This document outlines the syndromic approach to diagnosing and treating common sexually transmitted infections (STIs). It describes the symptoms of vaginal discharge, urethral discharge, and genital ulcers, which can be caused by organisms like Chlamydia, gonorrhea, trichomoniasis, and herpes. The approach involves taking a history, examining the patient, confirming the presence of symptoms, and providing treatment based on the syndrome presented and the likely causative organisms. Treatments aim to cover the major organisms and include antibiotics like azithromycin, doxycycline, and ceftriaxone, as well as antivirals like acyclovir. Partners are also treated to prevent

1. SYMPTOMS ASSOCIATED SYNDROMIC
APPROACH TO STIS
• Vaginal discharge
• Genital ulcers
• Lower abdominal pains
• Urethral discharge

2. Vaginal Discharge
• Discharge different from the usual in respect to colour, odour
consistency.
• Associated with vulvar pruritus, dysuria and dyspareunia
• Abnormal discharge is a sign of vaginitis or cervicitis
• Causative agents:
Vaginitis
Trichomonas vaginalis
Candida albicans(candidiasis)
Gardnerella vaginalis(bacterial vaginosis)
Cervicitis
Neisseria gonorrhea
Chlamydia trachomatis

3. Neisseria gonorrhea
• Purulent discharge
Chlamydia trachomatis
• Mild mucopurulent discharge
Trichomonas vaginalis
• Fishy,yellow-greenish discharge
Gardnerella vaginalis
• Thin gray or white discharge

4. APPROACH TO VAGINAL DISCHARGE
• Patient presents with vaginal discharge
• History and examination
• Assess for risk factors
• Confirm presence of discharge
• Presence of purulent discharge-Treat for cervicitis, bacterial vaginosis
and trichomoniasis
• Non purulent discharge-Treat for bacterial vaginosis and trichomoniasis
• Presence of discharge with vulvar oedema, erythema and excoriations
add treatment for candidiasis

5. Treatment
Cervicitis
Chlamydia
• Azithromycin PO: 1 g single dose
Doxycycline PO: 100 mg 2 times daily for 7 days
Gonorrhoea
• Ceftriaxone IM: 500 mg single dose
Bacterial vaginosis and trichomoniasis
• Tinidazole PO: 2 g single dose
or metronidazole PO: 2 g single dose

6. Vulvovaginal candidiasis
• Clotrimazole (500 mg vaginal tab)
• With extensive vulvar involvement
• Add miconazole 2% cream (one application to the vulva 2 times daily for 7 days)
Treatment of partner
• Receive similar treatment

7. Urethral Discharge
• Most common complaint
• Present together with dysuria
Causative organisms
Neisseria gonorrhea
Chlamydia trachomatis

8. Approach to urethral discharge
• Patient complains of urethral discharge
• History and examination
• Confirm presence of urethral discharge
• If confirmed treat for gonorrhoea and chlamydia
Lab
Chlamydia
• Cant be identified in a field lab give empiric treatment
Gonorrhoea
• Microscopy
• Gram negative diplococci

9. Treatment
• If microscopy of a urethral smear has been performed:
• In the absence of gonococci, treat for chlamydia alone
• In the presence of gonococci, treat for chlamydia and gonorrhoea
Chlamydia
Azithromycin or Doxycycline
Gonorrhoea
Ceftriaxone or Cefixime
Treatment of the partner
• The sexual partner receives the same treatment as the patient, whether
or not symptoms are present.

10. Genital ulcers
• Single or multiple vesicular, ulcerative or erosive lesions of genital
tract.
• Causative organisms
Treponema pallidum(syphilis chancre)
Haemophilus ducreyi(chancroid)
Herpes simplex virus(genital herpes)
Chlamydia trachomatis(lymphogranuloma venerum)

11. Herpes simplex
• Clear vesicles on erythematous base(dew drop on rose petal)
• Progress to ulcers and crusted lesions
Haemophilus ducreyi
• Small ulcers 3-5mm in width
• Sharply defined and rugged border
Syphillis
• Single indurated ulcer-primary syphilis
• Wart like lesions-secondary syphilis
• Destructive nodules(gumma)-tertiary syphilis

12. Approach to genital ulcers
• Patient presents with a genital ulcer
• History and examination
• Presence of small painful vesicles sometimes in clusters or small
ulcers with history of recurrent vesicles
• Treat for genital herpes
• Other ulcerations treat for syphilis and chancroid

13. Treatment
Herpes
• Local treatment: clean the area with soap and water.
• Antiviral treatment: aciclovir
Syphillis
• Benzathine benzylpenicillin IM: 2.4 MUI per injection (half the
dose in each buttock)
• for penicillin-allergic patients;
erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily
or
doxycycline PO: 100 mg 2 times daily for 14 days
or
azithromycin PO: 2 g single dose

14. Chancroid
• azithromycin PO: 1 g single dose
or
ceftriaxone IM: 250 mg single dose
or
erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily for 7
days
Treatment of the partner
• The sexual partner receives the same treatment as the patient,
whether or not symptoms are present, except in the case of
genital herpes (the partner is treated only if symptomatic).