providers often misdiagnose STIs when they rely on their
clinical experience.
Often mixed infections occur, and it is not possible to differentiate
clinically between the different infections. A client who has multiple
infections must be treated for each of these infections. Failure to
treat one infection may result in the development of serious
complications.
The best alternative to aetiological and clinical diagnoses is

syndromic diagnosis. Syndromic diagnosis identifies all possible STIs
that could cause the symptoms. The syndromic approach to STI case
management provides health care providers with practical tools to
improve the diagnostic and treatment process. Based upon what is
known about the prevalence of specific STIs including drug resistant
strains, case management protocols have been developed using
common STI-related syndromes as the starting point and the patient
management decision as the end point. This approach also directs
health care providers to educate clients about STI prevention,
partner notification and management.
The main benefit of syndromic case management of STIs is that

clients are treated rapidly and effectively, rendering them symptom-
free and non-infectious as soon as possible. This is also one-way of 13
interrupting the cycle of STI transmission, and in turn, the spread of
HIV. If they are treated effectively, patients will be happy to return if
they become ill again and it should make them more willing to help
service providers trace their partner(s).
These guidelines are aimed at equipping primary health care

workers with the knowledge to provide rapid, simple, inexpensive
and effective diagnosis and treatment to STI clients and their
partners using the syndromic approach.

Chapter 2.0
Prevention of Sexually
Transmitted Infections
Education and Counselling
It is important to educate and counsel every client visiting a health
facility for STI treatment. The service provider has an excellent

opportunity to help the client reduce his/her risk of getting STI,
including HIV, or spreading it to other people. The client will be
interested in the information because of his/her condition. This
may be one of the few opportunities that the client may have with
the health system to find out more about STIs and safer sexual
practices. It may also be one of the few opportunities for service
providers to break the cycle of transmission of STIs in a community.
Education involves giving clients practical information about their
STI. It also helps clients to understand how STIs spread, why it is
important to treat them, and help patients to understand how they
can protect themselves, their partners and children in the future.
Counselling is a process in which a counsellor assists the client(s) in

14 making choices, plans, adjustments or decisions with regard to
their situation. Counselling of STI clients could involve a wide
range of skills from listening to their problem, giving them vital
information and helping them to solve their problems.
Every STI client should leave a clinic understanding and

remembering these vital messages:
• Take all medications as instructed even if symptoms

disappear or one feels better(Drug Compliance).
• Avoid spreading STIs by abstaining from sex until all

medications are taken as directed and there are no more
symptoms. Clients must also be encouraged not to have sex
until their partner is treated(Abstinence).
• Help their sexual partner(s) to get treatment
(Partner Notification /Management)
• Come back to make sure they are cured (Follow-up care)
• Stay cured with safer sex practices, including the use

of condoms (Risk Reduction).
Approaches to STI Prevention

Abstinence: A reliable way to avoid transmission of STIs is to
abstain from oral, vaginal, and anal sex. For persons who are being
treated for an STI (or whose partners are undergoing treatment),
counselling that encourages abstinence from sexual intercourse
until completion of the entire course of medication is crucial.
Being Mutually Faithful: Being in a long term mutually

monogamous relationship with an uninfected partner is one of the
most reliable ways to avoid STIs. For persons embarking on a
mutually monogamous relationship, screening for common STIs
before initiating sex might reduce the risk for future disease 15
transmission. It is important to have an open and honest
conversation with your partner.
Condoms: Correct and consistent use of the male and female

condoms is highly effective in reducing STI transmission including
HIV. Condoms should be used every time one engages in anal,
vaginal, or oral sex.
Diagnosing STIs Early: This is important in breaking the cycle of

STI transmission, preventing complication and possible sequelae.
Vaccination: Pre-exposure vaccination is one of the most effective

methods for preventing transmission of some STIs. Vaccines are
safe, effective and recommended ways to prevent Hepatitis B and

Human Papilloma Virus (HPV) in both males and females. There
are HPV vaccines available for females aged 9–26 years to prevent
cervical pre cancer and cancer. Hepatitis B vaccination is
recommended for all unvaccinated, uninfected persons being
evaluated for STIs.
Neonates born to HBsAg positive mothers must receive Hepatitis B

specific immunoglobulin 200units IM and vaccinated as per the
rapid vaccination schedule (0, 1, 2, 12 months). All other children
should be vaccinated as per the national immunization protocols
(receiving doses at 6, 10 and 14 weeks of age).
NB. If history suggest sexual abuse, offer Post-Exposure

Prophylaxis (PEP) for HIV as per national guidelines and
vaccination against hepatitis B infection (using HBV
immunoglobulin 500Units IM plus 3 doses of hepatitis B vaccine at
0, 1 and 6 months.
Reduced number of sex partners: Reducing the number of sexual

partners can decrease the risk for STIs, including HIV. This must be
16 stressed during counselling and education.
Partner Management
Partner management means tracing all the sexual partners of
clients treated for STI and treating them as well. STI clients must be
told how important it is to have all their partners treated and how
they will risk getting re-infected if their partners are not treated.
In order to control STI, the health worker must:
• Treat the STI patient – also known as the index patient;
• Trace and treat the source of contact – the person who

originally infected the index patient;
• Know the period of infectiousness – the time when the
index patient was infected until treatment was successfully
completed; and
• Trace and treat any secondary sexual contacts – anyone that

the index patient has had sex with and possibly infected after
becoming infected until treatment was successfully
completed.
Index patients must be encouraged to notify their partner(s). The

patient may provide their partners with information or accompany
them to the clinic.
The following information is needed by the index patient to give to

the partner.
• How they have been exposed;

• Why they would need syndromic management;
• Where to get treatment; and
• Why they should avoid sexual contact until treated.
17
Partner management should be voluntary. Index patients should

receive all the treatment and counselling they need whether or not
they are willing to help trace partner(s). However, sometimes an
index patient will refuse to either trace their partner(s) or allow the
health worker to trace the partner(s). In this case, the health worker
may decide that the risk to the partner(s) and others (such as a
foetus) may be so great that it would be unethical not to inform the
partner(s). This decision should only be taken after the health
worker has spent some time counselling the index patient and
informing him/her of the need to break confidentiality.

Surveillance
Disease Surveillance is the systematic and regular collection of
information on the occurrence, distribution and trends of a
disease on an on-going basis with sufficient accuracy and
completeness to provide a basis for action (disease control).
STI surveillance:
• Assesses the magnitude of the STI burden at global, regional

& country levels;
• Identifies vulnerable population groups;
• Provides data to advocate for resources for intervention
activities; and
• Monitors the impact of these intervention activities.
In addition, the following components of STI surveillance systems

are required to provide effective management of STI patients:
• Studies on relative prevalence of responsible pathogens

18 for STI syndromes; and
• Antimicrobial resistance patterns of these pathogens.
STI surveillance data should actively be used to improve the

quality and effectiveness of STI and HIV prevention and other
sexual and reproductive health programmes. STI surveillance is
considered by WHO/UNAIDS to be a key component of second-
generation HIV and AIDS surveillance systems.
There are five components of STI surveillance that are necessary
for effective control programmes:
1. Case reporting: This is the routine systematic recording and
reporting of number of STI patients seen at health care
facilities and of the specific diseases or syndromes these
patients have. This reporting can be done at all health care
facilities using the Integrated Disease Surveillance and
Response (IDSR) monthly summary report form (Annex 2E of
Technical Guidelines for IDSR in Ghana) or the use of the
sentinel surveillance form attached to this document as
Appendix 1. Additionally monthly reports may be captured
using the attached reporting format (Appendix 2).
2. Prevalence assessment and monitoring;
3. Assessment of STI syndrome aetiologies;
4. Antimicrobial resistance monitoring; and
5. Special studies.
In summary, prevention and control of STIs are based on the

following principles:
• Education and counselling of persons at risk on ways to 19

avoid STIs through changes in sexual behaviours and use of
recommended prevention services;
• Identification of asymptomatically infected persons and of
symptomatic persons unlikely to seek diagnostic and
treatment services;
• Effective diagnosis, treatment, and counselling of infected
persons;
• Evaluation, treatment, and counselling of sex partners of
persons who are infected with an STI; and
• Pre-exposure vaccination of persons at risk for vaccine-
preventable STIs.
For additional information on counselling, refer to the National

Guidelines on HIV Testing and Counselling.

Chapter 3.0
History taking
and Physical Examination
H istory taking and examination is an essential component in

STI management. Taking the patient's history enables the
health worker to establish acquaintance and learn about the

patient's symptoms. It also helps the healthcare worker to identify
the possible partners who may have been infected. A complete
physical examination of the client enables the health worker make
the right diagnosis.
History
It is important to gain the patient's trust and confidence in order to
take an effective history for various reasons. Firstly, the questions
we need to ask are personal, so the patient may be unwilling to
answer or feel uncomfortable talking about sex. Secondly, (s)he
may withhold information in order to protect sexual partners.
Thirdly, the patient may be intimidated by a service provider who
may have a different socio-cultural background.
20
It is important to avoid judging clients about their behaviour or
imposing one's moral values on them. Assure clients that
whatever they say will be confidential.
To help put the patient at ease:

• Create a private and friendly environment;
• Greet the patient in a friendly manner;
• Make sure your body gives the same friendly,
relaxed message as your words;
• Use words that the client can understand and are
culturally acceptable;
• Ask the client's permission to bring up personal questions;
and
• Avoid dwelling on a sensitive subject if the patient is reluctant
to answer.
Questions to ask should relate to:
General Information
- Name
- Age/date of birth
- Occupation
- Marital status
- Contact Address
Present illness
Presenting complaints and duration
If genital ulcer - painful, recurrent; spontaneous onset?
If inguinal
swelling/bubo - painful, associated with genital ulcer?
If genital discharge
In Males - dysuria; frequency of micturition
In Females - type of discharge, colour, odour, amount;

dysuria; dysmenorrhoea; lower abdominal 21
pain; vaginal bleeding, irregular menses;
missed or delayed period;
oral contraceptive use and IUCD in-situ
Other symptoms
Medical History
Past STI - type; dates; treatment and response;
Other illness
Drug History
Past medications
Current medication
Drug allergies

Sexual History
Last sexual intercourse - when; with whom; use of
condom?
Type of sexual contact engaged in - oral, anal, vaginal, etc.
Previous sexual intercourse - when; with whom; use of
condom?
New partner in the last three months

Number of sexual partners
Partner(s) also symptomatic?
Social History
Drug and Alcohol use - type, frequency and amount
Physical Examination
Performing a physical examination of a patient is important because
it enables one to confirm the symptoms the patient has described
22 and, if possible, to check for signs of STI.
All physical examination must be conducted in the presence of a

chaperone.
In preparing patients for the examination:

- Privacy and confidentiality are essential
- Inform the patient about the importance of the
examination and what it entails.
- Avoid showing your own embarrassment or shyness
If enlarged lymph nodes are present, record their size,

consistency and number, and also whether they are painful.
Examining male patients:
1. Ask the patient to loosen his shirt or remove it
2. Ask him to sit on a chair, palpate the:

- anterior and posterior triangles of the neck
- submental and suboccipital areas
- axillae and epitrochlear regions
3. Ask the patient to stand up and lower his pants so that he is

stripped from the chest down to the knees. It may be possible
to examine him while he is standing up, though you will
sometimes find it easier if the patient lies down.
4. Look for rashes, swellings and ulcers by inspecting the skin of

the chest, back, thighs, abdomen, buttocks, groin and genitals.
5. Examine the pubic hair for nits and lice
6. Palpate the inguinal region in order to detect the presence or

absence of lymph nodes and buboes.
7. Palpate the scrotum, feeling for individual parts of the

anatomy: 23
- testis
- epididymis
- spermatic cord
8. Examine the penis, noting any rashes or sores.

Then ask the patient to retract the foreskin if present, and
look at the:
- glans penis
- coronal sulcus
- frenum
- urethral meatus
If you cannot see an obvious urethral discharge, the urethra
should be gently milked in order to express any discharge.
9. Inspect and examine the anus and peri-anal region noting any
evidence of pruritus, ulcers/sores, discharge and masses.

Examining female patients:
1. While the patient is seated on a chair examine her for enlarged

lymph nodes in the
- anterior and posterior triangles of the neck:
- the submental and suboccipital areas
- the axillae and epitrochlear regions

If these are present, record their size, consistency and number,
and also whether they are painful.
2. Ask the patient to remove her clothing from the chest down, and
then to lie on the couch. In order to save her embarrassment, use
a sheet to cover the parts of the body that you are not examining.
3. Look for rashes, swellings and ulcers by inspecting the skin of the
chest, back, abdomen, thighs, buttocks, groins and genitals.
4. Examine the pubic hair for nits and lice.
5. Ask the patient to bend her knees and separate them, then
examine the vulva and perineum.
6. Examine her for the presence of inguinal lymphadenopathy.

24
7. Palpate the abdomen for pelvic masses, taking great care not to
hurt the patient.
8. Record the presence or absence of

- rashes
- nits and lice
- lymphadenopathy
- buboes
- ulcers
- vaginal discharge, noting the type, colour, odour and
amount.
9. Conduct a bimanual pelvic examination if there is lower

abdominal pain.
10. Inspect and examine the anus and peri-anal region noting any
evidence of pruritus, ulcers/sores, discharge and masses.
Chapter 4.0
Urethral Discharge in Males
Definition
Urethral discharge is the presence of exudates in the anterior
urethral opening. This is often accompanied by dysuria or urethral
discomfort.
Public Health Importance

Urethral discharge is the most common presenting complaint of
men with STI. Untreated urethritis may lead to epididymo-orchitis
and other complications such as urethral stricture and infertility. It
also facilitates the transmission of HIV.
Aetiology
In men with a history of sexual exposure, urethral discharge usually
is caused by Neisseria gonorrhoea, Chlamydia trachomatis, and
Mycoplasma genitalum and rarely by other STI agents. For practical
purposes STI–related urethritis is sub-divided into gonococcal
urethritis, caused by N. gonorrhoea and non-gonococcal urethritis 25
(NGU), which is usually caused by C. trachomatis. Persistent or
recurrent symptoms of urethritis may be due to drug resistance,
poor compliance to treatment or re-infection. In some cases there
may be infection with Trichomonas vaginalis.
Non-infectious traumatic urethritis resulting from excessive

manipulation of the penis may be seen in some patients.
Occasionally the leakage of prostatic fluid may occur during
straining.
Gonococcal urethritis tends to produce more severe symptoms

and has a shorter incubation period (2-3 days) than NGU (1-3
weeks). Consequently, one may rely on the characteristics of the
urethral discharge to differentiate between the two. For example

gonorrhoea produces abundant and purulent discharge, whilst
that of NGU is scanty to moderate and white, mucoid or serous.
However, the quantity and appearance of the discharge can only
be used to accurately distinguish between gonococcal and non-
gonococcal urethritis in about 75-80% of the cases who have not
urinated within the previous two hours, but not the diagnosis of
dual infections with N. gonorrhoea and C.trachomatis.
Management
A careful history and genital examination should always be carried
out before applying the management algorithm or flowchart (see
Fig 1). In uncircumcised men it is important to check that the
discharge is coming from the urethral meatus and not from the
glans.
The choice of an effective treatment regimen is crucial. This

regimen must be effective for both gonococcal and non-
gonococcal urethritis.
26
Fig 1.Urethral Discharge In Males flowchart
Patient complains of
urethral discharge
Take a history and examine:

Milk urethra if necessary
No No • Counsel
Discharge Ulcer
confirmed? present • Offer HTC
• Promote and
provide condoms
Yes Yes • Educate

• Review if
symptoms persist
Treat for gonorrhoea, chlamydia Use
appropriate
27
and mycoplasma:
flow chart
• Counsel
• Offer HTC
• Provide and promote condoms
• Partner management
•Educate
• Return in 7 days

Urethral Discharge – Treatment Regimen
Treat for Gonorrhoea and Chlamydia
Gonorrhoea
IM Ceftriazone 250mg stat

Or
Tab Cefixime 400mg stat
Or
Tab Ciprofloxacin 500 mg stat
Plus
Chlamydia / Mycoplasma
Caps Doxycycline 100mg 12 hourly for 7 days

Or
Caps Tetracycline 500mg 6 hourly for 7 days
Or
Tab Erythromycin 500mg 6 hourly for 7 days
28 Or
Tab Azithromycin 1g stat
Chapter 5.0
Persistent/Recurrent Urethral Discharge
P ersistent or recurrent symptoms of urethritis may be due to
drug resistance, poor compliance or reinfection. In some cases
there may be infection with Trichomonasvaginalis(T. vaginalis ).
There is evidence suggesting high prevalence of T. vaginalis in men

with urethral discharge in some geographical settings. Where
symptoms persist or recur after adequate treatment for
gonorrhoea and chlamydia in the index patient and partner(s), the
patient should be treated for T. vaginalis after ruling out poor
compliance and/or reinfection. If symptoms still persist at follow
up, the patient must be referred.
29

Fig 2. Persistent Urethral Discharge In Males Flow Chart
persistent/ recurrent urethral discharge?
Take a history and examine:

Milk urethra if necessary
• Educate
• Counsel
Discharge No Any other No
• Promote and
confirmed? sign of STI? provide condoms
• Offer HCT
Yes
Yes
Use appropriate flow chart
Does history
confirm re-infection No Treat for Trichomonas Vaginalis
or poor • Counsel
compliance? • Offer HTC
30 • Partner management
Yes • Promote and provide condoms
• Educate
Repeat urethral discharge • Return if necessary
management
• Counsel
• Offer HTC
• Promote and provide condoms
• Educate
• Return if necessary
No
Improved? Refer
NB: This flowchart assumes that patient has had effective therapy for gonorrhoea and
chlamydia prior to this consultation.
Persistent Urethral Discharge Treatment Regimen
This regimen assumes that effective therapy for gonorrhoea and
chlamydia has been received and taken by the patient prior to
consultation
Trichomonas vaginalis
Tab Metronidazole 400mg b.d x 7 days

Or
Tab Metronidazole 2g stat.
Or
Tab Tinidazole 2g stat
Or
Tab Secnidazole 2g stat.
31

Chapter 6.0
Vaginal Discharge
Definition
STI-related vaginal discharges are abnormal in colour, odour
and/or amount. Vaginal discharge may be accompanied by

pruritus, genital swelling, dysuria, or lower abdominal / back pain.
Public health Importance

Although vaginal discharge is the most common gynaecological
complaint of sexually active women, not all vaginal discharges are
abnormal or indicative of an STI. Vaginal discharge may be
associated with a physiological state (menses or pregnancy), or
with the presence or use of foreign substances in the vagina.
Careful history taking should reveal whether a vaginal discharge
might be the result of chemical vaginitis, due to topical self-
medication, or repeated douching with abrasive substances.
Vaginal discharge caused by STI organisms may result in serious

32 complications such as pelvic inflammatory disease with sequelae
like infertility, ectopic pregnancy and an increased risk of HIV
infection.
Aetiology
Trichomonas vaginalis, Candida albicans*, and a combination of
Gardnerella vaginalis and other organisms cause vaginal discharge
directly, while Neisseria gonorrhoeae and Chlamydia trachomatis
do so indirectly via cervical and urethral discharge. Extensive first
episode herpes simplex virus infection also may cause visible
vaginal and vulval exudates.
NB: *Candida albicans: Although vulvo vaginal candidiasis usually is not transmitted
sexually, it is included in this section because it is frequently diagnosed in women
who have vaginal complaints or are being evaluated for STIs. In Ghana it is the
commonest cause of vaginal discharge
Management
A careful history and genital examination should be carried out
before applying the flowchart. During the history taking, risk
factors for gonorrhoea and chlamydia should be enquired about.
These include:
• Partner being symptomatic of an STI

• Having multiple and concurrent sexual partners
• Having new sexual partner(s) in the last 3 months.
Characteristics of the discharge cannot, in most instances, be used

to accurately identify the causative organism. Considerations for
selecting treatment include pregnancy status, patient discomfort,
and the most likely aetiology. Suspicion of gonococcal or
chlamydial aetiology warrants immediate treatment of the patient
and her partner(s).
Except in candidiasis and bacterial vaginosis, which are not

commonly sexually transmitted, the sexual partner(s) should be 33
included in the management of all cases.
The patient should however not be denied treatment if she is not

able to, or refuses to present the partner for treatment.

Fig 3. Vaginal Discharge Flowchart (without Speculum)
vaginal discharge,
vulval itching or burning?
Take history and examine

patient and assess risk
• Educate
Abnormal • Counsel
No Any other No
discharge or vulval • Promote and
genital provide
erythema? disease? condoms
• Offer HTC
Yes
Yes
Use appropriate flow chart for
additional treatment
34
Lower Risk Treat for bacterial

No No
abdominal assessment vaginosis,
tenderness? positive trichomoniasis
and candidiasis
Yes Yes
Use flow chart Treat for Chlamydia, • Counsel

for lower Gonorrhoea, • Offer HTC
abdominal pain Bacterial vaginosis, • Promote and
Trichomoniasis, provide condoms
and Candidiasis
• Partner
Management
• Educate
Fig 4. Vaginal Discharge Flow Chart
(with Speculum And Bimanual Examination)
Patient complains of vaginal discharge,

vulval itching or burning?

patient (external, bimanual and speculum)
and assess risk
Cervical muco-pus
or cervical erosions No Treat for Bacterial
OR vaginosis,
Was risk assessment trichomoniasis,
positive? and candidiasis
35
Yes
Treat for chlamydia,

gonorrhoea, • Counsel
bacterial vaginosis,
trichomoniasis, and • Offer HTC
candidiasis • Promote and provide
condoms
• Education
• Return in 7 days

Vaginal Discharge – Treatment Regimen
Treatment for vaginitis when the risk assessment is negative.
Trichomoniasis and Bacterial vaginosis

Tab Metronidazole 2g stat
Or
Tab Metronidazole 400mg 12 hourly for 7 days

Or
Tab Secnidazole 2g stat
Or
Tab Tinidazole 2g stat
NB: Metronidazole, Secnidazole and Tinidazole are

contraindicated during 1st trimester of pregnancy.
Clindamycin (2%) cream may be used instead in
pregnancy.
Plus
36 Candidiasis
Miconazole vaginal tablets 200mg at night for 3 days.
Or
Clotrimazole vaginal tablets or cream 200mg at night
for 3 days
A. If risk assessment positive, add the following treatment

for cervicitis:
Gonorrhoea
IM Ceftriazone 250mg stat.
Or
Or
Tab Ciprofloxacin 500mg stat.
Plus
Chlamydia
Or
Or
Or
Tab Azithromycin 2gm stat.
NB: Avoid Doxycycline, Tetracycline and Ciprofloxacin

in pregnant women and lactating mothers.
37

Chapter 7.0
Lower Abdominal Pain
Definition
Lower abdominal pain in women is often associated with Pelvic
Inflammatory Disease (PID). PID is used to denote suspected or

proven pelvic infections in women caused by micro-organisms
which generally ascend from the lower genital tract to invade the
endometrium, fallopian tubes, ovaries and peritoneum.

Sexually transmitted pelvic infections are a major cause of
infertility, ectopic pregnancy, and chronic lower abdominal pain.
PID is a common reason for admission to emergency rooms and
gynaecological wards. Complication, such as tubo-ovarian abscess
and ectopic pregnancy require major surgical procedures and may
cause death.
Aetiology
38 Common sexually transmitted pathogens which cause PID are N.
gonorrhoeae and C. trachomatis. Anaerobic bacteria are also
found frequently, especially in clinically severe and recurrent
infections.
Post-partum and post-abortion ascending infections, although

usually related to lack of hygiene and poor obstetric care, may
occasionally be associated with gonococcal and/or chlamydial
infections.
The presence of intrauterine contraceptive device (IUCD) favours

the development of PID, particularly in the month following
insertion.
Management
A careful history and examination should always be carried out.
Mild to severe lower abdominal pain may first be noticed during or
shortly after menses. When the pain is associated with fever and/or
symptoms like vaginal discharge, dysuria or urethral discomfort, it
should arouse suspicion. Similar previous episodes should be
asked about.
Objective assessment for the following should be done:

Lower abdominal tenderness
Vaginal discharge
Ulceration on the genitalia
Presence of IUCD
Open cervix, products of conception
Cervical excitation tenderness
Adnexal tenderness and /or masses on bimanual examination
Physical examination should exclude medical-surgical 39

emergencies such as:
Septic abortion
Intestinal obstruction
Ruptured bowel
Appendicitis
Ectopic pregnancy

Indications for hospital admission for women with acute PID
include:
Uncertain diagnosis
High fever and rigors with dehydration
Diffuse peritonism
Adnexal mass
HIV positive women with immuno-suppression if pelvic
abscess is suspected
Intravenous drug users if poor treatment compliance and
social circumstances
Intercurrent medical illnesses such as sickle cell disease and
insulin dependent diabetes mellitus.
40
Fig 5. Lower Abdominal Pain Flowchart
lower abdominal pain
Any of the
following
Any of the present?
following present? • Educate
• Lower
abdominal • Counsel
• Missed or overdue
period tenderness
and vaginal • Offer HTC
• Recent delivery/ discharge • Promote and
miscarriage/ abortion No No provide
• Cervical condoms
• Abdominal guarding excitation
and/or rebound tenderness
tenderness, Follow up if
• Recent pain persists
• Abdominal mass beyond 3
IUCD days
• Abnormal vaginal insertion
bleeding
Yes 41
Yes Treat for PID
• Counsel
Refer • Offer HTC
• Promote/provide
condom Partner
Follow up after
3 days or sooner
if pain persists
No
Improved? Refer
Yes
Continue Treatment

Lower Abdominal Pain Treatment (Out-Patients)
Plus
Tab Doxycycline 100mg 12 hourly x 14 days
Plus
Tab Metronidazole 400mg 12 hourly x 14 days

Or
Tab Ciprofloxacin 500mg 12 hourly x 3 days
Plus
Tab Doxycycline 100mg 12 hourly x 14 days
Plus
Lower Abdominal Pain Treatment (In-Patients)

IM Ceftriaxone 250mg daily x 3 days
Plus
42
Tab Doxycycline 100 12 hourly for 3 days
Plus
Then
Tab Doxycycline 100 12 hourly x 14 days
Plus
N.B: Remove IUCD three days after initiation of therapy.

Provide counselling on contraception and offer alternative
contraceptive.
Chapter 8.0
Genital Ulcer
Definition
Genital ulcer is loss of continuity of the skin of the genitalia. Genital
ulcers may be painful or painless and frequently are accompanied
by inguinal lymphadenopathy.

Genital ulcers may have serious consequences such as late
symptomatic syphilis, mutilating lesions and enhanced
transmission of HIV. Clinical manifestations and patterns for genital
ulcer disease may be altered by HIV infection.
Aetiology
Common STI pathogens producing genital ulcers are Human
Herpes (Herpes simplex), Treponema pallidum, Haemophilus
ducreyi and Calymmatobacterium granulomatis. Ulcers due to
trauma can become infected by bacteria.
43
Recent studies from Ghana indicate that 50% of Genital Ulcer
Disease (GUD) is due to Human Herpes Virus. Ulcers due to
herpes tend to be painful, multiple and have well-defined edges.
Vesicular lesions may be present. The infection is incurable and the
lesions recurrent. However, outbreak of vesicular lesions
diminishes over time.
The hallmark of primary syphilis is a primary genital or anal

chancre, which is classically single, painless, indurated with a clear
base and well-defined edges. However, syphilitic ulcers may be
multiple, painful non-indurated or have a purulent base.
Moreover, mixed infections, especially with chancroid are
frequent. A week after the onset of the primary lesion a discrete,
firm, painless, inguinal lymphadenopathy appears.

The primary lesion usually heals within six weeks, without usually
leaving a scar.
The onset of granuloma inguinale is insidious with a small papule

that eventually erodes and progresses into an enlarging
granulomatous ulcer that is indurated and beefy red. The lesions
bleed easily with trauma and are usually painless. The edges are
well defined. Lesions occur most frequently on the genitals but in
half of the cases they extend to the inguinal region. Lesions of the
inguinal area ('pseudobuboes') usually involve only the skin and
subcutaneous tissue, but not lymph nodes. Healing is not
spontaneous and is accompanied by extensive scarring.
Ulcers due to chancroid are painful and have undermined ragged

edges. The base is covered with a purulent exudate and easily
bleeds to touch. Several ulcers may coalesce to form
serpentiginous lesions. Lymphadenopathy is usually unilateral and
may become fluctuant.
Management
44 Syndromic management is recommended because of the poor
specificity of above clinical features and also due to mixed
infections. A careful history and examination should be carried out
before applying the flowchart. Gloves should always be worn for
palpation.
Fig 6. Genital Ulcer Flow Chart
genital sore or ulcer
• Educate and
No No counsel
Only vesicle Sore or ulcer
present? • Promote and
present? provide condoms
• Offer HTC
Yes Yes
Treat for syphilis Treat for syphilis and

chancroid
Treat for HSV - 2 Treat for HSV - 2
·Educate and counsel on risk reduction

·Promote and provide condoms
45
·Offer HTC
·Review in 7 days
Ulcer(s) No Ulcer(s) No
Refer
healed? improving?
Yes Yes
·Educate and counsel

on risk reduction Continue
·Promote and provide treatment for a
condoms further 7 days
·Offer HTC
·Manage and treat
partner

Genital Ulcer Treatment Regimen
Herpes simplex
Tab Acyclovir 200mg 5 x /day x 7- 10 days
Or
Tab Acyclovir 400mg 8hourly x 7 days
For HIV co- infected:

Tab Acyclovir 400mg tid for 7-10 days
Or
Tab Acyclovir 800mg bid for 7 – 10 days
Episodic therapy for recurrent episodes:

Tab Acyclovir 400mg tid for 5days
Or
Tab Acyclovir 800mg bid for 5 days
Or
Tab Acyclovir 800 mgs tid for 2 days
Suppressive therapy in HIV co-infected:

46 Tab Acyclovir 400-800mg bid or tid for 2 to 6 years
General Measures Keep lesions dry and clean, acyclovir

cream or Gentian violet paint may be
applied topically over the lesions.
Give analgesics to relieve pain if necessary.
Plus
Syphilis
Benzathine Penicillin G 2.4 million units in 2
intramuscular injections during one clinic visit;
give one injection in each buttock.
Or
Aqueous Procaine Penicillin 1.2 million units daily, by
deep intramuscular injection for 10 days
For persons allergic to penicillin:

Caps Doxycycline 100 mg 12 hourly for 14 days
Or
Tetracycline 500 mg 6 hourly for 14 days
For pregnant women with Penicillin allergy:

Tab Erythromycin 500mg 4 times a day for 14 days
Or
Tab Azithromycin 500mg daily for 10 days
NB: Mothers treated with erythromycin or azythromycin may be

considered for re-treatment with doxycycline after delivery
and when breastfeeding is stopped. 47
Plus
Chancroid
IM Ceftriazone 250mg stat.
Or
Cap Azithromycin 1g stat
Or
Tab Ciprofloxacin 500mg b.d x 3days
Or
Tab Erythromycin 500mg 6 hourly for 7 days.

Chapter 9.0
Scrotal Swelling
Definition
Scrotal swelling can be caused by trauma, a tumour, torsion of the
testis or inflammation of the epididymis (epididymitis).

Epididymitis is usually accompanied by pain, oedema and
erythema and sometimes by urethral discharge, dysuria, and/or
frequency of micturition. The adjacent testis may often be
involved resulting in epididymo-orchitis.

When not effectively treated, STI –related epididymo-orchitis may
lead to infertility.
Sudden onset of unilateral swollen scrotum may be due to trauma

or testicular torsion and requires immediate referral.
Aetiology
48 Causative sexually transmitted agents are C. trachomatis, N.
gonorrhoea, and very rarely Treponema pallidum.
Mycobacterium tuberculosis is a relatively common cause in some
developing countries, while Gram-negative bacilli, especially of
the family Enterobacteriaceae, and Pseudomonas aeruginosa are
common causes in older men with complicated urinary tract
infections. Mumps virus is a causal agent in post-pubertal males.
Management
A careful history and examination should be carried out before
applying the flowchart.
The patient presents with an acute onset of a painful swollen

scrotum, which is almost always unilateral. In STI–related
epididymo-orchitis, there is often either a recent history of urethral
discharge or such a discharge can be seen on physical
examination. Sudden onset or a history of trauma or of recurrent
urinary tract infection may help to identify non-STI–related
causes.
On examination, epididymo-orchitis is usually unilateral. The

scrotum may appear red and oedematous, and tender on
palpation. Evidence of urethral discharge should be sought.
The most important concern is either to rule out surgical

emergencies or, if present, to refer them immediately. Sudden
onset and rapid progression of unilateral scrotal swelling in a young
patient may be indicative of testicular torsion requiring specialized
care.
General measures: Pain relief, bed rest and scrotal support

must be provided until inflammation and
fever subsides.
49

Fig 7. Scrotal Swelling Flowchart
scrotal swelling/pain
• ?Reassure patient/educate
• ?Promote and provide
Swelling /pain No condoms
confirmed? • ?Offer HTC
• ?Provide analgesics if
Yes necessary
Testis rotated or Treat gonorrhoea and chlamydia

No
elevated or history • Counsel
of trauma? • Offer HTC
• Promote and provide condoms
50 • Partner management
Yes • Educate
• Review in 7 days; if worse refer
Refer immediately
Scrotal Swelling – Treatment Regimen
Treat for gonorrhoea and chlamydia
Gonorrhoea
IM Ceftriaxone 250mg stat
Or
Tab Cefixime400mg stat
Or
Tab Ciprofloxacin 500mg stat
Plus
Chlamydia
Tab Doxycycline 100mg 12 hourly for 7 days
Or
Or
Cap Azithromycin 1g stat 51
Or
General measures : • Pain relief

• Bed rest
• Scrotal support

Chapter 10.0
Inguinal Bubo
Definition
Inguinal and femoral buboes are localized enlargement of lymph
nodes in the groin area, which are painful and may be fluctuant.

Buboes are important because inadequate treatment can lead to
rupture with chronic fistulae formation and scarring. They may
occur with ano-rectal bleeding and clinical manifestation of
proctocolitis in patients who practice anal sex
Aetiology
Sexually transmitted inguinal buboes are mainly a manifestation of
Lymphogranuloma venereum caused by C. trachomatis serovars
L1 – L3. In the presence of a genital ulcer however buboes may be
due to chancroid.
52 Non-sexually transmitted local or systemic infections (e.g.

infections of the lower limb) can also cause inguinal adenopathy.
Management
applying the flowchart.
Most patients complain of pain and swelling in the groin although

buboes can be painless. It is important to find out how long the
problem has been there and whether there was preceding genital
ulceration.
Buboes can be unilateral or bilateral. Palpation may reveal pain or

fluctuation. In uncircumcised males, the prepuce should be
retracted to look for ulcers.
Where genital ulcers are present, the genital ulcer flowchart
should be used.
Fluctuant buboes must be aspirated through adjacent healthy skin.

Incision and drainage should NOT be attempted. If buboes persist,
the patient should be referred.
In principle, the same treatment should be offered to sexual

partners.
Fig 8. Inguinal Bubo Flowchart
inguinal swelling

Reassure
·
Educate
·
Any other No and counsel
Inguinal/femoral No sign of STI Promote
·
buboes present? present? and provide
53
condoms
Offer HTC
·
Yes
Yes
Use appropriate flow chart
Treat for lymphogranuloma venereum

Ulcer(s) No and chancroid
present?
• Educate on drug compliance
• Counsel on risk reduction
Yes • Promote and provide condoms
• Offer HTC
Use genital ulcer • Advise to return in 7 days and continue
flow chart treatment if improving and refer if worse

Inguinal Bubo-Treatment Regimen
Treat for Lymphogranuloma venereum (LGV) and Chancroid
Caps Doxycycline 100mg 12 hourly x 21 days

Or

Or
Tab Erythromycin 500mg 6 hourly 14 days
If a bubo becomes fluctuant, pus should be aspirated with a wide

bore needle and syringe every second or third day through
adjacent healthy skin. Incision and drainage must not be
attempted.
Urethral strictures, ano-rectal and recto-vaginal fistula may require

surgery.
54
Chapter 11.0
Ano-rectal Related Syndromes
Definition
Ano-rectal syndromes are characterized by anal ulcers, growths
and discharge often accompanied with itchiness, rectal pain,
bleeding, tenesmus, and constipation. The infection and
inflammation of the anorectal area is known as proctitis.
Public health importance

When not treated anal ulcers and discharge may lead to fistulae
such as recto-vaginal fistulae in females as well as strictures.
Aetiology
Common STI pathogens are C. trachomatis, HSV-2, N.
gonorrhoea, and T. pallidum. Undiagnosed N. gonorrhoeae and C.
trachomatis infections can pose a potential risk for HIV
transmission. Failure to diagnose and treat these infections may
result in serious complications, as well as increase the risk for HIV
infection. In addition Lymphogranuloma venereum caused by C. 55
trachomatis (serovars L1, L2, and L3) and other intestinal
pathogens may cause gastrointestinal symptoms also referred to as
proctocolitis that present with mucoid and/or hemorrhagic
diarrhoea, constipation, abdominal and rectal pain. T. pallidum
and HSV are the most common sexually transmitted pathogens
involved. In clients co-infected with HIV, Herpes proctitis can be
severe. It is common in persons who participate in receptive anal
sex and is associated with HIV infection.
Management
applying the flow-chart. History should include last and previous
anal sexual intercourse. Clients who admit to having anal
intercourse in the past six months and/or who report anal

symptoms, should undergo an anorectal examination.
Visual inspection of the peri-anal area may show evidence of

pruritus, ulcers/blisters, discharge, growths and bleeding. A digital
anal examination can then be conducted to assess the rectal area
for tenderness, discharge, bleeding and any masses. If the client is
able to tolerate the digital examination without much pain,

protoscopy may be introduced to further inspect the rectum
especially for any masses that may have been felt on palpation.
If anal ulcers are found, clients should be offered treatment for

HSV-2, syphilis, chlamydia and gonorrhoea. For anal discharge
accompanied with pain, treatment for HSV-2 must be offered. If
no pain is present, then chlamydia, syphilis and gonorrhoea
should be considered as the potential causes and appropriate
treatment offered.
Patients who do not respond to treatment for STI-related proctitis

and proctocolitis should be referred for further investigations and
possible surgery.
56
Fig 9: Anorectal Infections Flow Chart
Patient presents with history of

receptive anal sex in past 6 months
and/or anal symptoms
Take further history including

risk assessment and examine
• Risk Assessment
No Ano-rectal No
Ano-rectal (Unprotected sex with
ulcer ulcer
and/or pain partner with STI,
present?
present? multiple sexual
partners)
Yes
Yes • Counsel on risk
reduction
Treat for Treat for HS-V 2, • Offer HTC
N. Gonorrhoea, N. Gonorrhoea, • Provide condoms
C. Trachomatis C. Trachomatis and lubricant
and Syphilis and Syphilis
57
• Educate
• Return if any
symptoms occur
• Counsel on risk reduction

• Offer HTC
• Provide condoms and appropriate lubricant
• Educate and
• Return in 7 days; refer if necessary

A. Ano-rectal Discharge
Gonorrhoea
Or
Tab Cefixime 400 mg stat
Or
Plus
Chlamydia
Or
Or
Or
58
B. Ano-rectal Ulcers/Vesicles
For first episode of vesicular lesions treat for Herpes Simplex

Tab Acyclovir 200mg 5x/day for 7 days
Or
Tab Acyclovir 400mg 8 hourly for 7days
For recurrent vesicular lesions episodic treatment of Herpes

Simplex
Treatment should start on first day of appearance of lesions

Tab Acyclovir 400mg 8 hourly for 5 days
Or
Or
General Measure: Keep lesions dry and clean.

Acyclovir cream 2% to be applied.
Mercurochrome or Gentian violet may be
used to paint lesions in the absence of
59
Acyclovir cream.
Plus
Syphilis
Benzathine Penicillin G 2. 4 million units in 2
intramuscular injections during one clinic visit;
give one injection in each buttock
Or
Aqueous Procaine Penicillin 1.
2 million units daily, by
deep intramuscular injection for10 days
For persons allergic to penicillin use:

Cap Doxycycline 100mg 12 hourly for 14 days
Or

Cap Tetracycline 500mg 6 hourly for 14 days
Or
Tab Erythromycin500mg6hourly for14 days
Plus
Chlamydia
Caps Doxycycline 100mg 12 hourly for 7days
Or
Caps Tetracycline 500mg 6 hourly for 7days
Or
NB: Avoid Doxycycline/Tetracycline in pregnancy and

nursing mothers.
Plus
Chancroid
60 IM Ceftriazone 250mg stat.
Or
Or
Tab Ciprofloxacin 500mg b.d x 3days
Or
Chapter 12.0
Genital Warts
Definition
Genital warts are flat papular or pedunculated growths on the skin
and mucus membranes of the genitals, and may be found on the
penis, vulva, urethra, vagina, cervix, and the peri-anal region.

Genital warts are painless and do not lead to serious
complications, except where they may cause obstruction.
Aetiology
Human papilloma virus (HPV) is the causative agent for genital
warts and is sexually transmitted. HPV infection spreads from one
person to another through sexual contact involving the penis,
anus, mouth, or vagina. Genital warts can spread even when not
visible to the naked eye. Some types of HPV have been found to
cause cancer of the cervix and vulva, and is the main cause of
61
cervical cancer. HIV infection increases chances of acquiring and
transmitting HPV.
Not everyone who has come into contact with the HPV and genital
warts will develop them. Sexual partners should be examined for
evidence of warts. Patients with ano-genital warts should be made
aware that they are contagious to sexual partners.Genital warts
may also occur with genital itching, increased vaginal discharge
and vaginal and/or anal bleeding during or after sex.
Management
A careful history and examination should always be carried out

Genital Warts -Treatment Regimen
Chemical treatment
Apply Podophyllin 10–25% in compound tincture of
benzoin carefully to the warts avoiding normal tissue.
Protect normal skin with Vaseline(paraffin).External

genital and perianal warts should be washed thoroughly 1
to 4 hours after application of Podophyllin.Treatment
should be repeated at weekly intervals.
Or
Trichloroacetic acid(TCA)(80- 90%) applied carefully to
the warts avoiding normal tissue, followed by powdering
of the treated area with Talcum powder to remove
unreacted acid. Treatment should be repeated at weekly
intervals.
Or
Podophyllotoxin 0.5% applied twice a day, three times a
week for four weeks.
Or
Imiquimod 5% cream applied three times a week for 16
62 weeks. Should be washed 6 to 10 hours after application.
NB: Do not use Podophyllin and TCA during pregnancy

and lactation.
Physical treatment
Cryotherapy with liquid nitrogen,solid carbon dioxide,
or a cryoprobe. Repeat applications every1-2weeks.
Or
Electrosurgery
Or
Surgical removal
NB: For cervical and meatal warts cryotherapy should be used.

Do not use Podophyllin or TCA.
Prevention
The use of condoms is recommended to help reduce sexual
transmission.
Certain specific types of the HPV(HPV types 16 & 18) may cause
invasive cervical carcinoma. Regular Pap smears are
recommended for women who have had genital warts, or have a
sexual partner with genital warts or have multiple sexual partners.
Women with cervical warts need to have Pap smears every 3 to 6
months after the first treatment.
Young women and girls (9 – 26 years) should be vaccinated against

HPV where feasible and accessible, even if they already have
genital warts.
63

Chapter 13.0
Scabies
Definition
Scabies is an intense allergic itchy contagious skin infection.
Public health importance

Scabies is common all over the world and it affects people of all
races and social classes. Scabies spreads quickly in crowded
unhygienic living conditions where there is frequent skin-to-skin
contact between people.
Crusted scabies, formerly known as Norwegian scabies, is a more

severe form of the infection often associated with immune-
suppression.
Aetiology
Scabies is caused by the mite Sarcoptes scabiei which burrows
under the host's skin, causing the intense allergic itching which is
64 worse at night. The disease may be transmitted from objects but is
most often transmitted by direct skin-to-skin contact, with a higher
risk with prolonged contact.
Management
Scabies -Treatment Regimen.

Apply Benzyl benzoate 25% lotion to entire body from neck
down to the feet for two or three consecutive nights. Avoid
applying lotion on the face.
Patients may bathe before reapplying the drug and 24 hours
after final application.
Close contacts (sexual and household) of the index patient
should be examined and treated as above.
Clothing or bed linen used within two days of treatment
should be washed and well dried or dry-cleaned.
Alternative treatment for scabies:

Apply 0.5% Malathion lotion to the whole body and
wash after 12 hours.
Or
Apply 5% Permethrin lotion to the whole body and
wash after 12 hours.
65

Chapter 14.0
Pediculosis Pubis (Pubic Lice)
Definition
Pediculosis pubis or pubic lice is a parasitic infestation found
primarily in the pubic or genital area of humans.

Pediculosis Pubis is common all over the world and it affects
people of all races and social classes. They are blood-sucking
nuisances and a cause of social embarrassment
Aetiology
Pediculosis Pubis is caused by the pubic louse, Phthirus pubis. It is
usually transmitted from person to person during close bodily or
sexual contact.
The spread of pubic lice via infested bedding and toilet seats can
occur, but is not common because pubic lice die within a few
66
hours once they are off a human host. In children, pubic lice may
be found in the eyebrows or eyelashes and can be a sign of sexual
abuse. However, children can sometimes catch pubic lice from
heavily infested parents simply by sharing a communal bed.
Management
Pediculosis Pubis - Treatment Regimen
Apply any of the following to all hairy areas except the scalp but
including the beard and moustache:
• 0.5% Malathion
Or
• 0.5% Carbaryl,
Or
• 1% Permethrin cream rinse
Or
• 0.2% Phenothrin
Wash off the applications after 24hours.
The recommended regimens should not be applied to the eyes.

Patients with pediculosis pubis should be evaluated for other STIs.
67

Chapter 15.0
In Children
Neonates, pre-pubertal and pubertal children are also at risk of
contracting STIs. The modes of transmission for these children are
mostly through:
1. Maternal infections;
2. Sexual abuse or exploitation; and
3. Voluntary sexual activity in older children.
The STIs that neonates, pre-pubertal and pubertal children are at

risk for include:
1. Neonatal Conjuctivitis (OphthalmiaNeonatorum)
2. Urethral discharge syndrome
3. Vaginal discharge syndromes
68 4. Lower abdominal pain syndrome

5. Genital ulcer syndromes
6. Ano-rectal related syndrome
7. Genital warts
8. Scabies and Pubic lice
Some of these STIs (e.g., gonorrhea, syphilis, and chlamydia), if

acquired after the neonatal period, are indicative of sexual
contact. For other STIs, (e.g., HPV infections and vaginitis), the
association with sexual contact is not clear.
A . Neonatal Conjunctivitis
(Opthalmia Neonatorum)
Definition
Ophthalmia Neonatorum is defined as acute purulent
conjunctivitis of the newborn in the first month of life, usually
contracted during birth from infectious genital secretions of the
mother.

Ophthalmia Neonatorum can lead to blindness, especially when
caused by N. gonorrhoea.
Aetiology
The most important sexually transmitted pathogens, which cause
ophthalmia neonatorum, are N. gonorrhoea and C.trachomatis.
The relative frequency of infections with the two agents depends
on their prevalence in pregnant women and on the use of eye
prophylaxis, which is effective against N. gonorrhoea but often not
against C. trachomatis. 69
If the mother is infected at the time of vaginal delivery, the risk of

transmission to the eyes of the neonate is between 30% and 75%
for both N. gonorrhoea and C. trachomatis.
Management
A careful history and examination must be done before applying
the flow chart.
Examination may show:

- Discharge, which may be purulent
- Redness and swelling of the conjunctivae,
- Oedema and redness of the eyelids.

All ophthalmia neonatorum should be managed as gonococcal
and chlamydial infection to prevent eye damage. The mother and
sexual partners should be treated for gonorrhoea and chlamydia
infection.
The mother's partner(s) should always be treated for urethritis, and

the genitals examined for discharge or other STI syndromes.
Prophylaxis of Ophthalmia Neonatorum

A policy of neonatal eye prophylaxis should be implemented and
include the cleaning of the eyes immediately after birth plus
application of 1% tetracycline ointment into the eyes.
70
Fig 10. Neonatal Conjunctivitis Flowchart
Neonate with eye discharge
Take history from mother

and examine
Bilateral or unilateral Reassure mother

·
No
swollen eyelids with Advise to return if
·
purulent discharge necessary
Yes
Treat gonorrhoea and

chlamydia in child, mother
and partner(s)
71
• Educate and counsel mother
• Offer HTC
• Advise to return in 3 days
No
Improved? Refer
Yes
• Continue treatment until

completed
• Reassure mother

Neonatal Conjunctivitis - Treatment Regimen
Treat baby for gonorrhoea and chlamydia
Gonorrhoea
Injection Ceftriazone 50mg/kg body weight (maximum
125mg) stat
Or
IM Cefotaxime 100mg/kg body weight stat.
Chlamydia
Syrup Erythromycin 50mg/kg body weight/day orally in 4
divided doses for 14 days
If no improvement after treatment, return.
A. Treat mother for gonorrhoea and chlamydia
Gonorrhoea
72 I.M. Ceftriazone 250mg stat
Plus
Chlamydia
B. Treat partner(s) for gonorrhoea and chlamydia
Gonorrhoea
IM Ceftriazone 250mg stat
Or
Or
Tab Ciprofloxacin 500mg stat
Plus
Chlamydia
Or
Cap Tetracycline 500mg 6 hourly for 7 days
Or
Or
Tab Azithromycin 1gm stat.
73

B. Management of specific STI
and STI Sydromes in Children
Management Of Urethral Discharge Syndrome In

Children
A careful history and examination should be carried out. Use the

same flow chart (Figure 1.) as for adults to decide which treatment
to give.
Gonorrhea
i. Child < 12 years (or child < 45 kg)
ii. Child >12 years(or child >45 kg)

Or:
Plus
74 Chlamydia
i. Child < 12 years
Oral Erythromycin 50 mg/kg body weight/day orally in 4
divided doses daily for 14 days
ii. Child >12 years

Azithromycin 1g orally in a single dose
Or
Doxycycline 100 mg orally bd x 7 days
Or
Erythromycin 500 mg orally qds x 7 days
Management of Vaginal Discharge Syndrome
in Children
A careful history and examination should be carried out. Use the
Vaginal Discharge Flow Chart (without speculum) (Figure 3.) as for
adults to decide which treatment to give.
Vaginitis (Trichomoniasis and Bacterial vaginosis)

i. Child < 12 years(child < 45 kg)
Oral Metronidazole 7.5mg/kg body weight 12 hourly for
7days
ii. Child >12 years

Tab. Metronidazole 400mg bd for 7days
Or
Tab Metronidazole 2g stat
Plus
Candidiasis
Clotrimazole cream 2% topical application 2-3 times
daily for 7days
Or
75
Oral Fluconazole 3-6mg/kg body weight stat
NB: Intravaginal treatment is not recommended for younger

girl;.oral treatment may be more appropriate.
General measures: a. Good genital hygiene

b. Use lose underwear
c. Cotton underwear
d. Dry underwear in the sun or iron with
hot plate iron
e. Ensure good peri-anal hygiene
f. Avoid douching-herbal or chemical
g. Avoid medicated soaps

For cervicitis add the following treatment:
Gonorrhea

Or
Plus
Chlamydia
i. Child < 12 years
ii. Child >12 years

Or
76 Doxycycline 100 mg orally bd x 7 days
Or
Management of Lower Abdominal Pain (PID)
Syndrome in Children
It is important to take a detailed history from children and their

guardians/parents where there is complaint of lower abdominal
pains. This should be followed by careful examination before using
the same flow chart (Figure 5.) as for adults to decide which
treatment to give. All children presenting with suspected case of
PID must be admitted to hospital for inpatient management.
i. Child < 12 years(child < 45 kg)

Plus
Plus
Oral Metronidazole 7.5mg/kg body weight 12 hourly for
14 days
ii. Child >12 years

IM Ceftriaxone 250mg stat 77
Plus
Tab. Doxycycline 100mg bd for 14 days
Plus
Tab. Metronidazole 400mg bd for 14 days

Management of Genital Ulcer Syndrome in Children
Syphilis
i. Child <12 years
IV Benzyl penicillin sodium 200,000 to 300,000
mg/kg body weight/day (to be given as 50,000
units/kg every 4-6 hours) for 10 days

Or
IM Procaine penicillin G 50,000iu/kg body weight
daily in a single dose x 10.
(Maximum daily dose of 750,000 units).
ii. Child >12 years

intramuscular injections during one clinic visit; give
one injection in each buttock
Or
Aqueous Procaine Penicillin 1.2 million units daily,
by deep intramuscular injection for 10 days
Or
78 IV Benzyl penicillin sodium 200,000 to 300,000
units/kg body weight/day (given as 50,000units/kg
every 4-6 hours) for 10 days.

Or
Plus
Chancroid
i. Child <12 years ( <45 kg)
Or
Oral Erythromycin 50 mg/kg body weight/day in
4 divided doses daily for 7 days
ii. Child >12 years

Or
Or
Cap Doxycycline 100 mg bd for 7 days
Or
Tab Erythromycin 500 mg qds for 7 days
Plus
Genital herpes simplex 79

i. Child < 2 years
Oral Acyclovir 100mg five times a day for 5 days
NB: The recommended regimen for infants treated for known or

suspected neonatal herpes is acyclovir 20 mg/kg IV every 8
hours for 21 days for disseminated and CNS disease or for
14 days for disease limited to the skin and mucous
membranes.
ii. Child >2 years


Management of Ano-Rectal Related Syndromes
in Children
A. Ano-rectal Discharge
Gonorrhea

Or
Plus
Chlamydia
i. Child < 12 years
80
ii. Child >12 years
Or
Doxycycline 100 mg orally bd x 7 days
Or
B. Ano-rectal Ulcers/Vesicles
Syphilis
Child <12 years
IV Benzyl penicillin sodium 200,000 to 300,000 mg/kg
body weight/day (to be given as 50,000 units/kg every
4-6 hours) for 10 days
Or
IM Procaine penicillin G 50,000iu/kg body weight daily
in a single dose x 10.
(Maximum daily dose of 750,000 units).
i. Child >12 years

intramuscular injections during one clinic visit; give one
injection in each buttock
Or
Aqueous Procaine Penicillin 1.2 million units daily, by
deep intramuscular injection for 10 days
Or
IV Benzyl penicillin sodium 200,000 to 300,000 units/kg 81
body weight/day (given as 50,000units/kg every 4-6
hours) for 10 days.

Or
Plus
Chancroid
i. Child <12 years ( <45 kg)
Or
Oral Erythromycin 50 mg/kg body weight/day in 4
ii. Child >12 years
Or
Or
Cap Doxycycline 100 mg bd for 7 days
Or
Tab Erythromycin 500 mg qds for 7 days
Plus
Genital Herpes Simplex

i. Child < 2 years
NB: The recommended regimen for infants treated for known

or suspected neonatal herpes is acyclovir 20 mg/kg IV
every 8 hours for 21 days for disseminated and CNS
disease or for14 days for disease limited to the skin
and mucous membranes.
82
ii. Child >2 years
Management of Genital Warts in Children
The treatments available for use in children are:

1. Cryotherapy with or without Local topical anaesthestic agent
2. Excision/electro surgery under general anaesthesia if the

above fails.
NB: Podophyllotoxin and Imiquimod are however not

used in children.
Management of Scabies and Pubic Lice in Children
Scabies
Permethrin 5% dermal cream
Apply over whole body [including face, neck, scalp and
ears in children aged >2 years]; wash off after 8-12 hours.
Do not use more than once a week for three consecutive
weeks.
83
NB: Medical supervision of treatment required in
children aged two months to two years
Or
Malathion liquid 0.5% in aqueous base.

Apply over whole body [including face, neck, scalp and
ears in children aged >2 years]; wash off after 24 hours.
Do not use more than once per week for three
consecutive weeks.
NB: Medical supervision of treatment required in children aged

less than six months.

Pubic Lice
Malathion liquid 0.5% in aqueous base
Apply over whole body and allow to dry naturally.
Wash off after 12 hours or overnight.
Repeat after 1 week.
84
One
Ghana Health Service/Ministry of Health
STI Sentinel Surveillance Report Form
Appendix
Region District
OPD No. Health Facility
Date seen
Age: Age month year Sex: Male Female
Occupation
Marital Status: (Single/Married/Divorce/Widowed/Separated)
STI Syndromes
Tick in the appropriate box
Genital Ulcer Vesicular Yes No
Genital Ulcer Non-Vesicular Yes No

85
Urethra l Discharge Yes No
Vaginal Discharge Yes No

- Vaginitis Yes No
- Cervicitis Yes No
Scrotal Swelling Yes No
Lower Abdominal Pain/PID Yes No
Inguinal bubo Yes No
Neonatal Conjunctivitis Yes No

Ano -rectal Syndrome (Specify) Yes No
Others (specify)

Contact Yes No
Any sexual contact within the past 4 weeks Yes No
No. of sexual partners made within past weeks Yes No
Type of sexual contacts made: Husband Wife

Boyfriend Girlfriend
Casual Friend Sex Worker
Others (specify)
Name of Clinician/HCW: Signature:
86
Two
GHS/MOH Sexually Transmitted Infections (STI)
Quarterly Reporting Format
Appendix
Region District
Name of HCW Reporting Health Facility
Date (DD/MM/YYYY)
Number of cases per month/quarter

Syndromes Adult and
Adolescents Children<13years Total
Vaginal Discharge
Male Urethral Discharge
Female Genital Ulcer
Male Genital Ulcer
Scrotal Swelling 87
Lower Abdominal Pain/PID
Inguinal Bubo
Genital warts
Scabies
Pediculosis Pubis (Pubic lice)
Ano-rectal syndromes
Neonatal conjunctivitis NA*
NB: These are to be reported as part of Disease Surveillance data monthly

or quarterly
*Not Applicable

References
1. WHO Training Modules for the Syndromic Management
of Sexually Transmitted Infections,
2007.http://www.who.int/reproductivehealth/publicatio
ns/rtis/9789241593407/en/index.html
2. BASHH Guidelines on Management of Sexually

Transmitted Infections in Adults and Children, 2013.
3. Ghana National Standard Treatment Guidelines (MOH)

Sixth Edition, 2010
4. Expanded Program on Immunization website, Ministry

of Health, Ghana.
http://www.ghanahealthservice.org/epi.php
88
5. Sexually Transmitted Infections, Guidelines for
Treatment, 2008 (NACP/GHS).
6. CDC Mortality and Morbidity Weekly Report:

Guidelines for the Treatment of Sexually Transmitted
Infections,
2010.http://www.cdc.gov/std/treatment/2010.
7. Technical guidelines for Integrated Disease Surveillance

Response in Ghana. GHS/MOH, Second Edition,
May, 2011

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SEXUALLY TRANSMITTED

The Republic of Ghana

Guidelines for Management

National AIDS/STI Control Programme

GUIDELINES FOR MANAGEMENT

National AIDS/STI Control Programme

2.0 Prevention of Sexually Transmitted Infections 14 - 19

3.0 History Taking and Physical Examination 20 - 24

2 4.0 Urethral Discharge in Males 25 - 28

5.0 Persistent/ Recurrent Urethral Discharge 29 - 31

6.0 Vaginal Discharge 32 - 37

8.0 Genital Ulcer 43 - 47

9.0 Scrotal Swelling 48 - 51

11.0 Ano-rectal Related Syndromes 55 - 58

Guidelines For Management

14.0 Pediculosis Pubis (Pubic Lice) 66 - 67

15.0 Sexually Transmitted Infections in Children 68

B. Management of specific STI & STI syndromes in children 74 - 84

2. Persistent Urethral Discharge In Males Flow Chart 30 5

3. Vaginal Discharge Flowchart (without Speculum) 34

4. Vaginal Discharge Flow Chart

5. Lower Abdominal Pain Flowchart 41

6. Genital Ulcer Flow Chart 45

7. Scrotal Swelling Flowchart 50

8. Inguinal Bubo Flowchart 53

9: Anorectal Infections Flow Chart 57

10. Neonatal Conjunctivitis Flowchart 71

Guidelines For Management

CHAG Christian Health Association of Ghana

Comprehensive management of STIs is important and comprises

In March 1993 the National AIDS/STI Control Programme (NACP) 7

This edition incorporates new developments and recommendations

Guidelines For Management

It is expected that these guidelines will be adapted to develop

(HCWs). To enhance the use of these guidelines, specific

The support of the President’s Emergency Plan for AIDS Relief

Dr. Ebenezer Appiah-Denkyerah

Dr. Ronald Sowa

Dr. Thomas Agyarko-Poku

Dr. Afua Asabea Amoabeng Nti

Dr. Anthony Ashinyo

Dr. Kimberly Green

Mrs. Nana Fosua Clement

Guidelines For Management

Dr. Henry Narh Nagai

Ms. Caroline Adonadaga

Ms. Winifred N. O. Armah-Attoh

Mrs. Angelina Kodua Nyanor

Dr. Stephen Ayisi Addo

Dr. Bernard Tei Dornoo

Dr. Nii Akwei Addo

Dr. Nii Akwei Addo

Due to their frequency of occurrence and potential for morbidity,

• Interrupting the transmission of sexually acquired infections;

These goals can be achieved through:

• Primary prevention directed at reducing the incidence

Guidelines For Management

• Promotion of safer sexual behaviour and practices;

Secondary prevention activities are:

• Promotion of health care seeking behaviour directed

Effective client management remains the cornerstone for

Aetiological diagnosis is often regarded as the ideal approach in

Clinical diagnosis is identifying the STI causing the symptoms

The best alternative to aetiological and clinical diagnoses is