Syndromic approach to STI

1. Syndromic Approach
Syndrome – is group of symptoms patient
complains about and clinical signs you
observe during examination
Different organisms that cause STIs give rise
to only limited number of syndromes
Although many different pathogens cause
STIs, some of them give rise to similar or
overlapping clinical appearances
WHO recommendation

2. Syndromic Approach cont’d
The syndromic approach using flowcharts
to guide diagnosis and treatment is more
accurate than diagnosis based on clinical
judgment alone

3. THE MAIN SYNDROMES OF COMMON STIS :
SYNDROME MOST COMMON CAUSE
Vaginal discharge Vaginitis(trichomniasis,candid
isis),
Cervicitis(gonorrhea,
chlamydia)
Urethral discharge Gonorrhea, chlamydia
Genital ulcer Syphilis, chancroid, herpes
Lower abdominal pain Gonorrhea, chlamydia, mixed
anaerobes
Scrotal swelling Gonorrhea, chlamydia
Inguinal bubo LGV, Chancroid
Neonatal conjunctivitis Gonorrhea, chlamydia

4. Key Features of Syndromic Management
Problem oriented (responds to patient’s symptoms
)
Highly sensitive and does not miss mixed
infections
Treats the patient at first visit
Can be implemented at primary health care level
Use flow charts with logical steps
Provides opportunity and time for education and
counseling

5. The Five Steps in Syndromic STI Case
1. History taking and examination
2. Syndromic diagnosis and treatment, using flow
charts
3. Education and counseling on HIV testing and
safer sex, including condom promotion and
provision
4. Management of sexual partners
5. Recording and reporting

6. Criteria for the selection of STI drugs
A. Availability
B. Low cost
C. High efficacy (at least 95%)
D. Acceptable toxicity and tolerance (safety)
E. Organism resistance unlikely to develop or likely to
be delayed
F. Single dose
G. Oral administration
H. Not contraindicated for pregnant or lactating

7. .
Urethral discharge and/or burning
Common symptoms of urethritis in men
History taking and examination:
Take history and examine the patient.
Inspect genital organs.
Do not forget to inspect the interior part
of the prepuce and the covered part of
glans penis.

8. Reasons for medical examination:
 To confirm the presence of urethral discharge
 To rule out existence of other STIs

9. Major pathogens
causes urethral discharge:
Neisseria Gonorrhoea and Chlamydia
trachomatis (2nd in Ethiopia)
Rarely other causes mycoplasma
genitalium
Occur in NGU (Chlamydia trachomatis the
most common)

11. Treatment Regimen for Urethral Discharge in
Men

12. Persistent (Recurrent Urethral
discharge
Pt present with persistent or recurrent
burning sensation on urination with or with
out discharge
Cause can be:
In adequate Rx
Re infection
Infection by drug resistance

15. Genital Ulcer /vesicular or non
vesicular ulcer)
History taking and examination:
 Take the client’s history and conduct an
examination.
 Inspect the genital organs.
 Do not forget to inspect the interior part of
the prepuce and the covered part of the glans
penis in men and the skin of the external
genitalia, including the mucous surfaces of the
labia and anus in women.

16. Reasons for medical examination:
To confirm the presence of ulcer(s)
To ensure no other STIs are present

17. Special Circumstances
If there are no ulcers, the patient may have
grouped vesicular lesions with a history of
recurrence that require the management of
Herpes
Ulcers due to drug intake (fixed drug eruption),
scabies and trauma can be excluded by
determining the patient’s history and through a
urine analysis
If you have not been able to confirm the presence
of STIs, reassure your patient, educate him/her
and promote the use of condoms

18. Major Pathogens
Treponema pallidum (Syphilis)
Hemophilus ducreyi (Chancroid)
Herpes simplex virus (Genital herpes)
Chlamydia trachomatis (LGV)
Calymmato bacterium granulomatis
(Donovanosis)

21. Vaginal discharge syndrome
Most cases of vaginal discharge are not of an
STI origin, Candidiasis and bacterial vaginosis
are the most common causes.
History taking and examination:
Take history and try to assess clients STI risks.
An STI risk assessment is considered positive if the
patient or her partner has an STI or a high-risk
behavior.
 Examine the patient.

22. Vaginal discharge syndrome cont’d
Remember:
Vaginal discharges may be physiological.
Using speculum, if available, inspect the cervix
and the vagina to locate the origin of the
discharge.
Do not forget to note the type, color, odor and
amount of discharge.
Ask whether the patient also has pain in the lower
abdomen.

23. Vaginal discharge syndrome cont’d
The wet mount/gram stain microscopy of
vaginal specimen will help in the diagnosis of:
Trichomoniasis: mobile trichomonads
Candidiasis: Budding yeasts or
pseudohyphae
Bacterial vaginosis: presence of Clue
cells plus pH > 4.5 or KOH positive

24. Cause
•Vaginitis
•Cervicitis

25. Major Pathogens that cause Vaginitis
• Trichomonas vaginalis
• Candida albicans
• Non specific vaginitis (Gardnella vaginalis)

26. Major Pathogens that cause Cervicitis:
Neisseria gonorrhea (Gonorrhea)
Chlamydia trachomatis (Chlamydial infection)
Bacterial vaginosis (Gardnella vaginalis) is the
leading cause of vaginal discharge in Ethiopia.
List of cause of vaginal discharge from
commonest to less common :-
Vaginosis (G.vaginalis) , candidiasis,
Trichomoniasis ,Gonorrhoea& Chlamydia

27. Complication of Cervicitis and vaginitis
PID
PRM
 pre-term labour
Infectivity
 chronic pelvic pain

28. Risk assessment
one or more:
Multiple sexual partner in last 3 month
New sexual partner in last 3 month
Ever traded sex and Age below 25 years

30. Lower Abdominal Pain syndrome in Women
All sexually active women presenting with lower
abdominal pain should be evaluated for the
presence of Pelvic Inflammatory Disease (PID):
Salpingitis
Endometritis
tubo ovarian abscess
 pelvic peritonitis,
inflammation around the spleen and liver.
How ever ; PID is a result of polymicrobial-
mycoplasma, Bacteroids, streptococcus, E.coli or
H. Influenzae.

31. Lower Abdominal Pain syndrome in Women
cont’d
History taking and examination:
Take history and examine the patient.
 In the history, check for other symptoms,
such as a missed or overdue period, recent
delivery or abortion, or vaginal bleeding.
 During examination look for vaginal bleeding,
this is a sign of ectopic pregnancy and will
require a gynecological referral.

32. Lower Abdominal Pain syndrome in Women cont’d
Bimanual Examination:
During bimanual examination look for
swelling or lumps in the patient's abdomen.
 Notice tenderness on cervical mobilization

33. Lower Abdominal Pain syndrome in Women cont’d
During the examination, keep the following
points in mind:
Tenderness: superficial palpation
Rebound tenderness: deep palpation – severe
tenderness when pressed slowly and pressure
is suddenly removed
Guarding: rigid abdominal muscles

34. Major Pathogens:
Neisseria gonorrhea (Gonorrhea)
Chlamydia trachomatis (Chlamydial infection)
Anaerobic Bacteria
Clinical manifestation
Bilateral lower abdominal pain
CMT

35. Complications
Ectopic pregnancy
Infertility
Peritonitis and intera-abdominal abscess
Adhesion or intestinal obstruction

38. Note:
No pain killers should be used since they may
mask serious complications.
Patients receiving metronidazole should be
cautioned to avoid alcohol.
Persistence of lower abdominal pain may be
due to:
Incorrect diagnosis
Complicated infections
Incorrect use of anti-microbial drugs

39. Hospitalization should be considered in the following
circumstances:
The diagnosis is uncertain
Surgical emergencies, such as appendicitis and
ectopic pregnancy
Suspected pelvic abscess
Severe illness
The patient is pregnant
The patient failed to respond to outpatient
therapy

40. Scrotal Swelling and Pain syndrome
• Inflammation of the epididymis (epididymitis)
usually manifests itself by acute onset of
unilateral testicular pain and swelling.
• The adjacent testis is often inflamed
(orchitis), giving rise to epididymo-orchitis.

41. Scrotal Swelling and Pain syndrome
History taking and examination:
Take history and examine the patient In the
history, check whether the patient has injured
himself or whether the patient has had an STI
in the last six weeks.
Inspect the scrotal skin for bruising.
Do not forget to palpate the scrotal sac,
comparing the two sides, and check for
swelling and pain in the testis, position of the
testis in the scrotal sac (elevation, rotation or
torsion).

42. The reasons for examination are:
To exclude the presence of swelling and or
pain in the testis
To exclude rotation or elevation or torsion or
trauma to the testis
To exclude inguinal hernia
To exclude trauma to tests
To confirm the presence of urethral discharge
To make sure that there are no other STIs

43. Testicular torsion and Epi.orchits
Epididymitis/
Orchitis

44. Major Pathogens
• Neisseria gonorrhea (Gonorrhea)
• Chlamydia trachomatis (Chlamydial
infection)
• The cause varies according to the age of the
pt.
If younger than 35 years – the cause likely N.
Gonorrhoea or C. Trachomatis
If older than 35 year – gram negative organisms
Possibly TBC if not involved in unsafe sex
• Other causes may be Brucellosis, mumps,
onchocerciasis, w. Flariasis

45. Complications
• scrotal swelling by STI
• Epididymitis
• Infertility
• Impotence
• Prostatis
Scrotal edema

48. Inguinal Bubo syndrome (Inguinal Swelling)
Swelling of inguinal lymph nods as a result
of STI
Inguinal bubo is an abscess of a lymph
node.
It presents as a localized enlargement,
which is often painful and may be fluctuant.
Frequently, inguinal bubo is caused by LGV
and chancroid.

49. Inguinal Bubo syndrome (Inguinal Swelling
cont’d
• Acute infection of either the lower limbs or
genital region may cause inguinal
Adenophathy.
• The enlarged lymph nodes may appear in
syphilitic or HIV infection.
• These lymph nodes are not really
considered as bubo.

50. Inguinal Bubo syndrome (Inguinal Swelling cont’d
• If the patient presents with bubo and
associated ulcers, the care provider must
refer to the genital ulcer flow-chart.
• This would include treatment for syphilis and
Chancroid.
• If a patient complains of having bubo
without the presence of ulcers, use the
inguinal bubo flow chart in determining
proper treatment.

51. Inguinal Bubo syndrome (Inguinal
Swelling cont’d
History taking and examination:
• Take history and examine the patient.
• When taking the history, check to determine
whether the patient has groin pain, recent
or past genital ulcer or swelling anywhere in
the body.
• Inspect the lymph nodes and examine to
confirm whether the enlarged node is
painful, warm, and tender to palpation and
fluctuant.

52. Inguinal Bubo syndrome (Inguinal
Swelling cont’d
If a bubo is present, do not forget to
inspect the interior part of the prepuce
and covered part of the glans penis in men
and external genitalia and mucous surface
of the labia in women, to exclude the
presence of genital ulcer.
If the patient does not have any ulcers, the
patient may have vesicular lesions. If this is
the case, the care provider should provide
treatment for herpes.

53. Inguinal bubo

54. Reasons for the examination:
• To confirm the presence of bubo
• To exclude the presence of ulcers
• To make sure the patient does not have
another STI
• If you have not been able to confirm the
presence of STIs, reassure your patient,
educate him/her and promote the use of
condoms.

55. Major Pathogens:
• Lymphogranuloma venereum Chlamydia
• Hemophilus ducreyi (Chancroid)
• Chlamydia granulomatis
• Sometimes T.Palladium (does not produce
necrosis & abscess)

58. Neonatal conjunctivitis
• Conjunctivitis in a newborn may be caused by
• infection,
• a blocked tear duct, or by
• irritation produced by the antibiotic eye drops
given at birth.

59. Neonatal conjunctivitis cont’d
Many organisms can cause infection in the
eyes of newborn infants.
The most common bacterial infections with
potential to cause serious eye damage are
gonorrhea and Chlamydia, which can be
passed from mother to child during birth.
The viruses that cause genital and oral herpes
can also cause neonatal conjunctivitis and
severe eye damage.

60. Prevention of Neonatal Conjunctivitis:
• Immediately after delivery, the eyelids are
cleaned with hydrophilic cotton; before the
eyes are opened
• 1% tetracycline eye ointment is applied into
each inferior conjunctival sac
• The management of neonatal conjunctivitis
must be applied for any baby less than 1
month of age that is suffering from eye
suppuration

61. History taking and examination
• Take history from the mother andexamine the
baby. Ask the mother if she or her sexual
partner(s) have any STI symptoms. Inspect the
baby's eyes for a purulent conjunctival
discharge. Do not forget to separate or press
the eye lids, to look for pus pouring out from
beneath them.

62. Reasons for history taking and examination
• To confirm the presence of purulent
conjunctival discharge frombaby's eyes
• To make sure that the mother does not have
any other STIs

63. Major Pathogens:
• Neisseria gonorrhea (Gonorrhea)
• Chlamydia trachomatis (Chlamydial infection)

64. Clinical manifestations
• Pre-orbital swelling
• Redness of the eye
• Purulent discharge from eye

65. Complications
• Blindness if not treated early

68. Summary
STD’s can be transmitted by any sexual activity
between opposite sex or the same sex partner
Havening one STD does not confirm future
immunity except probably hepatitis B
Sexual partner of infected person needs
treatment
STD affects people of all socioeconomic class
 women bears disproportionate effect of STD

69. Summary cont’d
• Frustration, anger, anxiety ,fear , shame and guilty
are common emission associated with STD diagnose
and treatment
• Different STDs frequently co-exist in the same client
• There are sexually transmitted enteric infections by
oral anal contact.
Examples:
Shigelosis ,salmunellosis ,ameobiasis and giardiasis