1. Sexually transmitted diseases (STDs) are caused by bacteria, viruses, parasites or fungi transmitted through sexual contact. Common STDs include chlamydia, gonorrhea, HIV/AIDS, herpes and syphilis. 2. India has a major problem with STDs, with millions of new infections acquired each year. High-risk groups include sex workers, their clients like truck drivers, and individuals with multiple partners or broken homes. 3. Syndromic management is used to clinically diagnose and treat STDs based on symptoms rather than definitive diagnostic testing. It is effective against mixed infections but can promote antibiotic resistance.

1. Department of Community Medicine
Chhattisgarh institute of Medical Sciences ,Bilaspur
Sexually Transmitted Diseases
Dr Aditi Chandrakar
Assistant Professor
Dept of Community Medicine

2. Introduction
• Group of communicable diseases that are transmitted predominantly by sexual
contact and caused by wide range of bacterial, viral ,protozoal and fungal agents
and ectoparasites.
• In the last few decades , STDs have undergone a dramatic transformation.
a) Venereal disease to STDs.
b) List of pathogen extended from 5 to more than 20.
c) Not only symptoms are important but also the clinical syndrome associated with
this diseases.

3. Problem statement
• True incidence-not known because of inadequate reporting due to
secrecy that surrounds them.
• More that 1 million STIs are acquired every day.
• Each year, there are estimated 357 million new infections with 1 of 4
STIs.
• STIs have serious consequences beyond the immediate impact of the
infection itself like mother to child transmission of STIs can result in
still birth neonatal death, LBW , PID and infertility among females.

4. India
• Major public health problem in India
• During the serological survey of syphilis, about 19,808 cases reported in the year
2017.
• Gonorrhoea more widely than syphilis and about 59,266 cases reported in the year
2017.
• LGV and Donovanosis more common in southern states of Tamil Nadu , Andhra
Pradesh, Karnataka

5. Epidemiological determinants
• Agent factors
Pathogen Diseases or syndrome
Neisseria Gonorrhoea Gonorrhea,urethritis,cervicitis,epididymitis,salpingitis,
PID,neonatal conjunctivitis
Treponema pallidum Syphilis
Hemophilus Ducreyi Chancroid
Chlamydia Trachomatis LGV, urethritis, cervicitis,
proctitis,epididymitis,infant pneumonia
Calymmatobacterium granulomatis Donovanosis (Granuloma inguale)
Herpes simplex virus Genital Herpes
Hepatitis B virus Acute and chronic hepatitis
Human Papilloma Virus Genital and anal wart
Human Immunodeficiency Virus AIDS
Molluscum Contagiosum Genital Molluscum Contagiosum
Candida Albicans Vaginitis
Trichomonas Vaginalis Vaginitis

6. Host factors
1. Age : more common in 20-24 years followed by 25-29 . Most common
morbidity is observed during foetal development and in the neonate.
2. Sex- higher in Men than women but severity is more in women.
3. Marital status: frequency is higher among single,divorced and separated persons
than among married.
4. Socio economic status: from low socio economic groups have highest morbidity
rate

7. Demographic factors:
1. Population explosion
2. Marked increase in the number of young people’
3. Rural to urban migration.
4. Increasing educational opportunities for women delaying their marriage

8. 1.Prostitution : major factor in the spread of STDs. Act as reservoir of infection
2. Broken Homes : Promiscus women are usually drawn from broken homes .homes which are usually broken
either due to death of one or both parents or their separation. The atmosphere in such homes is unhappy and
children reared in such an atmosphere are likely to go stray in search of other avenues of Happiness.
3. Sexual disharmony : married people with strained relations, divorced and separated persons are often
victims.
4. Easy Money : Prostitution is reflection of poverty. Occupation for earning easy money.
5. Urbanization and industrialization : long working hours, relative isolation from family.
6.Social disruptions: caused by disasters,wars,civil unrest.
7. Changing behavioural patterns.
8. Social stigma. 9.Alcohol
Social factors

9. Vulnerable groups for STI – High Risk groups
• In certain group of individual the incidence and Prevalence of the STIs are
generally more than a normal population, they are called as “Core Groups”.
• Includes :-
 Commercial Sex workers (CSW)
 Injecting Drug Users and their partners
 Prisoners
 Street Children
 Group of individuals who are client to CSWs like long distance truck drivers,
tourists/travellers

10. Clinical Spectrum
• STD’s of Concern
•
Actually, all of them
• “Sores” (ulcers)
• Syphilis
• Genital herpes (HSV-2, HSV-1)
• Others uncommon in the U.S.
• Lymphogranuloma venereum
• Chancroid
• Granuloma inguinale
• “Drips” (discharges)
• Gonorrhoea
• Chlamydia
• Nongonococcal urethritis / mucopurulent cervicitis
• Trichomonas vaginitis / urethritis
• Candidiasis (vulvovaginal, less problems in men)
Other major concerns
Genital HPV (especially type
16, 18)
Cervical Cancer

11. Genital Ulcer Diseases
Does It Hurt?
• Painful
• Chancroid
• Genital herpes simplex
• Painless
• Syphilis
• Lymphogranuloma venereum
• Granuloma inguinale

12. Prevention and Control
• Main components of STI control :
1. Elimination of reservoirs
2. Breaking the chain of Transmission.
3. Protection of the susceptible.
4. Other measures

13. 1. Elimination of reservoir
• Main emphasis: detection and control of infection in core group members.
1. Case detection :early detection is backbone.
2. Screening :
• STI show ice berg phenomena: selective screening for core group population and
opportunistic screening for at risk.
• Screening for antenatal mothers and blood donors also.
3. Contact tracing :
• Tracing the sexual partners by rapid means before incubation period.
• After identification, counselling to be done for- STI clinic visit, examination and
treatment.

14. 4. Cluster testing :
• Testing of those who reside in the same socio sexual environment of any diagnosed STI
cases.
• Most effective way of identification of CSWs, Homosexuals-if confidentiality is
maintained.
5. Case holding and Treatment :
Administration of Full course of treatment to all the contacts or to recently exposed people
before getting investigations results referred as “ Epidemiological Treatment or Contact
Treatment
Follow up is mandatory
Incomplete treatment and drop out result in anti microbial
resistance
After identification of case , by screening procedure
Provide complete treatment with confidentiality

15. 2. Breaking the chain of Transmission
• Abstinence – absolute and impractical method
• Safe sex practice with barrier method.
3. Protection of the susceptible
Safe sex to be practice in the community.
• Faithful to one sexual partner
• Using barrier method- correct & consistent use

16. 4. Other measures :
1. Health education : changes behaviour to minimize the disease acquisition & spread.
2. Vaccination : Only Hep B vaccine available for Control
3. STI clinics / Suraksha Clinic :
• Delivers sexual & reproductive health services
• NACO –through its network establishes STI/RTI clinics (at Govt Facility at district level
and above) , provides free standardized STI/RTI services.
• Treatment is as per syndromic management approach.
• RPR kits to diagnose syphilis and follow color coded treatment protocol.
• Free counselling services to patient and their partners by trained counsellors.

17. Treponema pallidum – The Agent of Syphilis
• Spirochete
• Obligate human parasite
• Transmission:-Sexual,Trans-placental,Percutaneous following contact with infectious
lesions, Blood Transfusion
• Incubation Period – 21 days (median)
• 3 clinical stages of syphilis
– Primary:
•Painless sore (chancre) at inoculation site
– Secondary:
• Rash, Fever, Lymphadenopathy, Malaise
– Tertiary/Latent:
• CNS invasion, organ damage

18. Primary Syphilis – Clinical Manifestations
• Incubation: 10-90 days (average 3 weeks)
• Chancre
– Early: macule/papule erodes
– Late: clean based, painless, indurated ulcer with smooth firm borders
• Unnoticed in 15-30% of patients
• Resolves in 1-5 weeks
• HIGHLY INFECTIOUS
• Primary Syphilis Chancre
• Represents haematogenous dissemination of spirochetes
• Usually 2-8 weeks after chancre appears
• Findings:
• rash - whole body (includes palms/soles)
• mucous patches
• Condylomata lata - HIGHLY INFECTIOUS
• constitutional symptoms
• Sn/Sx resolve in 2-10 weeks

19. Congenital Syphilis
• Congenital syphilis usually
occurs following vertical
transmission of T. pallidum
from the infected mother to
the fetus in utero, but neonates
may also be infected during
passage through the infected
birth canal at delivery.

20. DIAGNOSIS OF SYPHILIS
1. History and clinical examination.
2. Dark-field microscopy: special technique use to demonstrate the spirochete as
shiny motile spiral structures with a dark background.
• The specimen includes oozing from the lesion or sometimes L.N. aspirate. It is
usually positive in the primary and secondary stages and it is most useful in the
primary stage when the serological tests are still negative.
• Laboratory Testing
• Direct examination of clinical specimen by dark-field microscopy or fluorescent
antibody testing of sample.
• Non-specific or non-treponemal serological test to detect reagin, utilized as
screening test only.
• Specific Treponemal antibody tests are used as a confirmatory test for a positive
reagin test.

22. Genital herpes simplex
Manifestations
•Direct contact – may be with
asymptomatic shedding
•Primary infection commonly
asymptomatic; symptomatic cases
sometimes severe, prolonged, systemic
• manifestations
• Vesicles painful ulcerations crusting
• Diagnosis:
• – Culture
• – Serology (Western blot)
• – PCR
Epidemiology of Genital Herpes :
• One of the 3 most common STDs.
• HSV-2: 80-90%, HSV-1: 10-20%.
• Most cases subclinical.
• Transmission primarily from subclinical
Infection.
• Complications: neonatal transmission, enhanced HIV

23. Herpes simplex lesion

24. Gonorrhoea
Clinical Manifestations
• Urethritis - male
– Incubation: 1-14 d (usually 2-5 d)
– Sx: Dysuria and urethral discharge (5% asymptomatic)
– Dx: Gram stain urethral smear (+) > 98% culture
– Complications
• Urogenital infection - female
– Endocervical canal primary site
– 70-90% also colonize urethra
– Incubation: unclear; symptoms usually in l0 d
– Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial
pain/swelling, abd. pain
– Dx: Gram stain smear (+) 50-70% culture

25. Gonorrhea and its gram stain

26. Nongonococcal Urethritis
Etiology:
– 20-40% C. trachomatis
– 20-30% genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma genitalium)
– Occasional Trichomonas vaginalis, HSV
– Unknown in ~50% cases
• Sx: Mild dysuria, mucoid discharge
• Dx: Urethral smear 5 PMNs (usually 15)/OI field
• Urine microscopic 10 PMNs/HPF
• Leukocyte esterase (+)

27. Chlamydia
• Chlamydia is an infection of the penis, vagina, throat, or tube that carries urine.
• Chlamydia is caused by bacteria (a kind of germ).
• You get it by having sex with someone who has Chlamydia.
• Chlamydia can be spread by the vagina, penis, mouth, or anus.
• Responsible for causing cervicitis, urethritis, Proctitis, lymphogranuloma
venereum, and pelvic inflammatory disease
• Potential to transmit to newborn during delivery causes Conjunctivitis, pneumonia

28. Chlamydia
Normal cervix

29. Pelvic Inflammatory Disease (PID)
• l0%-20% women PID
• CDC minimal criteria
• – uterine adnexal tenderness, cervical motion tenderness
• Other symptoms include
– endocervical discharge, fever, lower abd. pain
• Complications:
– Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia

30. Chancroid
• painful genital ulcer and tender Suppurative inguinal adenopathy suggests
Chancroid
• Purposes, can be made if all of the following criteria are met:
1. The patient has one or more painful genital ulcers;
2. The patient has no evidence of T. pallidum infection by dark field examination of
ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset
of ulcers;

31. Granuloma Inguinale (Donovanosis)
• Granuloma inguinale is a genital ulcerative disease caused by the intracellular
gram-negative bacterium Klebsiella granulomatis (formerly known as
Calymmatobacterium granulomatis).
• Clinically, the disease is commonly characterized as painless, slowly progressive
ulcerative lesions on the genitals or perineum without regional lymphadenopathy;
subcutaneous granulomas (pseudoboboes)
• The lesions are highly vascular (i.e., beefy red appearance) and bleed easily on
contact.

32. Lymph Granuloma Venereum
• Lymph granuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2,
or L3 .
• Most common clinical manifestation of LGV among heterosexuals is tender
inguinal and/or femoral lymphadenopathy that is typically unilateral.

33. Trichomoniasis
Occurs in vagina of women so may be sexually transmitted to men using infected wash cloths and
towels.
• It is transmitted to the baby during delivery.
• It also can occur in the urethra (carries urine to penis) in men, doesn’t have symptoms usually.
SYMPTOMS:
• Appear within 5 to 28 days of exposure
• Women usually have a vaginal discharge that
FEMALE SYMPTOMS:
• Itching and burning at the outside of the opening of the vagina and vulva.
• Painful and frequent urination
• Heavy, unpleasant smelling greenish, yellow discharge
MALE SYMPTOMS:
• Usually nothing, or discomfort in urethra, inflamed head of the penis.

34. Syndromic Management of STIs
ADVANTAGES
• No need for a specialist
• Simple, Inexpensive
• No need for a specific
investigation
• Effective against mixed infection
• Instant management
• Free from errors of clinical
judgement
DISADVANTAGES
• Not a scientific procedure.
• Drug wastage
• Statistical reports on specific STDs
cannot be produced.
• Promotes antibiotic resistance.

35. STI Associated Syndromes

37. 1. Urethral discharge in males
Urethral discharge confirmed by clinician
Compliance good and Reinfection
unlikely : Refer the patient
Compliance bad and/or reinfection
likely : start protocol again
Lab investigations (if available)
Treatment of gonorrhoea and chlamydial infection, health
education and counselling, Examine and treat partners.
Follow up 7-14 days after treatment. Clinical cure
Discharge persist
Assess the treatment

38. URETHRAL DISCHARGE IN MALES
1. Gonorrhoea
2. C. trachomatis D to K
3. Trichomonas vaginalis
• HISTORY-Urethral discharge, Pain / burning
micturition,Increase in frequency of urination,Oro-genital sex.
• EXAMINATION-Redness & swelling over urethral meatus,
Urethral Discharge, milk the penis.
TREATMENT
• Treat both Chlamydia & Gonorrhoea
• Uncomplicated C + G
• T. Cefixime 400mg single dose +
• T. Azithromycin 1g single dose (supervised)
• T. Erythromycin 500mg QID 7D (allergy to Azithromycin)
If symptoms persist or
recur
T. Secnidazole 2gm
single dose
( for T. vaginalis)
Not resolving: Prompt
referral e

39. PARTNER MANAGEMNET
• Treat all recent partners.
• Treat similarly for G/C
• R/O pregnancy & allergy
• sexual abstinence / use of condom
• Testing of HIV/syphilis.
• Follow up – in a week’s time
FOLLOW UP after 7 days
Reports of HIV, syphilis & Hepatitis B
Persisting symptoms - failure or re-infection
For prompt referral

40. • TREATMENT OF PREGNANT PATNER
• Per speculum / per vaginal examination
• Treat for G/C
• Gonococcal – Cephalosporins – safe & effective
• T. Cefixime 400mg single dose (or) Inj. Ceftriaxone 125mg IM +T. Erythromycin
500mg QID X 7D
Chlamydial – C. Amoxicillin 500mg TDS X 7D
• Quinolones & Doxycycline - Contraindicated

41. 2. Scrotal Swelling
• Neisseria Gonorrhea
• Chlamydia Trachomatis D to K

42. • HISTORY
Scrotal swelling & pain
Pain or burning micturition
Malaise, fever
Oro-genital sex
• EXAMINATION
Scrotal swelling
Redness and edema of overlying skin
Tenderness – epididymis & V. deferens
Discharge, ulcer, inguinal nodes
Trans-illumination test-to rule out
hydrocoele.
DIFFERENTIAL DIGNOSIS
Scrotal swelling – Infectious causes
TB, filariasis, coliforms, pseudomonas,
mumps
Non infectious causes
Trauma, hernia, hydrocoele, Testicular
torsion/ tumour

43. Treat for G/C
• T. Cefixime 400mg single dose + T.
Azithromycin 1 gm orally single dose.
• Supportive treatment – scrotal elevation
using T bandage, analgesics.
• If not respond-Prompt referral.
Long term parental : complicated G. infection
Delay in treatment : scarring / sub-fertility
Treatment of pregnant
Partner
• Doxycycline & Erythromycin
esolate (hepatotoxic) is
Contraindicated.
• Erythromycin base (or)
erythromycin ethyl succinate (or)
amoxicillin can be used.

44. 3. INGUINAL BUBO
• Chancroid- Haemophilus ducreyi
• LGV - C. trachomatis (L1,L2,L3)

45. HISTORY
• Inguinal swelling (painful)
• Preceding ulcer / discharge
• Malaise, fever
• Oro-genital sex
EXAMINATION
• Enlarged inguinal nodes – tender fluctuant
• Redness and edema of skin
• Multiple sinuses
• Oedema – genital & lower limb
• Genital ulcer / discharge
DIFFERENTIAL DIAGNOSIS
• TB, Filariasis
• Acute infection – pubic area, genitals,
buttocks,anus, lower limb
• Suspected malignancy (or) TB –
biopsy

46. TREATMENT
• LGV : Doxycycline 100mg BD X 21 days
+
• Chancroid : T. Azithromycin single dose
(or)
• T. Ciprofloxacin 500mg BD X 3 days
• Never incise a bubo – fistula
• Surgical intervention – severe vulval
edema
Partner management
 Treat all recent partners.{last 3
months}
 Treat similarly for LGV &
chancroid.
 Sexual abstinence / Use of condom.
 Follow up – in a week’s time.
TREATMENT OF PREGNANT PATNER
• Doxycycline, Quinolones, sulphonamides Erythromycin esolate (hepatotoxic)
Contraindicated.
• Erythromycin base 500mg QID x 21D (or)Erythromycin ethyl succinate can be used
Refer to higher centre

47. 4. Genital Ulcers
• Granuloma inguinale (K. granulomatis)
• Chancroid (Haemphilus ducreyi)
• Genital Herpes (Herpes simplex)
• Syphilis (Treponema pallidum)
• LGV ( Chlamydia trachomatis)

48. • HISTORY
• Genital ulcer / vesicles
• Burning sensation in the genital region.
• Oro-genital sex
• EXAMINATION
 Painless ulcer + shotty lymph node – Syphilis
 Painful ulcer (single/ multiple) ± painful bubo – Chancroid
 Painful vesicle / ulcer (single/multiple) – Herpes simplex
 Painless ulcer, No lymph node – G.I
Transient ulcer with inguinal lymph nodes-LGV

50. • TREATMENT
• Herpes : T. Acyclovir 400mg TDS x 7D ORALLY
• Syphilis:
Inj Benzathine penicillin 2.4 million IU IM in two divided dose (or)
Doxycycline 100mg BD x 14D
+
T. Azithromycin 1g single dose
(or)
T.Ciprofloxacin 500mg BD x 3D
(to cover Chancroid)
TREATMENT SHOULD BE EXTENDED BEYOND 7 DAYS IF
ULCER IS NOT EPITHELIALIZED .
PARTNER MANAGEMENT
• Treat all recent partner
(with in 3 months).
• Sexual abstinence / use of
condom.
• Testing for HIV, Hepatitis B.
• Follow up – in a week’s time

51. TREATMENT OF PREGNANT PARTNER
• Contraindicated
Doxycycline, Quinolones, Erythromycin esolate (hepatotoxic),Sulphonamides
• RPR +ve patients - should be considered infected (unless adequate treatment is
documented & antibody titers have declined)
• Syphilis (primary, secondary or early latent) –
• Inj Benzathine penicillin 2.4million IU IM + 2nd dose after 1 week of initial dose.
• Penicillin allergy - Erythromycin 500mg QID x 15D
(Erythromycin base or erythromcin ethyl succinate)
• Neonates should be treated for syphilis after delivery.
• Genital herpetic lesions at the onset of labour – caesarean section to prevent neonatal
herpes
• Genital Herpes (first episode or recurrent) with no active lesions - oral Acyclovir

52. 5. VAGINAL DISCHARGE
• N. gonorrhoea
• C. trachomatis D to K
• T. vaginalis
• Herpes simplex
• Candida albicans
• Gardnerella vaginalis
• Mycoplasma
• Vaginitis
• Chlamydial cervicitis
• Gonococcal cervicitis

53. HISTORY
• Menstrual history-to rule out
pregnancy.
• Nature & type of discharge -
(amount, smell, consistency)
• Genital itching, Burning
micturition, frequency
• Ulcer / swelling, Low backpain
EXAMINATION: per speculum
Discharge in vaginitis
 Trichomoniasis – greenish frothy
 Candidiasis – curdy white
 Bacterial vaginosis – adherent discharge
 Mixed infection – atypical discharge
Cervicitis
 Erosion, ulcer, mucopurulent discharge
 Bimanual pelvic examination to rule out PID.
If speculum examination is not possible– treat
for both vaginitis and cervicitis

54. Per Speculum Examination

55. INVESTIGATION
• T. vaginalis - Wet mount microscopy
• C. albicans – 10% KOH
• B. Vaginosis – gram stain – clue cells
• N. gonorrhoeae – gram stain – gonococci
• Whiff test

56. Investigations

57. Vaginitis (TV + BV + Candida)
• T. Secnidazole 2g single dose (or)
• T. Tinidazole 500mg BD 5D
• T. Metoclopropramide 30 mts before T. secnidazole to prevent GI
Candidiasis
• T. Fluconazole 150mg single dose (or) Clotrimazole 500mg pessaries once
Cervicitis (chlamydia + gonorrhoea)
• T. Cefixime 400mg single dose + T. Azithromycin 1g 1 hour before lunch
• If vomiting within 1 hour – give anti emetic & repeat
• Avoid douching
• Récurrent infection – consider pregnancy, diabetes & HIV
• Follow up after a week

58. MANAGEMENT IN PREGNANT WOMAN
Per speculum examination
R/O complications like abortion & premature
rupture
Vaginitis (TV + BV + Candida)
1st trimester
• Candidiasis - Clotrimazole pessary/cream
(Flucanozole is contraindicated)
• TV or BV – metronidazole pessary/cream
2nd trimester- treatment same as non pregnant
PARTNER MANAGEMENT
Treat current partner if no
improvement after initial
treatment.
Treat using same protocol , if partner
is symptomatic.
Sexual abstinence / use of condom.
Follow up – in a week’s time,

59. 6. PELVIC INFLAMMATORY DISEASE( Lower abdominal Pain)
Causative organisms
• N. Gonorrhoeae
• C. Trachomatis
• Mycoplasma, Gardnerella
• Anaerobic bacteria (Bacteroides sp.gram +ve cocci)

60. HISTORY
Lower abdomen pain, Fever
Vaginal discharge, Menstrual irregularities
Dysmenorrhoea, Dyspareunia
Low backache, contraceptive use like IUD
EXAMINATION
• G/E – pulse, BP, Temp
• Per speculum – vaginal / cervical discharge,
congestion or ulcer
• Lower abdominal tenderness / guarding
INVESTIGATION
CBC, ESR
Urine microscopy – pus cells
Gram stain – Gonorrhoea
Wet smear examination
DIFFERENTIAL DIAGNOSIS
Ectopic pregnancy
Twisted ovarian cyst
Ovarian tumour
Appendicitis
Abdominal TB

61. Treatment
Mild / Moderate PID
• Cover C / G & anaerobes
• T. Cefixime 400mg BD stat
+
T. Metronidazole 400mg BD x 14D
+
T. Doxycycline 100mg BD x 14D
• T. Ibuprofen + T. Ranitidine
• Remove IUD under antibiotic cover
• Abstinence , correct and consistent use
of condom
SEVERE PID- HOSPITALIZATION
Uncertain diagnosis
Surgical emergencies appendicitis or ectopic
pregnancy
Suspected pelvic abscess
Intolerance to OP treatment
Fail to respond to OP treatment

62. Partner Management
Treat all recent partner.
Treat male partners for urethral discharge (G/C)
Sexual abstinence / use of condom
Testing for HIV, Syphilis & Hep B
Follow up
Management of Pregnant women : very rare in pregnancy .
Parental regimen is safe
Doxycycline is contraindicated
Metronidazole is not recommended during first 3 months
(Do not withhold for severely acute PID)

63. ORAL & ANAL STI
Causative Organism
N. gonorrhoea
C. trachomatis
T. pallidum
H. ducreyi
K. granulomatis
H. simplex

65. • HISTORY
Unprotected oral sex with pharyngitis
Unprotected anal sex with anal discharge/
tenesmus, diarrhoea, blood in stool, abdominal
cramping, nausea, bloating, rectal pus
• EXAMINATION
Oral ulcers, pharyngitis
Genital or anorectal ulcer
Vesicles
Rectal pus
Proctoscopy
INVESTIGATION
Syphilis – RPR / VDRL
Gonorrhoea (gram stain) gram –ve
intracellular diplococci

66. Colour coded drug kits fir STI Syndromic Management

67. Life is at risk with Sexually Transmitted disease

68. Thank you