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National STI Management Guidelines of Pakistan

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Presentation on theme: "National STI Management Guidelines of Pakistan"— Presentation transcript:

1 National STI Management Guidelines of Pakistan
The National AIDS Control Programme The Provincial AIDS Control Programmes The World Health Organization

2 Basic Outline and Concepts

3 Worldwide epidemiology of STIs
340 Million new infections annually Burden unevenly shared more by developing countries Account for app 17% of health expenses* HIV is an STI HIV-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

4 Common Terms Used Provider and clinician are used interchangeably
This can under some circumstances include non doctor providers

5 Epidemiology in Pakistan of STIs
Very common among high risk groups Moderately common among bridge groups Uncommon among general population Data 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 Lahore A national study (the ANC study 2001) showed that among women attending ANC clinics and labor wards, all STIs were less than 1%

6 Care seeking for STIs in Pakistan
Similar to other care in Pakistan: >70% in the private sector Different providers see different types of clients Syphilis testing and Tx is uncommon Partner management is rare Condom promotion is uncommon Data 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.

7 Counseling and condom promotion
Condoms are the best prevention measure Counseling works Patient-provider interactions are the best condom and risk behavior counseling opportunities Free condom provision Discussing STI risk behaviors Please 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.

8 Partner Management Patient>Partner>Patient reinfection cycle
Patient delivered medicines More important to focus on the patient’s regular partner Managing 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 patients We recommend that the patients be given medicines or prescriptions for the same medicines that they are receiving to be given to their partners.

9 Referrals Difficult STIs HPV/ warts
Decide or pre-identify whom to refer to Role of the provincial AIDS Programs Referrals 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.

10 Compliance, Counseling, Condoms and Contact (Partner) Management
The 4 Cs Compliance, Counseling, Condoms and Contact (Partner) Management The 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.

11 4 Cs: Compliance STI patients must be encouraged to comply with their prescribed treatment Instruct all patients to complete the full course of treatment Disappearance of symptoms during treatment does not mean that the patient is cured, full course of treatment must be completed Without proper treatment, STIs may cause severe complications Patient should avoid sexual contact during the treatment and until partner has been treated Ensure a follow-up visit

12 4 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 contact Information about safer sex practices and use of condom The mode of transmission of STIs, including HIV STI augments the risk of HIV transmission Offer HIV voluntary counseling and testing (VCT) Consider syphilis testing A 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

13 4 Cs: Condom Use To 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 correctly Clinic should supply condoms to STI patients Most 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 training Please 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

14 4 Cs: Contact (Partner) Management
Patients must understand the importance of partner management even if he/she is asymptomatic: Risk of re-infection from asymptomatic partner Risk of complications for his/her partner Possible ways of partner management include: Providing additional treatment regimens for the partner Encouraging partners to come to the clinic for treatment Re-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.

15 Reproductive Health Linkages
Two forms of linkages were identified in our consultations Gynecologists should act as the specialist to whom either difficult infections or patients with warts are sent to All 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 referring Anal 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.

16 Risk Assessment of patients
Some persons are at more risk of STIs than others due to: Their behaviors Where they live STI algorithms (those for women) work better with high risk patients It 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 setting Once 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)

17 What is Syndromic Management
History-Exam-Lab paradigm History-Exam paradigm Limited laboratory support in most areas Limited utility of labs when available Most 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.

18 Benefits of Syndromic Approach
Standardization of care Cost effectiveness It 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.

19 Limitations of the Syndromic Approach
Works better for male STIs No algorithms for anal symptoms Female algorithms work better in high risk settings Syphilis management which requires testing is not well addressed by these guidelines The algorithms work very well for male STIs Since there are no standard anal symptoms algorithms available: we constructed one for those anal symptoms that were identified during our consultations with providers Female algorithms work best when there is a high risk of STIs in the patient Since syphilis is the only condition that requires a test before treatment, its different for other syndromes. There is no particular syndrome associated with syphilis.

20 Syndromes discussed Urethral Discharge Genital Ulcer Scrotal Swelling
Vaginal Discharge Lower abdominal pain Anal symptoms

21 STIs 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 albicans Bacterial Vaginosis (BV)1 Syphilis (Treponema pallidum) Human Papilloma Virus (HPV) Haemophilus ducreyi (Chancroid)2 Lymphogranuloma Venereum (LGV)2 1. Not actually an STI, included here as it causes symptoms in women 2. Uncommon in Pakistan and therefore will not be addressed in any depth

22 Basic Etiology (causative organisms) of Syndromes
Symptoms Signs Most common causes Urethral discharge Urethral discharge Dysuria Frequent urination Gonorrhoea Chlamydia Genital ulcer Genital sore Syphilis Chancroid Genital herpes Scrotal swelling Scrotal pain and swelling Scrotal swelling Lower abdominal pain Lower abdominal pain Dyspareunia Vaginal discharge Lower abdominal tenderness on palpation Temperature >38° Mixed anaerobes Vaginal Unusual vaginal discharge Vaginal itching Dysuria (pain on urination) Dyspareunia (pain during sexual intercourse) Abnormal vaginal VAGINITIS: Trichomoniasis Candidiasis CERVICITIS: Anal Symptoms Anal Pain Anal Discharge Anal or peri-anal sores Anal tenderness Anal or peri-anal Ulcers HSV-2

23 Issues of antibiotic resistance
Empiric prescription of antibiotics Gonococcal resistance already a problem Syndromic approach can help or aggravate the problem Antibiotics 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 places Resistance manifests with failure of patient’s symptoms to resolve despite adequate therapy Many 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

24 Evidence Behind the Guidelines
Urethral Discharge: Senstivity 87-99% Labs seldom add to sensitivity Labs slightly enhance specificity for CT but not NG The main concern here is to not miss any infections. The high sensitivity ensures that few actual cases are missed.

25 Evidence Behind the Guidelines
Genital Ulcer: Senstivity: % More sensitive and specific for HSV and Syphilis Labs add very little to specificity Again high senstivity ensures few actual cases are missed

26 Evidence Behind the Guidelines
Vaginal Discharge: Senstivity: 73-93% when applied to women presenting for STI care Senstivity: 29-86% when applied to all women screened for STIs Only 10% of low risk women actually have an STI Speculum 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

27 Common Issues Syphilitic chancre of fingers
Protect yourself, wear gloves Protection of the provider is crucial and should be emphasized repeatedly Syphilitic chancre of fingers

28 Common Issues Protect yourself, wear gloves
STIs require contact between 2 individuals, think of the partner Prevent future problems: promote condoms Counseling when possible (remember the 4 Cs)

29 Referral Surgical Evaluations are usually emergent
Pre-determine possible providers in your area whom you will refer to Provincial 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.

30 Common STIs

31 Gonorrhoea Causes Major complications: Men: Urethral Strictures
In men In women Urethritis Cervicitis Proctitis Pharyngitis Causes Major complications: Men: Urethral Strictures Major complications: Women: PID Major complications: Disseminated Gonorrhoea

32 Treatment of Gonorrhoea
Uncomplicated Anal/ Genital Infection Ciprofloxacin 500 mg orally once only (Ciprofloxacin is contraindicated in pregnancy and for children or adolescents) OR Cefixime 400 mg orally once only Ceftriaxone 125 mg intramuscularly (IM) once only Spectinomycin 2 gm intramuscularly (IM) once only Disseminated Gonococcal infection Ceftriaxone 1 gm intramuscular or intravenous once daily for 7 days Spectinomycin 2 gm intramuscularly twice daily for 7 days Neonatal Ophthalmia Ceftriaxone 50mg/ kg intramuscularly as a single dose Kanamycin 25 mg/ kg intramuscularly as a single dose Spectinomycin 25 mg/ kg intramuscularly as a single dose

33 Treatment of Chlamydia
Uncomplicated Anal/ Genital Infection Doxycycline 100 mg orally twice daily for 7 days (Not to be used for pregnant women, children or adolescents) OR Azithromycin 1 gm orally once only Alternative Regimens Amoxycillin 500 mg orally 3 times a day for 7 days Erythromycin 500 mg 4 times a day for 7 days Ofloxacin 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

34 Chlamydia Usual presentation of Chlamydia are similar to Gonorrhoea
Chlamydia is also asymptomatic in many patients Common presentations of Chlamydia: In men In women Conjunctivitis Urethritis Proctitis Epidydmitis Prostatitis Cervicitis Endometritis Salpingitis Complications of Chlamydia: Infertility Ectopic pregnancy Miscarriage

35 Syphilis One of the oldest diseases on man
4 stages: Primary, secondary, late latent and tertiary Congenital syphilis in children born from infected mothers

36 Primary syphilis on finger
Early infection Lasts for 1-3 months Lesion is called chancre Occurs at the site of the entry of organism (usually genitalia but can be anywhere) Multiple chancres can occur Not possible to accurately distinguish from HSV-2 Primary Syphilis Primary syphilis on finger

37 Secondary Syphilis At this stage the organisms are multiplying and disseminating in the body Manifestations can occurs all over the body although most commonly happen in skin Lesions are macular, maculopapular, papular or pustular Most commonly on palms and soles May become a painless, broad, moist, gray white to erythematous highly infectious plaques called condyloma lata May also cause arteritis

38 Clinical Manifestations of Secondary Syphilis
Skin Rash Macular Maculopapular Papular Pustular Condyloma latum Generalized lymphadenopathy Pruritus Mouth and throat Mucous patches Erosions Ulcer (aphthous) Genital lesions Chancre Chondyloma latum Mucous patch Constitutional symptoms Fever of unknown origin Malaise Pharyngitis, laryngitis Anorexia, weight loss, Arthralgias Central nervous system Asymptomatic Symptomatic Headache Meningismus Meningitis Ocular Diplopia Decreased vision Otitic Tinnitus Vertigo Cranial nerve involvement (II–VIII) Renal Glomerulonephritis Nephrotic syndrome Gastrointestinal Hepatitis Intestinal wall invasion Arthritis, osteitis, and periostitis The list of manifestations is illustrative and need not be discussed in detail Plaques of Condyloma lata

39 Late Latent Syphilis This is the phase when the manifestations of the primary and secondary syphilis are over and yet the patient remains infected 10-25% of these individuals will go on to develop tertiary syphilis

40 Tertiary Syphilis This is the late stage
Involvement of CNS, eyes, cardiovascular system in addition to late benign syphilis (gumma)

41 Congenital syphilis Happens by infection of the baby in utero
Many complications – most are serious We recommend that this condition must always be referred to specialist care

42 Syphilis Testing 2 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 untreated FTA-ABS/TPHA take 2-3 months to turn positive and remain positive for life VDRL/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/RPR FTA-ABS/TPHA response to treatment is not known Some 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.

43 Treatment of Syphilis Early Syphilis (Primary, Secondary or Latent of less than 2 years duration) Benzathine Penicillin 2.4 million IU intramuscularly once Alternative Regimen Procaine Benzyl Penicillin 1.2 million IU intramuscularly once daily for 10 days Alternative Regimen (for Penicillin allergic patients and non-pregnant patients) Doxycycline 100 mg orally twice a day for 14 days OR Tetracycline 500 mg orally twice a day for 14 days Alternative Regimen (for Penicillin allergic patients and pregnant patients) Erythromycin 500 mg orally 4 times a day for 14 days

44 Late Latent Syphilis (Infection of more than 2 years duration)
Treatment of Syphilis Late Latent Syphilis (Infection of more than 2 years duration) Benzathine Penicillin 2.4 million IU intramuscularly once a week for 2 consecutive weeks Alternative Regimen Procaine Benzyl Penicillin 1.2 million IU intramuscularly once daily for 20 days Alternative Regimen for Penicillin allergic patients and non-pregnant patients Doxycycline 100 mg orally twice a day for 30 days OR Tetracycline 500 mg orally 4 times a day for 30 days Alternative Regimen for Penicillin allergic patients and pregnant patients Erythromycin 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 Syphilis Neurosyphilis Aqueous 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) OR Procaine 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 patients Doxycycline 200 mg orally twice a day for 30 days Tetracycline 500 mg orally 4 times a day for 30 days

46 Herpes Simplex type-2 (HSV-2)
Common Mostly asymptomatic Manifests as blisters or ulcers and is painful Treatment protocols divided as: first episodes, recurrent episodes and those requiring suppressive therapy Treatment suppresses symptoms but does not cure infection Difference 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.

47 Treatment of Herpes Simplex type 2 (HSV-2)
Treatment of First Episode: Acyclovir 400 mg 3 times a day for 7 days Treatment of Recurrent Episodes: Acyclovir 400 mg 3 times a day for 5 days Suppressive therapy: Acyclovir 400 mg twice a day continuously

48 Trichomonas Vaginalis
Usually presents as a vaginal discharge and vulvovaginal soreness or irritation Can also cause Dysuria or dyspareunia (usually severe) and lower abdominal discomfort Diagnosis is usually clinical

49 Treatment of Trichomonas Vaginalis
Metronidazole 2 gm orally once OR Tinidazole 2 gm orally once Alternative regimen (also used for urethral infections) Metronidazole 400 or 500 mg orally twice daily for 7 days Tinidazole 500 mg orally twice daily for 7 days

50 Bacterial Vaginosis Commonest cause of vaginal discharge
Not an STI (does not effect males) Represents alteration of the vaginal flora Presents as a smelly discharge in lower vagina and labia Discharge is grayish, thin, homogenous and contains bubbles BV is not an STI since there is no male version of the condition – therefore it can not be transmitted

51 Treatment of Bacterial Vaginosis
Metronidazole 2 gm orally once OR Clindamycin 2% vaginal cream, 5 gm intravaginally at bedtime for 7 days Metronidazole 0.75% gel, 5 gm intravaginally twice daily for 7 days Clindamycin 300 mg orally twice daily for 7 days Treatment during Pregnancy First Trimester (only if treatment is imperative): Metronidazole 2 gm orally once 2nd or 3rd trimesters: Metronidazole mg 3 times a day for 7 days Alternative regimen

52 Candida Due to overgrowth of candida around labia and surrounding areas Usually represents alteration of vaginal flora or other causes and not an STI Diagnosis is clinical Dysuria Excoriations (redness with peeling of skin) in the perivaginal area Shallow, radial, linear ulcerations Vaginal walls are red Discharge is thick, sticks to skin and has curds No smell

53 Treatment of Candida Miconazole or clotrimazole 200 mg intarvaginally daily for 3 days OR Clotrimazole 500 mg intravaginallly once Fluconazole 150 mg orally once Alternate Regimen Nystatin 100,000 IU intarvaginally daily for 14 days

54 Venereal Warts Caused by viruses called the Human Papilloma Virus or HPV Appear as skin tags Can be very small (barely visible) to several centimeters In men they are present around shaft of penis In women they are present around visible parts of the vagina and clitoris although they can be anywhere on the genitalia Peri-anal warts are present in those engaging in receptive anal sex and may be inside anal canal Due 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)

55 Treatment for Venereal Warts
Treatment is meant for external genitalia and vaginal. Please refer to gynaecologic specialist for cervical warts Consider sending patients with warts for gynaecological evaluation since the causative agent of warts (human papilloma virus) increases the risk of cervical cancer Provider 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. OR Cryotherapy (when available). Repeat after 1-2 weeks as needed Self 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.

56 STI Syndromes

57 Urethral Discharge Men mostly but women too
Gonorrhoea or Chlamydia or both Emphasize confirming discharge No discharge – other abnormality: appropriate algorithm No discharge – no abnormality: reassure A patient may have either GC, CT or both at the same time The main emphasis is on confirming the presence of discharge Many 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

58 Clinical case 25 year old man presents to the clinic, sits down and is uncomfortable discussing his complaints After some probing he admits some difficulty related to penis and some discomfort during urination He declines any extramarital sex activity and continues to look uncomfortable

59 Learning point Many patients will not openly discuss their STI related complaints Many may not accept extramarital sex Some may start with vague complaints and come to their STI symptom only when comfortable Confidence and Rapport building are crucial for good STI history taking Examination of penis to confirm diagnosis of urethral discharge is important

60 Discharge from Urethra Expressing discharge from Urethra
Urethral Discharge Discharge from Urethra Expressing discharge from Urethra

61 Emphasize the 4 Cs

62 Persistent or Recurrent Discharge
Definition: Discharges that continue to bother patient after 1 wk or more of appropriate Tx Significance: Non-adherence Resistance (gonorrhoea) Re-infection Missed Diagnosis Re-infection may require probing history about sexual relations Partner management issues

Take history and examine. Milk urethra if necessary Discharge confirmed? Any other genital disease Does History confirm re - infection or poor compliance Use appropriate flow chart Repeat Urethral Treatment 4 Cs Ask patient to return in 7 days if symptoms persist Refer for laboratory tests and Specialist Care PERSISTENT URETHRAL DISCHARGE Patient complains of urethral Discharge or dysuria Yes Not better No 4 Cs: 1. C ompliance Counseling 2. Promote & provide ondoms 3. ounseling for STI prevention, HIV testing; Educate and Reassure patient 4. Partner ( ontact) treatment TREATMENT OF GONORRHOEA Uncomplicated Anal/ Genital Infection Ciprofloxacin 500 mg orally once only (Ciprofloxacin is contraindicated in pregnancy and for children or adolescents) OR Cefixime 400 mg orally once only Ceftriaxone 125 mg IM once only Spectinomycin 2 gm IM once only TREATMENT OF CHLAMYDIA Doxycycline 100 mg orally twice daily for 7 days (Not to be used for pregnant women, children or adolescents) Azithromycin 1 gm orally once only Alternative Regimens Amoxycillin 500 mg orally 3 times a day for 7 days Erythromycin 500 mg 4 times a day for 7 days Ofloxacin 400 mg orally twice a day for 7 days Tetracycline 500 mg orally 4 times a day for 7 TREATMENT OF TRICHOMONAS Metronidazole 400 or 500 mg orally twice daily for 7 Tinidazole 500 mg orally twice daily for 7 days return in 7 days if symptoms persist Treat for Trichomonas

64 Genital Ulcers Confirm with exam
Critical distinction: Ulcer (sore) vs Vesicle (blister) Clinically impossible to differentiate between syphilis, HSV and chancroid in about ½ of ulcers Clinically relevant situation: Non healing ulcers vs slow healing ulcers HIV/HSV co-infection and HIV transmission

65 Clinical Case 21 y/o man presents with severe pain on penis for 3 days
It is causing difficulty with urination On exam, there is a single ¼ cm ulcer on the glans penis near the urethral meatus

66 Clinical Case 21 y/o woman presents with severe pain around vagina for 3 days It is causing difficulty with urination On 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

67 Clinical points Ulcers range from barely visible to over a centimeter in many of the patients They may be multiple Multiple ulcers may not all be together (ie they may be in different parts of the genitalia) They may occur around the anus In about half of the cases it is impossible to distinguish between HSV and syphilis

68 Vulvar ulcer – Primary syphilis
Genital Ulcers Vulvar ulcer - HSV Vulvar ulcer – Primary syphilis

69 Peri-vaginal Primary Herpes
Genital Ulcers Penile ulcer - HSV Peri-vaginal Primary Herpes

70 Penile ulcer – primary syphilis
Genital Ulcers Penile ulcer – primary syphilis Penile Vesicles - HSV


72 Scrotal Swelling Critical decision: Infectious or Non-infectious
History important for prior trauma Examination is important to distinguish rotation, elevation or rotation of testes Infectious causes are usually GC/ CT Non-infectious causes are usually surgical Surgical problems require (usually emergent) referral Remind patients that scrotal swellings particularly that are due to past trauma may take a long time to resolve….

73 Clinical Case 19 y/o man presents with scrotal discomfort
There was a history of difficulty urination and perhaps some urethral discharge about 3 weeks ago There is a history of penetrative sex with a Hijra in the past several weeks On exam the left side of scrotum is slightly swollen and slightly tender just under the base of penis

74 Clinical points It is absolutely essential to distinguish infection from surgical causes of scrotal swelling – when in doubt refer for surgical care


76 Anal Symptoms Main concerns:
Discharge Ulcers Warts Hemorrhoids Rectal Fissures Proctoscopy increases diagnosis for most common causes Warts a concern for future development of cancer Occasionally HSV can also cause anal discharges, Discharges not responding to GC/CT Tx may be tried on HSV-2 Tx

77 Clinical 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 ago On exam there is anal ulcers

78 Clinical Case A 35 y/o married man presents with soiling of underwear for a week The soiling is foul smelling and has caused embarassment for him at his office He denies any extramarital sex After some rapport building he admits to having sex with a male colleague but insists that he (your patient) only penetrated On exam there is purulent anal discharge

79 Clinical Case A 36 y/o disshevelled man presents with severe pain during defecation After rapport building he admits to using injected drugs On 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 trauma Anal Fissures may develop from this trauma as well

80 Anal Symptoms Courtesy CDC, USA Anal Warts Anal Fissure


82 Vaginal 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 risk High risk > Treat for cervicitis otherwise for vaginitis Speculum exam does not improve Dx HSV-2 can also cause rare discharge. Treatment non-responders must be re-assessed for risk and for HSV-2 Tx Asking about amount of discharge or smell may help distinguish cervicits from vaginits Because 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).

83 Vaginal Discharge: Causes
Vaginitis Cervicitis Caused by Trichomoniasis (TV), Candidiasis and Bacterial Vaginosis Caused by Gonorrhoea and Chlamydia Most common cause of vaginal discharge Less common cause of vaginal discharge Easy to diagnose Difficult to diagnose No complications Major complications Treatment of partner unnecessary, except for TV Need to treat partner

84 Clinical Case 21 y/o married mother of 2 children presents with a sore throat On a comprehensive review of systems she admits to having a vaginal discharge On exam there is a scant vaginal discharge Clinical point: This is likely physiological discharge and should not be treated

85 Clinical Case A 22 y/o mother of 1 child presents with vaginal discharge She describes some scant odor to the discharge which also itches On rapport building she admits that she occasionally has sex with a neighbor for money to make ends meet Clinical point: This is likely Cervicitis. Note that the critical point is the assessment of risk

86 Clinical Case 34 y/o somewhat obese woman presents with vaginal itching and discomfort One further questioning she also admits noticing a vaginal discharge On rapport building there is no history of risky sex behavior Clinical point: this is likely Candidiasis, this woman may have diabetes although having diabetes is not necessary for candidiasis


88 Lower Abdominal Pain Main concerns:
PID (infectious) Retained placenta/ dead fetus/ other products of conception Critical finding: Cervical Motion Tenderness Prompt referral for non-responders is critical Hospitalization important for serious patients

89 Clinical Case 32 y/o woman presents with lower abdominal pain for past 4 days She 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 Afghanistan On exam there is cervical motion tenderness Clinical point: This is likely PID

90 Clinical Case A 28 y/o woman presents with lower abdominal pain for 6 months - on and off Her 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 behavior She lives in a household of 14 people and her husband is the only bread earner There is no cervical motion tenderness Clinical point: This is unlikely to be infectious

91 Criteria for hospitalization:
Lower Abdominal Pain Criteria for hospitalization: Pregnant patient Cannot 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 medicines Unable to take or can not tolerate oral medicines Evidence of a tubo-ovarian abscess


93 Common side effects of medicines used

94 Acyclovir: 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.

95 Ceftriaxone: 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.

96 Clindamycin: 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.

97 Fluconazole: 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 miconazole Clotrimazole: 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 breathing Nystatin: diarrhea, nausea, gas, or vomiting as until the body adjusts to the medication. If these symptoms persist or get worse consider stopping the medicine.

98 Doxycycline: 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 treatment Metronidazole: 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.

99 Ciprofloxacin: 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.

100 Penicillin: 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. Podophyllin Swelling, pain, burning, itching, peeling skin, small sores, or headache may occur. Most serious side effect is bleeding.

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