3Worldwide epidemiology of STIs 340 Million new infections annuallyBurden unevenly shared more by developing countriesAccount for app 17% of health expenses*HIV is an STIHIV-STI co-infections (with HSV-2, H. ducreyi)The expenses of STIs include the cost of medial treatment of STIs as well as treatment of complications from STIs that were not managed promptly.Individuals that are infected with HIV and an STI such as HSV-2 or chancroid (H. ducreyi) will transmit HIV more effeciently to their partners during sexual contact. Conversely those only infected with an STI such as HSV-2 or chancroid (H. ducreyi) will acquire HIV from an HIV infected partner during sexual contact.*World Bank. World Development Report: Investing in Health. 1993
4Common Terms Used Provider and clinician are used interchangeably This can under some circumstances include non doctor providers
5Epidemiology in Pakistan of STIs Very common among high risk groupsModerately common among bridge groupsUncommon among general populationData with the National and Provincial AIDS Programs show that STIs are extremely common in certain groups such as sex workers and Hijras (transgenders). These STIs include syphilis, gonorrhoea etc. In groups that engage in anal sex, anal infections are also very common. For example one study from 2004 (the National RTI study) showed that among Hijras in Karachi 60% had syphilis and anal gonorrhoea among 30%.One study from Lahore (Faisel and Cleland, 2006) showed about 3% prevalence of STIs among migrant men in LahoreA national study (the ANC study 2001) showed that among women attending ANC clinics and labor wards, all STIs were less than 1%
6Care seeking for STIs in Pakistan Similar to other care in Pakistan: >70% in the private sectorDifferent providers see different types of clientsSyphilis testing and Tx is uncommonPartner management is rareCondom promotion is uncommonData come from the RTI study of 2004 and from over 50 in depth interviews, one focus group discussion and 2 consultative workshops conducted in order to find the implementation perspective for these guidelines.
7Counseling and condom promotion Condoms are the best prevention measureCounseling worksPatient-provider interactions are the best condom and risk behavior counseling opportunitiesFree condom provisionDiscussing STI risk behaviorsPlease stress that even a brief statement by the provider to either 1) use condoms, 2) reduce partners has an impact on their patients subsequent behavior. This means that although this is not a substitute for proper counseling, busy providers should at least add one or 2 statements to this respect when managing patients with STIs.Discussing STI risk behaviors (1. use condoms, 2. reduce partners) is difficult in any culture. However even in our culture, many clinicians (GPs and specialists) related with great pride their ability to conduct such a discussion. This suggests to others that it can be done. How it is done may vary by the situation. Some find it easier to invoke religious or cultural sensitivities, others appeal to personal safety. The exact method also varies by the client. The clinician must decide what is best in any given situation.
8Partner Management Patient>Partner>Patient reinfection cycle Patient delivered medicinesMore important to focus on the patient’s regular partnerManaging partners is crucial. If a patient is infected and then has sex with their regular partner (usually wife or husband) they will likely infect them as well. If you treat only the patient, they will get re-infected when they have sex with their partner again.We recommend that at least the regular partner be treated when possible. This means that if you are treating a sex worker, treating their husband (or wife) is more important than treating their clients. Clients may or may not have another sex encounter with your patient but their spouse is almost certain to do so.The difficulty of partner management are understood. However given their crucial importance we recommend that providers at least consider discussing this with patientsWe recommend that the patients be given medicines or prescriptions for the same medicines that they are receiving to be given to their partners.
9Referrals Difficult STIs HPV/ warts Decide or pre-identify whom to refer toRole of the provincial AIDS ProgramsReferrals are needed for difficult STIs (including those that do not respond to treatment) and for warts (since they carry a high risk of developing into cervical or anal cancer)Referrals may be to STI specialists (Skin specialists, Urologists, Infectious Diseases doctors) or to Gynecologists.Referrals may be facilitated by the Provincial AIDS Programs which also ensure facilitation to the specialists and possibly provide other services. This facilitation includes at least keeping of a list of providers in any given area that are willing to accept referred patients and to define and maintain minimal quality standards of the referral process.
10Compliance, Counseling, Condoms and Contact (Partner) Management The 4 CsCompliance, Counseling, Condoms and Contact (Partner) ManagementThe 4 Cs concept is introduced to enhance counseling and to reduce the time used to do so. The provider is emphasize at least these 4 things. With practice they will be able to reduce the time they spend doing so.
114 Cs: ComplianceSTI patients must be encouraged to comply with their prescribed treatmentInstruct all patients to complete the full course of treatmentDisappearance of symptoms during treatment does not mean that the patient is cured, full course of treatment must be completedWithout proper treatment, STIs may cause severe complicationsPatient should avoid sexual contact during the treatment and until partner has been treatedEnsure a follow-up visit
124 Cs: Counseling for Prevention Every patient presenting with STI symptoms must receive and understand education messages tailored for each patient regarding:STIs result from Sexual contactInformation about safer sex practices and use of condomThe mode of transmission of STIs, including HIVSTI augments the risk of HIV transmissionOffer HIV voluntary counseling and testing (VCT)Consider syphilis testingA list of venues where HIV VCT is done in each locality must be attached to the training manual and a local list must be provided to trainees (STI providers) during the training course
134 Cs: Condom UseTo minimize the further transmission of STIs, including HIV, it is essential to educate all clients on the proper use of condoms:Demonstrate to each patient how to use a condom correctlyClinic should supply condoms to STI patientsMost individuals do not know how to put on a condom properly. Where applicable this should be demonstrated to the patient. The trainers should provide a demonstration of correct condom use technique in the trainingPlease emphasize asking about the 5 condom errors: 1) Was the condom put on before penis touched vagina, 2) Did the condom tear or break, 3) Did penis touch vagina after condom was taken off, 4) Did the condom stay on the entire time you had sex, 5) Was the condom held while being pulled out
144 Cs: Contact (Partner) Management Patients must understand the importance of partner management even if he/she is asymptomatic:Risk of re-infection from asymptomatic partnerRisk of complications for his/her partnerPossible ways of partner management include:Providing additional treatment regimens for the partnerEncouraging partners to come to the clinic for treatmentRe-infection from regular partner is one of the commonest reasons for a patient to get re-infected. Sometimes re-infection is difficult to distinguish from Treatment failure.The partner you are most interested in treating is the patient’s regular partners (spouse, regular sex partner). This is true for sex workers as well, since they only occasionally meet their clients (usually the clients are not regular and the sex worker will not see them again). If they do not meet that client, there is little danger of re-infection from that client. Its their regular partner who are most likely to re-infect them.
15Reproductive Health Linkages Two forms of linkages were identified in our consultationsGynecologists should act as the specialist to whom either difficult infections or patients with warts are sent toAll patients that are considered for STI management in gynecology set up must be considered for syphilis testing and if positive for treatment.All patients presenting for STIs are sexually active. This is also an opportunity to discuss family planning and if the method used is condoms, they will provide dual protection (against STIs and from pregnancy)Referrals for warts are important. In our country gynecologists are reporting high numbers of cervical cancer that are caused by HPV, which also causes warts. It is essential that all women with warts be referred to gynecologists. The providers may provide treatment of warts in their clinic before referringAnal cancer occurs in individuals who have anal sex and is related to HPV. These individuals must be followed. Since there is no mechanism to address this providers are asked to discuss this with patients and seek their return for follow up if possible.
16Risk Assessment of patients Some persons are at more risk of STIs than others due to:Their behaviorsWhere they liveSTI algorithms (those for women) work better with high risk patientsIt is known that the risk of STIs is higher in certain parts of the city than in others. Recognizing this fact, clinicians must use this knowledge to form an assessment of risk of STIs in their patients.A specific list of questions for the risk assessment is not provided since these may vary from location to location and by patients. Providers are to be facilitated in recognizing which questions are appropriate in their settingOnce they identify these questions, they should will be able to use them for the risk assessment more readily. It is therefore that they identify these questions beforehand (ie before seeing patients)
17What is Syndromic Management History-Exam-Lab paradigmHistory-Exam paradigmLimited laboratory support in most areasLimited utility of labs when availableMost of us do syndromic management any way. We see patients. After history and exam, most of us rarely do tests. We form an opinion of what is going on with the patient based on our clinical experience and the pattern of the presentation of the patient. The syndromic management uses the same principle. Only it uses the experience of thousands of clinicians the World over when facing the same situation. Plus its decision processes have been scientifically validated. Therefore it uses our own usual approach but enhances its quality by making it more accurate.The History-Exam-Lab paradigm is what we are taught. Most of us working in resource limited settings seldom get to do labs and learn to practice without them. It is also known that lab tests sometimes are not very useful. The syndromic approach accounts for all of this and provides a scientific method of dealing with these situations and provide the best care possible.
18Benefits of Syndromic Approach Standardization of careCost effectivenessIt has been observed that different providers provide markedly different treatments for same conditions. Some of these are not appropriate, others unnecessary. This (syndromic) approach standardizes the treatment of conditions and is cost effective since it minimizes the overuse of antibiotics.
19Limitations of the Syndromic Approach Works better for male STIsNo algorithms for anal symptomsFemale algorithms work better in high risk settingsSyphilis management which requires testing is not well addressed by these guidelinesThe algorithms work very well for male STIsSince there are no standard anal symptoms algorithms available: we constructed one for those anal symptoms that were identified during our consultations with providersFemale algorithms work best when there is a high risk of STIs in the patientSince syphilis is the only condition that requires a test before treatment, its different for other syndromes. There is no particular syndrome associated with syphilis.
21STIs of interest Human Immunodeficiency Virus (HIV)§ Neisseria gonorrhoeae (NG or GC – short for GonoCocci)Chlamydia trachomatis (CT)Herpes simplex (HSV) (HSV-2)Trichomonas vaginalis (TV)Candida albicansBacterial Vaginosis (BV)1Syphilis (Treponema pallidum)Human Papilloma Virus (HPV)Haemophilus ducreyi (Chancroid)2Lymphogranuloma Venereum (LGV)21. Not actually an STI, included here as it causes symptoms in women2. Uncommon in Pakistan and therefore will not be addressed in any depth
22Basic Etiology (causative organisms) of Syndromes SymptomsSignsMost common causesUrethraldischargeUrethral dischargeDysuriaFrequent urinationGonorrhoeaChlamydiaGenital ulcerGenital soreSyphilisChancroidGenital herpesScrotalswellingScrotal pain and swellingScrotal swellingLowerabdominalpainLower abdominal painDyspareuniaVaginal dischargeLower abdominaltenderness on palpationTemperature >38°Mixed anaerobesVaginalUnusual vaginal dischargeVaginal itchingDysuria (pain on urination)Dyspareunia (pain during sexual intercourse)Abnormal vaginalVAGINITIS:TrichomoniasisCandidiasisCERVICITIS:Anal SymptomsAnal PainAnal DischargeAnal or peri-anal soresAnal tendernessAnal or peri-anal UlcersHSV-2
23Issues of antibiotic resistance Empiric prescription of antibioticsGonococcal resistance already a problemSyndromic approach can help or aggravate the problemAntibiotics are heavily overused in Pakistan this has led to widespread resistance to many antibiotics in Pakistan.Gonorrhoea is the only STI with which resistance has been seen clinically in most placesResistance manifests with failure of patient’s symptoms to resolve despite adequate therapyMany providers report problems with Ciprofloxacin (or Levofloxacin or Ofloxacin)Syndromic approach will minimize the over use of antibiotics by restricting antibiotics used to those needed for the syndrome. Usually this means between 1-3 drugs. This contrasts with the usual practice in Pakistan of “covering all STIs” and prescribing many antibiotics. In one case a provider described their practice of using 11 antibiotics for all male patients with urethral discharge.Some people fear that syndromic approach may lead to “blindly” prescribing many drugs for a syndrome thereby increasing resistance. However in practice this is not true since the actual drugs being prescribed are 1-3 in most cases and are scientifically directed at the cause of the syndrome
24Evidence Behind the Guidelines Urethral Discharge:Senstivity 87-99%Labs seldom add to sensitivityLabs slightly enhance specificity for CT but not NGThe main concern here is to not miss any infections. The high sensitivity ensures that few actual cases are missed.
25Evidence Behind the Guidelines Genital Ulcer:Senstivity: %More sensitive and specific for HSV and SyphilisLabs add very little to specificityAgain high senstivity ensures few actual cases are missed
26Evidence Behind the Guidelines Vaginal Discharge:Senstivity: 73-93% when applied to women presenting for STI careSenstivity: 29-86% when applied to all women screened for STIsOnly 10% of low risk women actually have an STISpeculum does not add very much to the reliability of the algorithm (sens: ~30, spec: ~50)These work well when there is a high risk of STIs for the patient.There is still a high number of women who will be overtreated (the algorithm is not very specific)Use of speculum does not enhance the reliability of the algorithm
27Common Issues Syphilitic chancre of fingers Protect yourself, wear glovesProtection of the provider is crucial and should be emphasized repeatedlySyphilitic chancre of fingers
28Common Issues Protect yourself, wear gloves STIs require contact between 2 individuals, think of the partnerPrevent future problems: promote condomsCounseling when possible (remember the 4 Cs)
29Referral Surgical Evaluations are usually emergent Pre-determine possible providers in your area whom you will refer toProvincial AIDS Program recommends this provider for ……Conditions that require referral for surgery are usually emergencies.For efficiency it is best that providers identify in advance whom they will send patients to when needed.PACPs may help with the referral process as described above. Trainers please highlight any referral linkages in your area if they exist.
31Gonorrhoea Causes Major complications: Men: Urethral Strictures In menIn womenUrethritisCervicitisProctitisPharyngitisCausesMajor complications: Men: Urethral StricturesMajor complications: Women: PIDMajor complications: Disseminated Gonorrhoea
32Treatment of Gonorrhoea Uncomplicated Anal/ Genital InfectionCiprofloxacin 500 mg orally once only (Ciprofloxacin is contraindicated in pregnancy and for children or adolescents)ORCefixime 400 mg orally once onlyCeftriaxone 125 mg intramuscularly (IM) once onlySpectinomycin 2 gm intramuscularly (IM) once onlyDisseminated Gonococcal infectionCeftriaxone 1 gm intramuscular or intravenous once daily for 7 daysSpectinomycin 2 gm intramuscularly twice daily for 7 daysNeonatal OphthalmiaCeftriaxone 50mg/ kg intramuscularly as a single doseKanamycin 25 mg/ kg intramuscularly as a single doseSpectinomycin 25 mg/ kg intramuscularly as a single dose
33Treatment of Chlamydia Uncomplicated Anal/ Genital InfectionDoxycycline 100 mg orally twice daily for 7 days(Not to be used for pregnant women, children or adolescents)ORAzithromycin 1 gm orally once onlyAlternative RegimensAmoxycillin 500 mg orally 3 times a day for 7 daysErythromycin 500 mg 4 times a day for 7 daysOfloxacin 300 mg orally twice a day for 7 days(Please note that all formulations of Ofloxacin in the market have 200 mg, so 2 capsules or tablets will be required)Tetracycline 500 mg orally 4 times a day for 7 days
34Chlamydia Usual presentation of Chlamydia are similar to Gonorrhoea Chlamydia is also asymptomatic in many patientsCommon presentations of Chlamydia:In menIn womenConjunctivitisUrethritisProctitisEpidydmitisProstatitisCervicitisEndometritisSalpingitisComplications of Chlamydia:InfertilityEctopic pregnancyMiscarriage
35Syphilis One of the oldest diseases on man 4 stages: Primary, secondary, late latent and tertiaryCongenital syphilis in children born from infected mothers
36Primary syphilis on finger Early infectionLasts for 1-3 monthsLesion is called chancreOccurs at the site of the entry of organism (usually genitalia but can be anywhere)Multiple chancres can occurNot possible to accurately distinguish from HSV-2Primary SyphilisPrimary syphilis on finger
37Secondary SyphilisAt this stage the organisms are multiplying and disseminating in the bodyManifestations can occurs all over the body although most commonly happen in skinLesions are macular, maculopapular, papular or pustularMost commonly on palms and solesMay become a painless, broad, moist, gray white to erythematous highly infectious plaques called condyloma lataMay also cause arteritis
38Clinical Manifestations of Secondary Syphilis SkinRashMacularMaculopapularPapularPustularCondyloma latumGeneralized lymphadenopathyPruritusMouth and throatMucous patchesErosionsUlcer (aphthous)Genital lesionsChancreChondyloma latumMucous patchConstitutional symptomsFever of unknown originMalaisePharyngitis, laryngitisAnorexia, weight loss, ArthralgiasCentral nervous systemAsymptomaticSymptomaticHeadacheMeningismusMeningitisOcularDiplopiaDecreased visionOtiticTinnitusVertigoCranial nerve involvement (II–VIII)RenalGlomerulonephritisNephrotic syndromeGastrointestinalHepatitisIntestinal wall invasionArthritis, osteitis, and periostitisThe list of manifestations is illustrative and need not be discussed in detailPlaques of Condyloma lata
39Late Latent SyphilisThis is the phase when the manifestations of the primary and secondary syphilis are over and yet the patient remains infected10-25% of these individuals will go on to develop tertiary syphilis
40Tertiary Syphilis This is the late stage Involvement of CNS, eyes, cardiovascular system in addition to late benign syphilis (gumma)
41Congenital syphilis Happens by infection of the baby in utero Many complications – most are seriousWe recommend that this condition must always be referred to specialist care
42Syphilis Testing2 types of tests: Treponemal (VDRL, RPR) and Non-treponemal (FTA-ABS, TPHA)VDRL/RPR become positive earlier and may turn negative in 3-5 years even when untreatedFTA-ABS/TPHA take 2-3 months to turn positive and remain positive for lifeVDRL/RPR turn negative in 1+ year after successful treatment (may be upto 2 years)These patients will require follow up with the titer of VDRL/RPRFTA-ABS/TPHA response to treatment is not knownSome patients who get successfully treated will continue to show positive tests for months and years after treatment. This does not mean that the infection is continuing. For these patients it is essential to follow the titer of VDRL or RPR. A falling titer is satisfactory. If it does not fall or rises at 3 monthly re-checks, the treatment must be repeated. Treatment of choice for re-treatment is the same: Penicillin. Clinically no resistance has been documented against Penicillins in syphilis.
43Treatment of SyphilisEarly Syphilis (Primary, Secondary or Latent of less than 2 years duration)Benzathine Penicillin 2.4 million IU intramuscularly onceAlternative RegimenProcaine Benzyl Penicillin 1.2 million IU intramuscularly once daily for 10 daysAlternative Regimen (for Penicillin allergic patients and non-pregnant patients)Doxycycline 100 mg orally twice a day for 14 daysORTetracycline 500 mg orally twice a day for 14 daysAlternative Regimen (for Penicillin allergic patients and pregnant patients)Erythromycin 500 mg orally 4 times a day for 14 days
44Late Latent Syphilis (Infection of more than 2 years duration) Treatment of SyphilisLate Latent Syphilis (Infection of more than 2 years duration)Benzathine Penicillin 2.4 million IU intramuscularly once a week for 2 consecutive weeksAlternative RegimenProcaine Benzyl Penicillin 1.2 million IU intramuscularly once daily for 20 daysAlternative Regimen for Penicillin allergic patients and non-pregnant patientsDoxycycline 100 mg orally twice a day for 30 daysORTetracycline 500 mg orally 4 times a day for 30 daysAlternative Regimen for Penicillin allergic patients and pregnant patientsErythromycin 500 mg orally 4 times a day for 30 days
45(Ideally it should be referred for admission) (or should we admit all) Treatment of SyphilisNeurosyphilisAqueous Benzyl Penicillin 2-4 million IU by intravenous injection every 4 hours for 14 days (12-24 millions units a day for 14 days)(Ideally it should be referred for admission) (or should we admit all)ORProcaine Benzyl Penicillin 1.2 million IU intramuscularly once daily plus Probenecid 500 mg orally 4 times a day, both given for days(Although this regimen is meant for outpatient therapy, please ensure that the patient will remain compliant with FULL treatment)For Penicillin allergic non-pregnant patientsDoxycycline 200 mg orally twice a day for 30 daysTetracycline 500 mg orally 4 times a day for 30 days
46Herpes Simplex type-2 (HSV-2) CommonMostly asymptomaticManifests as blisters or ulcers and is painfulTreatment protocols divided as: first episodes, recurrent episodes and those requiring suppressive therapyTreatment suppresses symptoms but does not cure infectionDifference between recurrent episodes and suppressive therapy: Occasional recurrent episodes may be treated with a short course of Acyclovir. Those who have very frequent episodes that are SYMPTOMATIC may require suppressive therapy.
47Treatment of Herpes Simplex type 2 (HSV-2) Treatment of First Episode:Acyclovir 400 mg 3 times a day for 7 daysTreatment of Recurrent Episodes:Acyclovir 400 mg 3 times a day for 5 daysSuppressive therapy:Acyclovir 400 mg twice a day continuously
48Trichomonas Vaginalis Usually presents as a vaginal discharge and vulvovaginal soreness or irritationCan also cause Dysuria or dyspareunia (usually severe) and lower abdominal discomfortDiagnosis is usually clinical
49Treatment of Trichomonas Vaginalis Metronidazole 2 gm orally onceORTinidazole 2 gm orally onceAlternative regimen (also used for urethral infections)Metronidazole 400 or 500 mg orally twice daily for 7 daysTinidazole 500 mg orally twice daily for 7 days
50Bacterial Vaginosis Commonest cause of vaginal discharge Not an STI (does not effect males)Represents alteration of the vaginal floraPresents as a smelly discharge in lower vagina and labiaDischarge is grayish, thin, homogenous and contains bubblesBV is not an STI since there is no male version of the condition – therefore it can not be transmitted
51Treatment of Bacterial Vaginosis Metronidazole 2 gm orally onceORClindamycin 2% vaginal cream, 5 gm intravaginally at bedtime for 7 daysMetronidazole 0.75% gel, 5 gm intravaginally twice daily for 7 daysClindamycin 300 mg orally twice daily for 7 daysTreatment during PregnancyFirst Trimester (only if treatment is imperative): Metronidazole 2 gm orally once2nd or 3rd trimesters: Metronidazole mg 3 times a day for 7 daysAlternative regimen
52CandidaDue to overgrowth of candida around labia and surrounding areasUsually represents alteration of vaginal flora or other causes and not an STIDiagnosis is clinicalDysuriaExcoriations (redness with peeling of skin) in the perivaginal areaShallow, radial, linear ulcerationsVaginal walls are redDischarge is thick, sticks to skin and has curdsNo smell
53Treatment of CandidaMiconazole or clotrimazole 200 mg intarvaginally daily for 3 daysORClotrimazole 500 mg intravaginallly onceFluconazole 150 mg orally onceAlternate RegimenNystatin 100,000 IU intarvaginally daily for 14 days
54Venereal WartsCaused by viruses called the Human Papilloma Virus or HPVAppear as skin tagsCan be very small (barely visible) to several centimetersIn men they are present around shaft of penisIn women they are present around visible parts of the vagina and clitoris although they can be anywhere on the genitaliaPeri-anal warts are present in those engaging in receptive anal sex and may be inside anal canalDue to the danger of development of cancer, those treated for warts must be referred to assessment of cancer (Pap smear in women and follow up in men)
55Treatment for Venereal Warts Treatment is meant for external genitalia and vaginal. Please refer to gynaecologic specialist for cervical wartsConsider sending patients with warts for gynaecological evaluation since the causative agent of warts (human papilloma virus) increases the risk of cervical cancerProvider administered: Podophyllin 10-25% in compound of tincture or benzoin. Apply carefully avoiding normal tissue. External genital genitalia should be washed thoroughly in 1-4 hours. Allow the applied medicine to dry before removing speculum. Repeat application weekly as needed.ORCryotherapy (when available). Repeat after 1-2 weeks as neededSelf applied by the patient: Podophyllin 0.5% twice daily for 3 days then no treatment for 4 days. Follow this cycle for up to 4 times.
57Urethral Discharge Men mostly but women too Gonorrhoea or Chlamydia or bothEmphasize confirming dischargeNo discharge – other abnormality: appropriate algorithmNo discharge – no abnormality: reassureA patient may have either GC, CT or both at the same timeThe main emphasis is on confirming the presence of dischargeMany individuals may confuse ejaculations with discharge. These ejaculations may be due to masturbation or nocturnal (and therefore involuntary and unseen). Due to taboos in our society, many young adults feel uncomfortable with their ejaculations and turn for medical help when they do. These must be re-assured rather than treated with antibiotics
58Clinical case25 year old man presents to the clinic, sits down and is uncomfortable discussing his complaintsAfter some probing he admits some difficulty related to penis and some discomfort during urinationHe declines any extramarital sex activity and continues to look uncomfortable
59Learning pointMany patients will not openly discuss their STI related complaintsMany may not accept extramarital sexSome may start with vague complaints and come to their STI symptom only when comfortableConfidence and Rapport building are crucial for good STI history takingExamination of penis to confirm diagnosis of urethral discharge is important
60Discharge from Urethra Expressing discharge from Urethra Urethral DischargeDischarge from UrethraExpressing discharge from Urethra
62Persistent or Recurrent Discharge Definition: Discharges that continue to bother patient after 1 wk or more of appropriate TxSignificance:Non-adherenceResistance (gonorrhoea)Re-infectionMissed DiagnosisRe-infection may require probing history about sexual relationsPartner management issues
63PERSISTENT URETHRAL DISCHARGE Take historyand examine.Milk urethra ifnecessaryDischargeconfirmed?Any othergenitaldiseaseDoesHistoryconfirm re-infection orpoorcomplianceUseappropriateflow chartRepeat UrethralTreatment4 CsAsk patient toreturn in 7days ifsymptomspersistRefer forlaboratorytests andSpecialistCarePERSISTENT URETHRAL DISCHARGEPatientcomplains ofurethralDischarge ordysuriaYesNotbetterNo4 Cs:1.ComplianceCounseling2.Promote & provideondoms3.ounselingfor STIprevention, HIVtesting;Educate andReassure patient4.Partner (ontact)treatmentTREATMENT OF GONORRHOEAUncomplicated Anal/ Genital InfectionCiprofloxacin500 mg orally once only(Ciprofloxacin is contraindicated inpregnancy and for children or adolescents)ORCefixime400 mg orally once onlyCeftriaxone125 mg IM once onlySpectinomycin2 gm IM once onlyTREATMENT OF CHLAMYDIADoxycycline100 mg orally twice daily for 7 days(Not to be used for pregnant women, children oradolescents)Azithromycin1 gm orally once onlyAlternative RegimensAmoxycillin500 mg orally 3 times a day for 7daysErythromycin500 mg 4 times a day for 7 daysOfloxacin400 mg orally twice a day for 7 daysTetracycline500 mg orally 4 times a day for 7TREATMENT OF TRICHOMONASMetronidazole400 or 500 mg orally twice daily for 7Tinidazole500 mg orally twice daily for 7 days•return in 7 days ifsymptoms persistTreat forTrichomonas
64Genital Ulcers Confirm with exam Critical distinction: Ulcer (sore) vs Vesicle (blister)Clinically impossible to differentiate between syphilis, HSV and chancroid in about ½ of ulcersClinically relevant situation: Non healing ulcers vs slow healing ulcersHIV/HSV co-infection and HIV transmission
65Clinical Case 21 y/o man presents with severe pain on penis for 3 days It is causing difficulty with urinationOn exam, there is a single ¼ cm ulcer on the glans penis near the urethral meatus
66Clinical Case21 y/o woman presents with severe pain around vagina for 3 daysIt is causing difficulty with urinationOn exam, there is a single ¼ cm ulcer near the urethra___________________________Note: the ulcer may be on the labia, near or on clitoris/ urethra or any where in the genital area
67Clinical pointsUlcers range from barely visible to over a centimeter in many of the patientsThey may be multipleMultiple ulcers may not all be together (ie they may be in different parts of the genitalia)They may occur around the anusIn about half of the cases it is impossible to distinguish between HSV and syphilis
72Scrotal Swelling Critical decision: Infectious or Non-infectious History important for prior traumaExamination is important to distinguish rotation, elevation or rotation of testesInfectious causes are usually GC/ CTNon-infectious causes are usually surgicalSurgical problems require (usually emergent) referralRemind patients that scrotal swellings particularly that are due to past trauma may take a long time to resolve….
73Clinical Case 19 y/o man presents with scrotal discomfort There was a history of difficulty urination and perhaps some urethral discharge about 3 weeks agoThere is a history of penetrative sex with a Hijra in the past several weeksOn exam the left side of scrotum is slightly swollen and slightly tender just under the base of penis
74Clinical pointsIt is absolutely essential to distinguish infection from surgical causes of scrotal swelling – when in doubt refer for surgical care
76Anal Symptoms Main concerns: DischargeUlcersWartsHemorrhoidsRectal FissuresProctoscopy increases diagnosis for most common causesWarts a concern for future development of cancerOccasionally HSV can also cause anal discharges, Discharges not responding to GC/CT Tx may be tried on HSV-2 Tx
77Clinical case A 29 y/o man presents with anal discomfort for one week On probing, he admits to occasionally selling anal sex, last being about 2 weeks agoOn exam there is anal ulcers
78Clinical CaseA 35 y/o married man presents with soiling of underwear for a weekThe soiling is foul smelling and has caused embarassment for him at his officeHe denies any extramarital sexAfter some rapport building he admits to having sex with a male colleague but insists that he (your patient) only penetratedOn exam there is purulent anal discharge
79Clinical CaseA 36 y/o disshevelled man presents with severe pain during defecationAfter rapport building he admits to using injected drugsOn exam he has a stage 3 hemorrhoid (prolapses with minimal pressure) that has some ulceration and scarring on the mucosa____________________Learning point: Many IDUs sell anal sex for drugs. Advanced hemorrhoids are not uncommon among IDUs and are a result of repeated anal traumaAnal Fissures may develop from this trauma as well
82Vaginal Discharge Vaginal Discharge is a common complaint among women Critical point: Do not treat women that don’t present with this complaint (ie Vaginal discharge is not the reason why they came to see you)Critical point: Assessment of riskHigh risk > Treat for cervicitis otherwise for vaginitisSpeculum exam does not improve DxHSV-2 can also cause rare discharge. Treatment non-responders must be re-assessed for risk and for HSV-2 TxAsking about amount of discharge or smell may help distinguish cervicits from vaginitsBecause this algorithm works better with women who have a high risk of STIs and because international evidence favor, it is advisable that only those women who spontaneously complain of vaginal discharge be treated with this algorithm. If the provider has to elicit a history of vaginal discharge from a woman who has not herself complained of this symptom, the algorithm usually results in over treatment (treatment when not needed).
83Vaginal Discharge: Causes VaginitisCervicitisCaused by Trichomoniasis (TV), Candidiasis and Bacterial VaginosisCaused by Gonorrhoea and ChlamydiaMost common cause of vaginal dischargeLess common cause of vaginal dischargeEasy to diagnoseDifficult to diagnoseNo complicationsMajor complicationsTreatment of partner unnecessary, except for TVNeed to treat partner
84Clinical Case21 y/o married mother of 2 children presents with a sore throatOn a comprehensive review of systems she admits to having a vaginal dischargeOn exam there is a scant vaginal dischargeClinical point: This is likely physiological discharge and should not be treated
85Clinical CaseA 22 y/o mother of 1 child presents with vaginal dischargeShe describes some scant odor to the discharge which also itchesOn rapport building she admits that she occasionally has sex with a neighbor for money to make ends meetClinical point: This is likely Cervicitis. Note that the critical point is the assessment of risk
86Clinical Case34 y/o somewhat obese woman presents with vaginal itching and discomfortOne further questioning she also admits noticing a vaginal dischargeOn rapport building there is no history of risky sex behaviorClinical point: this is likely Candidiasis, this woman may have diabetes although having diabetes is not necessary for candidiasis
88Lower Abdominal Pain Main concerns: PID (infectious)Retained placenta/ dead fetus/ other products of conceptionCritical finding: Cervical Motion TendernessPrompt referral for non-responders is criticalHospitalization important for serious patients
89Clinical Case32 y/o woman presents with lower abdominal pain for past 4 daysShe denies any history of risky sex (was asked properly, with respect and tact)She did have increase in vaginal discharge 3 weeks ago (she usually notices some discharge every month) but was busy helping her husband with some essential house work before he started another truck trip to AfghanistanOn exam there is cervical motion tendernessClinical point: This is likely PID
90Clinical CaseA 28 y/o woman presents with lower abdominal pain for 6 months - on and offHer abdominal pain is not related to meals and she does not have diarrhea (if anything she often does not need to go to bathroom for 2-3 days)There is no risky sex behaviorShe lives in a household of 14 people and her husband is the only bread earnerThere is no cervical motion tendernessClinical point: This is unlikely to be infectious
91Criteria for hospitalization: Lower Abdominal PainCriteria for hospitalization:Pregnant patientCannot exclude surgical emergencies (ie appendicitis)Severe illness: Nausea and vomiting or Fever >39oC,Severe pain (enough to interfere with daily life)No response to oral medicinesUnable to take or can not tolerate oral medicinesEvidence of a tubo-ovarian abscess
94Acyclovir:Rare side effects in patients treated short-term with acyclovir are nausea, vomiting, and headache. Long-term treatment has the additional potential for rash and diarrhea.Azithromycin:Azithromycin is generally well tolerated. The most common side effects are diarrhea or loose stools, nausea, abdominal pain, and vomiting, each of which may occur in fewer than one in twenty persons who receive Azithromycin. Rarer side effects include abnormal liver tests, allergic reactions, and nervousness.
95Ceftriaxone:If administering Ceftriaxone into a muscle, it may be mixed with Lidocaine (Xylocaine, Lignocaine) to reduce pain at the injection site. Milder symptoms are: Diarrhea, stomach pain, upset stomach, vomiting. More severe symptoms include: unusual bleeding or bruising, difficulty breathing, itching, rash, hives, sore mouth or throat.Cefixime:Cefixime is generally well tolerated and side effects are usually transient. Reported side effects include diarrhea, pseudomembranous colitis (can occur even after cefixime is stopped) nausea, abdominal pain, vomiting, skin rash, fever, joint pain and arthritis, abnormal liver tests, vaginitis, itching, headaches, and dizziness.
96Clindamycin:Mild diarrhea or stomach upset may occur. If any of these effects persist or worsen, they should be observed carefully. Although unlikely, vaginal pain/itching/discharge may occur or worsen. These symptoms may be due to a new vaginal infection (e.g., yeast/fungal infection, trichomonas infection). This medication may infrequently cause a fungal infection in another part of the body (e.g., oral thrush). This may manifest as a change in vaginal discharge, white patches in your mouth, or other new symptoms. Many people using this medication do not have serious side effects. Serious side effects include: pain on urination, lower back pain, menstrual problems, abnormal vaginal bleeding. A very small amount of this medication may be absorbed into bloodstream and may rarely cause a severe intestinal condition (pseudomembranous colitis) due to a resistant bacterium. This condition may occur while receiving therapy or even weeks after treatment has stopped. Do not use anti-diarrhea products or narcotic pain medications if you suspect that the patient has this condition because these products may make them worse. Major signs of pseudomembranous colitis are persistent diarrhea, abdominal or stomach pain/cramping, or blood/mucus in stool. A very serious allergic reaction to this drug is unlikely, but requires immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include: rash, itching, swelling, severe dizziness, trouble breathing.
97Fluconazole:Up to 25% develop side effects from this medication. Headaches, nausea, abdominal pain, diarrhea or dizziness are common. Severe skin rash may occur but is uncommon.Miconazole:Irritation and burning have been reported by patients using topical or vaginal miconazoleClotrimazole:The most commonly noted side effects associated with clotrimazole are local redness, stinging, blistering, peeling, swelling, itching, hives, or burning at the area of application. All of these are quite unusual, however.Tinidazole:Tinidazole may cause side effects. Consider stopping it if any of these symptoms are severe or do not go away: sharp, unpleasant metallic taste, upset stomach, vomiting, loss of appetite, constipation, stomach pain or cramps, headache, tiredness or weakness, dizziness. Some side effects can be serious. The following symptoms are uncommon, but require that the medicine must be stopped immediately: seizures, numbness or tingling of hands or feet, rash, hives, swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, hoarseness, difficulty swallowing or breathingNystatin:diarrhea, nausea, gas, or vomiting as until the body adjusts to the medication. If these symptoms persist or get worse consider stopping the medicine.
98Doxycycline:Doxycycline is generally well-tolerated. The most common side effects are diarrhea or loose stools, nausea, abdominal pain, and vomiting. Tetracyclines, such as doxycycline, may cause tooth discoloration if used in persons below 8 years of age. Exaggerated sunburn can occur with tetracyclines; therefore, sunlight should be minimized during treatment.Tetracycline:Tetracycline is generally well-tolerated. The most common side effects are diarrhea or loose stools, nausea, abdominal pain, and vomiting. Tetracyclines may cause discoloration of teeth if used in patients below 8 years of age. Exaggerated sunburn can occur with tetracyclines; therefore, sunlight should be minimized during treatmentMetronidazole:Metronidazole is generally well tolerated with appropriate use. Serious side effects of metronidazole are rare; and include seizures and damage of nerves resulting in numbness and tingling of extremities (peripheral neuropathy). Metronidazole should be stopped if these symptoms appear. Minor side effects include nausea, headaches, loss of appetite, a metallic taste, and rarely a rash.
99Ciprofloxacin:Nausea, vomiting, diarrhea, abdominal pain, rash, headache, and restlessness. Rare allergic reactions have been described, such as hives and anaphylaxis (shock)Levofloxacin:The most frequently reported side events are nausea or vomiting, diarrhea, headache, and constipation. Less common side effects include difficulty sleeping, dizziness, abdominal pain, rash, abdominal gas, and itching.Ofloxacin:The most frequent side effects include nausea, vomiting, diarrhea, insomnia, headache, dizziness, itching, and vaginitis in women. Rare allergic reactions have been described, such as hives and anaphylaxis (shock). Symptoms of nervous system stimulation, such as anxiety, euphoria, and hallucinations have rarely been reported.
100Penicillin:This medication may cause mild diarrhea, stomach upset, nausea, vomiting or irritation at injection site during the first few days. If this irritation worsens or persist for more than a few days, stop the medicine. Medicine should be stopped if patient develops: watery diarrhea, stomach cramps, fever, unusual bleeding or bruising, yellowing of the eyes or skin, unusual tiredness or weakness. In the unlikely event of an allergic reaction to this drug, appropriate care for anaphylaxis should be provided. Symptoms of an allergic reaction include: wheezing, difficulty breathing, skin rash, hives, itching.PodophyllinSwelling, pain, burning, itching, peeling skin, small sores, or headache may occur. Most serious side effect is bleeding.