Professional Documents
Culture Documents
MANAGEMENT OF STI
Presenter – Dr. Jeebanjyoti Mishra
Senior Resident, MBBS ,MD(AIIMS)
OUTLINES
• Introduction
• Objectives
• Components
• Considerations in clinical management
• Steps
• Management of syndromes
• Syndromic management vs Etiologic management
• Limitations
INTRODUCTION
● Earliest diagnosis
● Partner treatment
STEPS
1. History
2. Physical examination
3. Treatment
4. Health education on prevention
5. Provide condoms and demonstrate use
6. Offer Partner treatment
7. Follow up or refer as needed
COMPONENTS :
Counselling
and
education of
patient
SIX C’s
Come back
Condom
for follow-
promotion
up
Compliance
with
treatment
SYNDROMIC MANAGEMENT OF STI/RTI
• Not for screening STI/RTI
Causative HISTORY
agents • Menstrual history
• Nature and type of Discharge
Trichomonas • Genital itching
Candida •Dysuria, increased frequency
Gardnerella • Presence of any ulcer, swelling on the vulval
Ureaplasma or inguinal region
• Genital complaints in Sexual Partners
Mycoplasma
• Low backache
EXAMINATION
CAUSATIVE AGENT
Neisseria
Chlamydia
Trichomonas
Others : Mycoplasma,HSV
Gonococcal urethritis : Inflamed
meatus with purulent discharge Enteric bacteria,Adeno virus
• History • Examination
• Urethral discharge • Redness and swelling of the
• Pain or burning while passing urethral meatus
urine • Urethral discharge
• Increased frequency of urination • Massage the urethra from the
• Sexual exposure including high ventral part of the penis towards
risk the meatus
• Practices like oro-genital sex in • Thick, creamy greenish-yellow
the previous 2 months or mucoid discharge
MANAGEMENT OF CERVICAL DISCHARGE SYNDROME
(CERVICITIS)
• Abnormal vaginal discharge & Inter-menstrual bleeding
• Purulent or mucopurulent endocervical exudate
• Sustained endocervical bleeding induced by
gentle passage of a cotton swab through cervical os
• Characteristic features
• Erythematous cervix
• Mucopurulent cervical discharge
• Bimanual pelvic examination to rule out PID
Cervical discharge on
Colposcopy
Causative Organisms
• N. gonorrhoeae
• C. trachomatis
• T. vaginalis
• HSV
• HPV
HISTORY EXAMINATION
• Swelling and pain in scrotum • Redness and oedema of the overlying
skin and raised local temperature
• Pain or burning while passing
• Tenderness of the epididymis and vas
urine deferens
• Urethral discharge • Associated urethral discharge/genital
• Systemic symptoms like malaise, ulcer/inguinal lymph nodes – if present
refer to the respective flowchart
fever
• Trans-illumination test to rule out
hydrocele
MANAGEMENT
Causative Organisms
• N.gonorrhoeae
• C. trachomatis
• Non STI infectious: tuberculosis, filariasis,
coliforms, pseudomonas, mumps virus
o Non-infectious :trauma with or without
haematoma, and torsion
HISTORY EXAMINATION
• Groin = Localized enlargement of lymph
• Painful swelling in inguinal region nodes (tender & fluctuant)
• Preceding history of genital ulcer • Inflammed skin over swelling
• Sexual exposure of either partner • Multiple sinuses
(oro-genital sex) • Oedema of genitals & lower limbs
• Systemic symptoms : malaise, fever • Genital ulcer/ urethral discharge : refer
to respective flowchart
Flowchart 7: Management of Inguinal Bubo
Causative organisms
C. trachomatis Serovars
L1,L2,L3 (LGV)
H. ducreii (Chancroid)
Inguinal Bubo
TREATMENT
• Cap. Doxycycline 100 mg BD for 21 days
PLUS
• Tab. Azithromycin 1 gm single dose
OR
• Ciprofloxacin 500 mg BD for 3 days
(chancroid)
• Causative Organisms
• N. gonorrhoeae
• C.trachomatis
• Mycoplasma
• Gardnerella
• Anaerobic bacteria (Bacteroides sp, gram positive cocci)
HISTORY EXAMINATION
Cervicitis/Urethral discharge • Treat ( last 30 days) , Sexual abstinence during the course of treatment
/Burning micturation males
Non Herpetic ulcer • Treat for syphilis and chancroid with same regimen.
• Client in last 3 months prior to the onset of ulcer
• Sexual abstinence during the course of treatment or till the lesions heal
Lower abdominal pain • Treat ( contact within 60 days ) , Male partners for urethral discharge
• Provide condoms, educate on correct and consistent use
Management during pregnancy
• Cervical discharge/Urethritis/Painful scrotal swelling : same as non pregnant (grey kit )
• Vaginal discharge :
• Per speculum examination (abortion, PROM)
• Clotrimazole vaginal pessary/cream
• Tab Metronidazole 400 mg bid for 7 days for BV/TV
• Lower abdominal pain : Yellow kit , need referral
• Ulcer non herpetic:
• RPR positive :Inj. Benzathine penicillin 2.4 million IU IM single dose (with emergency tray ready)
(for syphilis)
• If allergic to penicillin : Eryhromycin *
• Ulcer herpetic :
• Dose is same as non pregnant
• Genital herpetic lesions at the onset of labour : caesarean section( neonatal herpes )
• Tab. Acyclovir 400 mg three times a day during the last four weeks of pregnancy
Key counselling message
• Educate and counsel client and sex partner(s) regarding STI/RTI, safer
sex practices
• Importance of taking complete treatment
• Provide condoms, educate about their correct and consistent use.
• Treat partner(s) as per syndrome recommendations
• Advise sexual abstinence during the course of treatment
• Schedule return visit after 7 days
Follow up
Follow up after 7 days
• To document symptomatic cure/ results of tests done for HIV and syphilis/
• If symptoms/signs persist assess whether it is due to lack of
treatment compliance / treatment failure /re-infection and
advise prompt referral
• For inguinal swelling After 7, 14 and 21 days
• Painful scrotal swelling if symptoms persist after treatment, need referral
• For syphilis
• Follow up at 3, 6, 12 and 24 months
• During each follow up visit, conduct clinical examination, qualitative, and quantitative non-
treponemal tests (RPR/VDRL)
• Retreatment :serological evidence of re-infection or relapse
Comparison between Etiologic and Syndromic approach
Etiologic approach Syndromic approach
1. Possible to get an exact diagnosis using Diagnosis may be wrong in certain cases e.g. in case of
laboratory tests vaginal discharge syndrome, the approach is not
effective to manage gonorrhoea and chlamydia
infection
3. Patient must return for test results and must The patient is diagnosed and treated in one visit
wait for treatment till the lab results comes
PARTNER PREGNANCY
• For BV/Candida :Not required • Per speculum examination
• For Trichomonas: treat all • Metronidazole 400 mg tds for 7
partners within last 30 days days
• Abstinence during treatment • Fluconazole is contraindicated
• Clotrimazole cream/pessary