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DIRECTORATE OF LEARNING SYSTEMS
DISTANCE EDUCATION PROGRAMME
COMMUNICABLE DISEASES COURSE
Unit 6
Sexually Transmitted Diseases
Allan and Nesta
Ferguson Trust
Unit 6: Sexually Transmitted Diseases
A distance learning course of the Directorate of Learning Systems (AMREF)
© 2007 African Medical Research Foundation (AMREF)
This course is distributed under the Creative Common Attribution-Share Alike 3.0 license. Any
part of this unit including the illustrations may be copied, reproduced or adapted to meet the
needs of local health workers, for teaching purposes, provided proper citation is accorded
AMREF. If you alter, transform, or build upon this work, you may distribute the resulting work only
under the same, similar or a compatible license. AMREF would be grateful to learn how you are
using this course and welcomes constructive comments and suggestions. Please address any
correspondence to:
The African Medical and Research Foundation (AMREF)
Directorate of Learning Systems
P O Box 27691 – 00506, Nairobi, Kenya
Tel: +254 (20) 6993000
Fax: +254 (20) 609518
Email: [email protected]
Website: www.amref.org
Writer: Dr H. Irimu
Chief Editor: Anna Mwangi
Cover design: Bruce Kynes
Technical Co-ordinator: Joan Mutero
The African Medical Research Foundation (AMREF) wishes to acknowledge the contributions of
the Commonwealth of Learning (COL) and the Allan and Nesta Ferguson Trust whose financial
assistance made the development of this course possible.
Table of Contents
Introduction ................................................................................................................................... 1
Objectives ....................................................................................................................................... 1
6.1 Definition of Sexually Transmitted Diseases ....................................................................... 2
6.2. Epidemiology and Risk Factors for STDs ........................................................................... 3
Risk Factors for STIs .................................................................................................................. 4
Complications of STIs. ............................................................................................................... 6
6.3 Syndromic Management of STIs ........................................................................................... 7
Why the Syndromic Approach? .................................................................................................. 8
Advantages of the Syndromic Approach .................................................................................... 9
6.3 STDs That Present With Genital Discharge ...................................................................... 19
6. 3.1 Gonorrhoea.................................................................................................................... 19
6. 3.2 Chlamydia Urethritis ..................................................................................................... 24
6.3.3 Chomoniasis .................................................................................................................. 26
6.3.4 Vulvovaginal Candidiasis (VVC) .................................................................................. 27
6. 4. STDs Presenting With Genital Sores or Lumps. .............................................................. 28
6.4.1 Syphilis.......................................................................................................................... 28
6.4.2 Chancroid ...................................................................................................................... 30
6.4.3. Inguinal Bubo ................................................................................................................ 32
6.4.4. Lymphogranuloma Venereum ...................................................................................... 32
6.4.5 Genital Herpes Simlex Virus (Hsv) Infection .............................................................. 33
6.4.6 Genital Warts ................................................................................................................ 34
6.4.7 Molluscum-Contagiosum ............................................................................................... 35
6.4.8 Balanitis .......................................................................................................................... 35
6.4.
Prevention and Control of STIs .................................................................................... 36
3
Abbreviations
AIDS
Acquired Immune Deficiency Syndrome
ARV
Antiretroviral drugs
GUD
Genital Ulcer Disease
HIV
Human Immunodeficiency Virus
HPV
Human Papilloma Virus
HSV
Herpes Simplex Virus
LGV
Lymphgranuloma Venereum
NASCOP
National Aids and STI Control Programme
STDs
Sexually Transmitted Diseases
STIs
Sexually Transmitted Infections
QID
Four Times a Day
4
Unit 6: Sexually Transmitted Diseases
Introduction
Welcome to the sixth unit on sexually transmitted diseases. In the last unit you learnt about
contact diseases and saw that some of them like scabies and pubic lice can be spread
through sexual contact.
In this unit you will learn about various sexually transmitted
diseases, their epidemiology, mode of transmission, how to diagnose and treat them using
the syndromic management approach and also how to prevent them.
Let us start by looking at our objectives for this unit.
Objectives
By the end of this module the students should be able to:
1. Define sexually transmitted infections;
2. Describe the risk factors for STDs;
3. Explain the syndromic management of STDs;
4. Describe the clinical signs and symptoms of the common STDs;
5. Describe simple laboratory methods used for confirming the diagnosis of common
STDs;
6. Outline the management and treatment of common STDs;
7. Discuss how to prevent and control common STDs.
1
6.1 Definition of Sexually Transmitted Diseases
Before you read on do the following activity. It should take you 5 minutes to complete.
ACTIVITY
What are sexually transmitted diseases? Write down your definition in the space provided
below.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Now read through the text below and see if your ideas are included.
Sexually transmitted diseases are communicable diseases caused by organisms such as
bacteria, viruses and protozoa, which are transmitted through sexual contact. Some of these
organisms can also be transmitted from mother to unborn child (vertical transmission),
through blood transfusion as well as through contaminated needles and syringes. However,
just like with other germs, infection with these organisms does not always result in clinical
disease. For example, men may be infected with gonococcus but do not develop urethritis.
However they can transmit the organism to their sexual partners. This has given rise to the
term sexually transmitted infections as some persons are healthy carriers. In this Unit, we
shall discuss the clinical presentation and management of various sexually transmitted
diseases, divided into two main categories:

STDs that present with Genital Discharge;

STDs that present with genital sores or lumps.
We shall start our discussion by looking at the epidemiology and risk factors for STDs.
2
6.2. Epidemiology and Risk Factors for STDs
Sexually transmitted infections (STIs), which include Human Immunodeficiency virus (HIV),
have been recognized as a major public health problem for many years. It is estimated that
over 340 million new cases of curable STIs, namely those due to Treponema pallidum
(syphilis), Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis, occur
every year throughout the world in men and women aged 15–49 years, with the largest
proportion in the region of south and south-east Asia, followed by sub-Saharan Africa, and
Latin American and the Caribbean. In other words, almost one million new infections occur
every day.
According to WHO, the prevalence of STIs tends to be higher in urban areas than in the
rural areas, and higher in unmarried people and younger adults. New STI cases begin to
occur during adolescence and tend to be most frequent in the 15–44 age group, decreasing
in older adults. In terms of sex distribution, STIs are more frequent among females than
males between the ages of 14 and 19 years; slightly more frequently among males than
females over the age of 19 years.
The high prevalence among females 14-19 years is attributed to various factors such as :

Girls become sexually active earlier than boys;

The genital tract of young girls is especially vulnerable to infection;

Girls tend to have sex with older male partners who have more sexual experience
and therefore more likely to carry infections.
The epidemiology of STIs in Kenya is poorly understood due to an inadequate reporting
system in our health institutions. Also with the adoption of the syndromic approach in the
country, the prevalence of STIs is reported in syndromes. However, data available from the
National AIDS and STI Control Programme (NASCOP) on genital ulcer disease (GUD),
vaginal and urethral discharge reveals that STIs are common in the population. According
to the Kenya national guidelines for reproductive tract infection services, the trend from
1990-2000 of the GUD and vaginal discharge in 32 HIV sentinel surveillance sites indicated
that the prevalence rates of vaginal discharge and GUD was 11-27% and 20-37%
respectively. This was observed among patients seen with complaints of STIs.
3
Risk Factors for STIs
As society changes and liberal attitudes become the norm in formerly traditional societies,
there is a trend towards very early sexual debut among teenagers below 15 years. However
the greatest risk occurs in the age group 18-35 years. You also need to be aware that STDs
are now being found in younger children who are victims of sexual abuse.
The risk factors for STIs can be divided into three, namely:

Biological factors;

Social factors;

Behavioural factors.
Let us look at each in turn but before then, find out how much you already know by doing
the following activity.
ACTIVITY
List down one example of each of the three category of risk factors for STIs.
Biological factors
____________________________________________________________________
Social factors
_____________________________________________________________________
Behavioural factors
_____________________________________________________________________
Now read through the text below and see if your ideas are included.
4
Biological Factors
Certain biological factors influence the transmission of STIs. They are age, sex, immune
status of the host and the virulence of the organism.
Age
In young women, the vaginal mucosa and cervical tissue is immature. This immaturity
causes their cervical surface cells to readily allow infections to occur. Thus on average,
women become infected at a younger age than men.
Sex
Infections enter the body most easily through a mucosal surface such as the lining of the
vagina. Since the mucosal surface that comes into contact with the infective agent is much
greater in women than in men, women can be more easily infected than men.
Immune status
The immune status of the host and virulence of the infective agent affect transmission of
STIs. Indeed, certain STIs increase the risk of transmission of HIV, which in turn facilitates
the transmission of some STIs and worsens their complications by weakening the immune
system.
Next let us look at the social factors.
Social/Cultural Factors
In some societies men’s risky behaviour of multiple sexual partners is tolerated thus putting
them and their partners at risk of infection. Also in cultures where the girl-child is married off
to an adult male at a very young age exposes the girl to infection. Further, with growing
industrialisation and consequent urbanisation, there is a large group of single poorly paid
and unemployed young people who migrate from rural to urban areas in such for
employment. In such circumstances, sexual intercourse for pleasure and gain assumes an
important role. This promiscuous sexual behaviour is closely associated with the acquisition
of STIs.
5
Another risk factor is occupations that involve a lot of travelling or having multiple sex
partners, such as long distance drivers, bar maids, soldiers, and sailors.
Other risk factors include cultural practices that predispose to transmission of STDs. In
some communities, certain celebrations and rituals (such as cleansing after the death of a
family member) may involve high-risk sexual practices that predispose individuals to
transmission of STIs
Behavioural Factors
Risky behaviours such as having multiple sexual partners, having sex with commercial sex
workers, and having unprotected sexual intercourse makes it more likely for a person to
acquire an STI. Indeed, people who have had an STI in the last year are at risk of getting
infected again if they have not been able to change their sexual behaviour.
Having discussed the epidemiology and risk factors for STIs, let us now look at their
complications.
Complications of STIs.
Apart from facilitating the spread of HIV, STIs can cause serious and permanent
complications in infected people if they are not treated in a timely and effective way.
These
complications include:

Infertility in men and women;

Ectopic pregnancy due to tubal damage;

Blindness in infants caused by ophthalmia neonatorum;

Permanent brain and heart disease caused by syphilis;

Genital cancer caused by human papillomavirus.
That is why early diagnosis and treatment of STIs is very important.
Next, we shall discuss the integrated approache for STI management used in Kenya, known
as the Syndromic Management of STIs.
6
6.3 Syndromic Management of STIs
The syndromic management approach groups STIs by the syndrome, or the signs and
symptoms and helps in diagnosis and treatment without using the laboratory for testing. The
STIs that are treated syndromically are those caused by organisms that respond to similar
treatment.
Kenya is one of the countries in the world, which has adopted the syndromic approach,
which diagnoses conventional STIs on the basis of syndromes rather than by the causative
organisms.
Before you read on do the following activity. It should take you less than 5 minutes to
complete.
What do you understand by the term syndrome?
Compare your answer with the information given
below
A syndrome simply means a group of signs and symptoms. Although many different
organisms cause conventional STIs, these organisms give rise to a limited number of
syndromes.
7
Why the Syndromic Approach?
In the past, health workers either used the aetiological approach or the clinical approach to
the management of STIs. The aetiological approach required the use of a laboratory to
inform the treatment process. The clinical approach on the other hand requires the
presence of skilled clinicians to make a diagnosis based on their knowledge and experience
before initiating presumptive treatment. These approaches had a number of disadvantages.
Can you think of some of these disadvantages? Put your thoughts to paper by doing the
following activity.
ACTIVITY
Write down at least one disadvantage of the aetiological and clinical approach to STI
management.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Now read through the text below and see if your ideas are included.
The disadvantages of these two approaches were as follows:

Firstly, laboratory facilities are not easily available everywhere,

Secondly patients had to wait until the next day for results before they could start
treatment;

Thirdly, patients may fail to return for their results and will therefore not get treatment;

Fourthly, the clinical approach needs the presence of skilled clinicians which is not
always possible in our health system due to shortage of skilled personnel;

Lastly, some STIs present with similar symptoms thus making it difficult for health
workers to diagnose and treat the correct cause.
8
That is why the World Health Organisation came up with a third approach to the
management of STIs known as the syndromic case management.
Advantages of the Syndromic Approach
Before you read on, do the following activity. It will take you less than 5 minutes to complete.
ACTIVITY
List down at least three advantages of the syndromic approach
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Well, I hope your answer contained the following advantages of using the syndromic case
management of STIs:

It is able to respond to the patients symptoms;

It is highly sensitive and does not miss mixed infections;

Patients get treatment on the first visit;

It increases access to STI care as it is available even at dispensary level;

It uses flowcharts that guide the health worker through logical steps;

It provides an opportunity and time for education and counselling.
In the syndromic case management, the STIs are divided into 5 main syndromes as follows:

Vaginal discharge (Pruritus) in women;

Urethral discharge in men;

Lower abdominal pain in women;

Genital ulcer disease in both men and women;

Ophthalmia neonatorum in newborns.
9
The syndromic approach uses clinical algorithms or flow charts developed for each of the
above syndromes in STIs. The flow charts represent a combination of practical and
scientific information necessary for decision making. This approach has been widely used
especially in developing countries because it does not require equipment, its easy to use
and facilitates immediate provision of services to all clients. Many STIs can be identified and
treated based on characteristic symptoms and signs.
Table1 outlines the signs and symptoms for the main syndromes of STIs in Kenya and their
aetiologies. To understand the syndromes, study table 6.1 below for the clinical
presentation of the main syndromes , their aetiologies and complications..
Table 6.1 Associated features of STI Syndromes (Source: MOH, National Guidelines for Reproductive
Tract Infections Services, 2006.)
Syndrome
Possible
Clinical presentation Associated features
aetiologlcal agent
Vaginal
discharge
Complications
Neissena
gonorrhoea
Greenish yellow
discharge may be
massaged from the
urethra or seen oozing
from the endocervix!
Painful and frequent
micturation. Swollen and
tender Bartholin s glands
Lower abdominal pain.
Pelvic infection, tubal
blockage with infertility or
eclopic pregnancy,
bartholinitis. Bartholin’s
abscess, disseminated
infection, ophthalmia
neonatorum
Chlamydia
trachomatis
Scanty muco-purulent Minimal or no symptoms
or purulent discharge There may be painful
micturation and vulvovaginal itching.
Ophthalmia neonalorum,
pelvic infection with tubal
blockage and infertility or
eclopic piegnancy.
Trichomonas
vaginalis
Frothy, profuse,
greenish yellow, tout
smelling discharge
None special
Candida albicans,
or other Candida
species
Gadnerella
vaginalis
(anaerobic
bacteria)
Vulvo-vaginal itching,
painful swollen Bartholin’s
glands The cervixd may
have unctuate
haemorrhagic Spots.
Excoriation which may lead
to bleeding
White, curd-like
Itching of the vulva or
discharge involving
vagina. Inflamed and
the vaginal wall and swollen vulva leaves a raw
cervix
area in swabbing it off
Profuse foul smelling No itching, no vulva
and Homogenous
erythema
greyish white
•
discharge. Adherent
to vaginal wall.
10
Oral thrush in newborn
babies.
None special.
Urethral
discharge
Neisseria
gonorrhoea
Abundant pus-like
discharge dripping
from the urethra.
Incubation period 310 days
Painful and frequent
Urethral stricture,
micturition with or without epididymo-orchitis,
testicular pain.
prostatitis, watering can
perineum, infertility,
disseminated infection.
Chlamydia
trachomatis
Syndrome
Gerital ulcer
diseases
Mucoid or serous
Painful and frequent
discharge scanty,
micturition.
usually seen in the
morning. Incubation
period 10-14 days.
Urethral iritation
Possible aetiogical Clinical
Associated features
agent
presentation
Epididymo-orchitis
infertility
Complications
Herpes simplex
virus
Multiple shallow and Tender lymphadenopathy
tender ulcers. May
may be recurrent rarely
start as vesicles
suppurative.
grouped together.
Itchy. Incubation
period 1 week.
Infection of the newborn at
birth.
Treponema
pallidum
Single, painless,
Painless lymphadenopathy
relatively dean ulcers
without pus.
Incubation period up
to 3 weeks.
Secondary, tertiary,
congenital and latent
syphilis.
Hemophilus
ducreyi
Multiple, soft. Deep,
tender ulcers with
profuse pus.
Incubation period 1
week.
Very painful
lymphadenopathy which may
be fluctant disfiguration of the
genitalia secondary infection.
Disfiguration of the
genitalia and perineum
lymphatic obstruction
leading to elephantiasis of
the genitalia, necrosis.
Lymphogranuloma
venereum (LGV)
Single, small and
transcient ulcers.
Incubation period 12 weeks.
Lymphadenopathy. Several
glands may be matted
together. Fistula and stricture
formation.
Fistula formation,
destruction of tissues,
elephantiasis of genitalia
and lower limbs.
None or rarely
lymphadenopathy.
Pseudo-buboes.
Granulome
Large and beefy
inguinale, ,
ulcers. Variable
Calymatobacterium incubation period.
granulomatosis
(Donovan bacilli)
11
Inguinal bubo
Hemophilus
Several nodes mated There may be history of a
ducreyi, Chlamydia together.
healed ulcer
trachomatis (L1-L3
immunotypes),
Lymphogranuloma
venereum
See under LGV n table.
Syndrome
Possible
aetiological agent
Clinical
presentation
Complications
Genital
Venereal
Warts
Condyloma
acuminatum,
Human papiiloma
virus (HPV)
Cauliflower-like
Vaginal discharge, pain and
warts, may be single bleeding on coitus or touch.
or multiple on vulva,
vagina, perineal
areas, penis, urethra
and sub-prepuce.
Molluscum
contagiosum. Pox
group virus
Umblicated papules
multiple with
whitish, cheesy
material being
expressed when
squeezed.
Secondary infection spread to Secondary infection,
other sites.
Lower
Neisseria
abdominal pain gononorhoea,
Chlamydia
trachomatis
Cervical-vaginal
discharge, which is
purulent. Painful
with frequent
micturition, fever,
malaise, lower
backache. May
fallow menstrual
periods.
Pelvic inflammatory disease
(PID),
Opthalmia
neonatorum
Mucoid or purulent Inflammed and swollen
Blindness if untreated,
discharge within the eyelids and conjunctivae. The keratitis, cornea ulcers.
first month in life.
mother may have had vaginal
discharge.
Neisseria
gonorrhoea,
Chlamydia
trachomatis. And
Others.
Associated Feature
Secondary infection,
bleeding which may lead to
anaemia, cancer of the
penis, cervix, or vulva
Pelvic abscess, tubal
blockage with infertility,
ectopic pregnancy,
septicaemia bacteraemia.
If a client/patient presents with any of these syndromes, it is an indication of an STI and
requires prompt treatment.
For instance, the commonest cause of urethral discharge in
males in Africa is gonorrhoea and chlamydial urethritis, either individually or in combination.
In syndromic management, the patient is treated for both infections. Other causes are only
considered if there is no improvement. The advantage of this approach is that health
workers in resource constrained settings can treat patients effectively without requiring the
assistance of a laboratory or clinician.
12
The syndromic approach also emphasizes client education for STD prevention at the
personal level. This is commonly known as the 4 Cs. The 4Cs stand for:
Counselling: This requires that you discuss the condition with the client with an aim of
finding a solution or ways of preventing STIs re-infection and spread. (Revise counselling
skills).
Compliance: You need to explain to the client the danger of self-medication and that
she/he should take the full dose of the prescribed medicine for better results.
Condoms: You need to explain and demonstrate proper use of the condom, if abstinence is
impossible. Also condoms should be availed to those who need them to make sex safer.
Contact tracing: This is for the purpose of treating sex partner/s to avoid re-infection and
spread of STI.
As we mentioned earlier, the syndromic approach uses flow charts or diagrammatic maps
that guide you through a series of decisions or actions that you need to take. The following
section contains the various flow charts used in the syndromic management approach.
13
Figure 6.2: Syndromic Management of Urethral Discharge. Adapted from MOH National Guidelines
for Reproductive Tract Infection Services, 2006
History of urethral discharge or
symptoms
Take history and examine
Mil urethra if necessary
Discharge/Symptoms
confirmed?
Any Other
Genital
Disease
NO
NO
4Cs
YES
YES
Use appropriate flowchart
URETHRITIS
TREATMENT 4Cs
Persistent symptoms?
No Further Action
NO
URETHRITIS TREATMENT:
Norfloxacin 800mg and Doxyclycline 100mg BD x 7 days
YES
ALTERNATIVE TREATMENT:
IM Spectinomycin 2mg stat and Doxyclicline 100mg BD x 7
days
ALTERNATIVE
TREATMENT 4Cs
4Cs
1.
2.
3.
4.
Counselling: Empathise with your patient (put yourself in your patient’s place), dialogue with your
patient, discuss the other 3Cs.
Compliance: Your patient should avoid self-medication, take the full course of medication and not share or
keep it. Follow your other instructions.
Condoms: Proper condom use is the only other alternative. Give condoms to your patient. Explain and
demonstrate the proper use of condoms.
Contact tracing: Your patient should tell all his/her sexual partners to seek medication
14
Figure 6.3: Syndromic Management of Vaginal Discharge. Adapted from MOH National Guidelines
for Reproductive Tract Infection Services, 2006.
History of vaginal discharge
Enquire about lower abdominal
pain
Examine for
discharge and lower
abdominal pain
NO
VAGINITIS
TREATMENT 4Cs + DTC
YES
Pregnant
Use flow chart for lower
abdominal pain
Refer for gynaecological
assessment
VAGINITIS TREATMENT:
Clotrimazole 1 pessary Intraginally daily for 6 days and
Metronidazole 400 mg TDS x 5 days
IF PREGNANT:
Clotrimazole 1 pessary intravaginally daily for 6 days
No improvement
after 7 days?
Pregnant
CERVITIS
TREATMENT 4Cs
CERVICITIS TREATMENT
Norfloxacin 800mg stat and
Doxycycline 100 mg BD x 7 days
IF PREGNANT
IM Spectinomycin 2g stat and
Erythromycin 500mg QID x 7 days
Symptoms persist
after 7 days?
Refer for
investigations
4Cs
5.
6.
7.
8.
Counselling: Empathise with your patient (put yourself in your patient’s place), dialogue with your
patient, discuss the other 3Cs.
Compliance: Your patient should avoid self-medication, take the full course of medication and not share or
keep it. Follow your other instructions.
Condoms:
Proper condom use is the only other alternative. Give condoms to your patient. Explain and
demonstrate the proper use of condoms.
15
Contact tracing: Your patient should tell all his/her sexual partners to seek medication
Figure 6.4: Lower Abdominal pain in Women. Adapted from MOH National Guidelines for
Reproductive Tract Infection Services, 2006
Patient complains of lower
abdominal pain
Do abdominal and bimanual examinations
Abdominal mass,
abdominal tenderness
due to surgical or
gynaecological causes
Refer for surgical or
gynaecological assessment
Surgical or gynaecological
causes are determined by
rebound tenderness and/or
guarding: last menstrual
period overdue; recent
abortion or delivery
menorrhagia or
metrorhagia
Abdominal
tenderness or
tenderness on moving
the cervix
YES
No tenderness on
abdominal
examination
Symptomatic
treatment or
vaginitis treatment
if there is vaginal
discharge
PID TREATMENT and
4Cs
If no improvement after 3-7
days
If no improvement after 3-7
days
Refer for investigations
Start flow chart again after
repeating abdominal
examination
PELVIC INFLAMMATORY DISEASE TREATMENT
Norfloxacin 800mg start and doxycycline 100mg BD x 7 days and
Metronidazole 400mg BD x 10 days
IF PREGNANT
Refer for obstetric evaluation if PID is suspected
ALTERNATIVE TREATMENT: Azithromycin 1gm PO single dose or
Cefixime 400mg PO single dose
4Cs
1.
2.
3.
4.
Counselling: Empathise with your patient (put yourself in your patient’s place), dialogue with your patient, discuss the
other 3Cs.
Compliance: Your patient should avoid self-medication, take the full course of medication and not share or keep it.
Follow your other instructions.
Condoms: Proper condom use is the only other alternative. Give condoms to your patient. Explain and demonstrate the
proper use of condoms.
Contact tracing: Your patient should tell all his/her sexual16
partners to seek medication
Figure 6.5: Genital Ulcer Disease (GUD). Adapted from MOH National Guidelines for Reproductive
Tract Infection Services, 2006
Patient complains of a genital sore or ulcer
Examine for ulcer
Multiple vesicles grouped
together with history of
recurrence (Herpes)
Other GUD
GUD treatment and 4Cs
Acyclovir 400mg PO TDS x
7 days and 4Cs
If no improvement after 7
days
If no improvement after 7
days
Alternative GUD
treatment and
4Cs
Follow other GUD column
GUD heals slowly,
improvement is defined as
signs of healing and reduction
of pain. People with HIV
infection will be slower in
responding to GUD treatment
If no improvement after 7
days
Refer for investigations
Genital Ulcer Disease (GUD) Treatment
Erythromycin 500mg TID x 7 days and Benzathine Penicillin
2.4mg IM stat. If Penicillin allergy, use Erythromycin 500mg
QID x 14 days
Alternative GUD Treatment
Ciprofloxacin 500mg single dose
4Cs
5.
6.
7.
8.
Counselling: Empathise with your patient (put yourself in your patient’s place), dialogue with your patient, discuss the
other 3Cs.
Compliance: Your patient should avoid self-medication, take the full course of medication and not share or keep it.
Follow your other instructions.
Condoms: Proper condom use is the only other alternative. Give condoms to your patient. Explain and demonstrate the
proper use of condoms.
Contact tracing: Your patient should tell all his/her sexual partners to seek medication
17
Figure 6.6: Ophthalmia Neonatorum. Adapted from MOH National Guidelines for Reproductive Tract
Infection Services, 2006.
Neonate with eye discharge
Take history and examine
NO
NO FURTHER ACTION
DISCHARGE
PRESENT
YES
OPTHALMIA NEONATORUM
TREATMENT AND 4 Cs
Follow-up in 24 hours
Not better
ALTERNATE
TREATMENT AND 4Cs
Better
Continue with 1% tetracycline eye
ointment TDS x 10days and 4Cs
OPHTHALMIA NEONATORUM TREATMENT
1% tetracycline eye ointment TDS X 10 days
Treat mother for cervicitis and partner for urethritis
ALTENATIVE TREATMENT
Cetriaxone 62.5mg IM stat and 1% tetracycline eye ointment
TDS x 10 days 4Cs
4Cs
1. Counselling: Empathise with your patient (put yourself in your patient’s place), dialogue with your patient, discuss the other
3Cs.
2. Compliance: Your patient should avoid self-medication, take the full course of medication and not share or keep it. Follow
your other instructions.
3. Condoms: Proper condom use is the only other alternative. Give condoms to your patient. Explain and demonstrate the
proper use of condoms.
4. Contact tracing: Your patient should tell all his/her sexual partners to seek medication
18
Having looked at the risk factors for STIs and the syndromic management approach, let us
now discuss the common STIs, how they present and their management and prevention.
We shall divide them into two: those that present with genital discharge and those that
present with genital sores and lumps.
6.3 STDs That Present With Genital Discharge
There are a number of STDs which present with genital discharge. These include:

Gonorrhoea;

Urethritis due to Chlamydia trachomatis and occasionally other bacteria and viruses;

Trichomoniasis;

Bacterial vaginosis;

Candiadiasis.
Let’s start by looking at gonorrhoea.
6. 3.1 GONORRHOEA
Gonorrhea is a fairly common sexually transmitted disease caused by a gram negative
intracellular diplococcus bacterium, Neisseria gonorrheae. It is an acute or chronic purulent
infection characterized by urethral or vaginal discharge. It is often abbreviated as “gc”.
Gonorrhea is by far the commonest of the so-called “classical STDs”, that is STDS known
before the emergence of HIV all over the world.
Gonorrhoea can cause sterility in both
females and males and accounts for a serious decline in birth rate in some communities. In
females, gonorrhoea may cause death due to salpingitis and peritonitis or predispose them
to ectopic pregnancy. In males it may cause urethral strictures resulting in urine retention,
hydronephrosis and uraemia, also causing death.
Epidemiology
Gonorrhoea is caused by gonococcus, a Gram-negative kidney-shaped diplococcus, which
can only grow intracellularly. This type of gonococcus is known as Neisseria gonorrhoeae.
The gonococcus is not able to penetrate intact skin or squamous epithelium. It prefers
columnar epithelium, such as in the urethra, endocervix, rectum and conjuctiva.
While
contact of mucous membranes with gonococcal pus is usually only possible during sexual
19
intercourse, there are exceptions.
For instance, in the case of gonococcal opthalmia
neonatorum, the infection is contracted during passage through the birth canal. Another
exception is is gonococcal vulvo-vaginitis. The vagina of an adult woman of reproductive
age is lined with squamous cells which contain glygogen. Through bacterial action, this
glycogen is metabolised into lactic acid, thus producing a low pH. This low pH protects the
aginal wall from invading gonococci. The glycogen content of the cells is determined by
oestrogen levels and is therefore low before puberty and after menopause. So before
puberty and after menopause the vagina is less resistant to gonoccocal infections.
The sharing of towels or clothing promotes the spread of the infection from one girl to
another.
Gonococcus can survive for up to 24 hours in a discharge on a moist surface
such as a towel.
Mode of Transmission:
Mainly through sexual contact: vaginal, anal or oral sex. Bacteria are transmitted through
vaginal and seminal fluids and the incubation period is between 2-10 days. Transmission
can also occur to the neonate during delivery leading to Ophthalmia Neonatorum.
Risk Factors:

People who do not use condoms during vaginal, anal or oral sex;

Multiple sex partners;

History of sexually transmitted diseases;

Below the age of 30 have an increased risk of being infected with gonorrhea;

Low socio-economic status.
Clinical symptoms:
Once infected, the symptoms of gonorrhea can take between two and ten days to show up.
In males the common symptoms include:
20

Irritation at the urethral meatus;

Burning sensation (dysuria) when passing urine;

Purulent profuse yellowish discharge from the urethra;

Occasionally terminal haematuria (blood in the urine) may occur;

Swollen testicles;
Figure 6.1: Clinical picture of gonorrhoea in males
In women, about 50% of infected women have no symptoms. The female urethra is short
and the urethritis and discharge often go unnoticed. As a result of this, many women are
only seen in clinics when they have developed symptoms due to complications. The cervix
is usually the first site of infection. From there, the infection moves up into the uterus and
into the fallopian tubes. In those cases that develop symptoms, these are likely to include:

Bleeding after coitus;

Pain or burning sensation when urinating;

Frequency and urgency in micturition;

Vaginal discharge that is yellow or bloody;
21

Abdominal cramps.
In untreated cases, the infection in the majority of women remains latent for several months
or years, during which time they form an important reservoir for the spread of the disease.
Figure 6.2: Clinical picture of gonorrhoea in females
Diagnosis
The diagnosis is made by taking careful history and carrying out a physical examination.
The diagnosis is confirmed by examination of the following:

Urethral smear for men;

High vaginal swab;

Urinalysis for microscopy;

Gram stain showing pus cells and intracellular Gram-negative diplococci is 95%
sensitive.
22
Figure 6.3: Microscopic appearance showing intracellular diplococci
Treatment
While the treatment can clear up the infection, it cannot undo any damage gonorrhea may
have done to the reproductive system prior to treatment. The treatment of a patient with
urethral discharge in syndromic management is given in Figure 6.2.
1st line treatment
1. Doxycycline 100mg BD
2. Norfloxacin 800 mg Stat Orally
2nd line treatment and incase a woman is pregnant
1. Spectinomycin 2 gm im Stat
2. Ceftriaxone 250 mg IM Stat
Always remember to include the 4Cs of STD management in treating your patient. Also
remember that STD patients are at high risk of HIV infection and so whenever possible you
should counsel them to accept HIV testing as well.
If you do not have access to a
laboratory, you should treat all cases of genital discharge for both gonorrhoea and
chlamydia.
23
Complications:
If left untreated, gonorrhea can lead to infertility in both men and women. In women,
untreated gonorrhea often leads to pelvic inflammatory disease, which increases the risk of
ectopic pregnancy and infertility.
In men, gonorrhea that is not treated often leads to
inflammation of the testicles (epididymitis), which can lead to infertility. The infection can
also spread to the rest of the body and cause joint inflammation as well as infect the heart
valves and/or the brain.
Prevention:
You can prevent this disease through health education and early diagnosis and treatment of
contacts.
Gonococcal ophthalmia neonatorum can be easily prevented by routine eye
washingand application of 1% tetracycline eye ointment at birth.
Having discussed gonorrhoea, let us now look at chlymydia.
6. 3.2 CHLAMYDIA URETHRITIS
Chlamydia is a sexually transmitted disease caused by the bacteria Chlamydia trachomatis.
Because it is often associated with no symptoms, it is also called "The Silent Disease." More
than 75% of women and 50% of men exhibit no symptoms when suffering from the disease.
Chlamydia is one of the most commonly occurring STDs. Prolonged infection can cause
infertility and damage to the reproductive organs.
24
Symptoms of Chlamydia

Chlamydia symptoms may be mild and can easily go undetected. Women are more
likely to experience few symptoms associated with the infection although chlamydia in
men can also result in few or no symptoms.

Signs of chlamydia usually appear between 1 and 3 weeks after infection, though
sometimes they can take longer to manifest.

Early chlamydia signs and symptoms tend to be mild and include pain during urination,
frequent urination, and low fever.

Later symptoms can be more intense and include nausea, fatigue, and abnormal
discharge from the vagina or penis.

Oral chlamydia, usually passed through oral sex, can result in a sore throat and throat
infection. In anal infections, swelling of the rectum can occur. Though rare, males
suffering from the disease may experience swelling of the testicles.

Other symptoms in women include abdominal pain, lower back pain, irregular menstrual
bleeding or spotting, and pain during sex.
Complications of Infection
1. If left untreated, chlamydia can move through the body causing serious health problems.
As the infection travels, it can cause eye and throat infections as well as rectal
infections. Long-term infection can lead to damage in the uterus and fallopian tubes in
women and, in rare cases, sterility in men.
2. Chlamydia in women also leads to an increased risk for developing Pelvic Inflammatory
Disease (PID), which can cause fertility problems.
3. Chlamydia infection is dangerous to newborns. If one is pregnant and infected with
chlamydia, one can transmit the infection to the child.
4. Chlamydia infection also increases the risk of contracting HIV. Women with chlamydia
are up to 5 times more likely to contract HIV, the virus that leads to AIDS.
5. In rare cases, chlamydia can cause Reiter’s syndrome, a disease characterized by
arthritis, skin lesions, and inflammation of the urethra and eyes.
Diagnosis and Testing
1. Physical exam and History.
2. In women, chlamydia is best detected through a cervical swab. This procedure is very
similar to a pap smear.
25
3. The most common tests look for antigens that the bacteria produce in the body.
4. A culture test may also be performed. This test fosters the growth of chlamydia bacteria
in a dish so that it can be analyzed under a microscope.
Treatment
To manage Chlamydia use the flow chart on urethral discharge which is given in Figure 6.2.
The treatment is as follows:

Norfloxacin 800mg stat
AND

Doxycycline 100 mg orally twice a day for 7 days
OR

IM Spectinomycin 2mg stat and Doxycycline 100mg BD x 7 days.
6.3.3 TRICHOMONIASIS
Trichomoniasis is caused by the protozoan T. vaginalis. Some men who are infected with T.
vaginalis might not have symptoms. Many infected women have symptoms characterized
by a diffuse, malodorous, yellow-green vaginal discharge with vulval irritation.
Figure 6.4. Microscopic appearance of trichomonas vaginalis
26
Diagnosis
Diagnosis of vaginal trichomoniasis is usually performed by microscopy of vaginal
secretions, but this method has a sensitivity of only approximately 60%–70% and requires
immediate evaluation of wet preparation slide for optimal results. Culture is the most
sensitive and specific available method of diagnosis. In women in whom trichomoniasis is
suspected but not confirmed by microscopy, vaginal secretions should be cultured for T.
vaginalis.
Treatment
The management of trichomoniasis is outlined in the flow chart in figure 6.3 on vaginal
discharge.
6.3.4 VULVOVAGINAL CANDIDIASIS (VVC)
Vulvovaginal Candidiasis (VVC) is usually caused by C. albicans but occasionally is caused
by other Candida sp. or yeasts. Typical symptoms of VVC include pruritus, vaginal
soreness, dyspareunia, dysuria, and abnormal vaginal discharge.
Diagnosis
A diagnosis of Candida vaginitis is suggested clinically by the presence of external dysuria
and vulvar pruritus, pain, swelling, and redness. Signs include vulva edema, fissures,
excoriations, or thick curdy vaginal discharge. The diagnosis can be made in a woman who
has signs and symptoms of vaginitis when either a wet preparation (saline, 10% KOH) or
Gram stain of vaginal discharge demonstrates yeast cells.
Treatment
Short-course topical formulations (i.e., single dose and regimens of 1–3 days) effectively
treat uncomplicated VVC.
27
The topically applied azole drugs are more effective than nystatin.

Clotrimazole 1 pessary intravaginally daily for 6 days
AND

Mentronidazole 400mg TDS x 5 days
Refer to the flow chart for vaginal discharge in Figure 6.3.
6. 4. STDs Presenting With Genital Sores or Lumps.
6.4.1 SYPHILIS
Syphilis is a sexually transmitted disease caused by spirochaete bacteria, Treponoma
pallidum. It is often called the "Great Imitator" because syphilis symptoms resemble those of
other common diseases. The majority of syphilis sufferers are male, accounting for about
60% of all cases. Syphilis is the 2nd most common genital ulcer disease in Kenya, the first
being genital herpes. It is a disease characterised by a primary lesion on the skin or
mucous membrane followed by a long period of latency and then late lesions.
Modes of Transmission:

Syphilis is almost always transmitted through sexual contact with an infected person.
The syphilis bacteria can easily spread from the ulcers on an infected person to the
mucous linings of the mouth, genitals, and anus of an uninfected sexual partner

Though unlikely, it is possible to contract the infection by coming into contact with the
broken skin of an infected person.

Syphilis can also be passed from an infected mother to her unborn child (Congenital
route).

Through blood transfusion with blood from an infected person
Risk Factors:

Multiple sex partners are also at risk.

Health care workers may be at risk of contracting the disease, due to increased contact
with those infected with the disease.
28

Drug users who share needles or pipes are also at risk as are those working and living in
a corrections facility.
Symptoms:
Syphilis symptoms occur in stages.
1. Primary syphilis results in painless firm ulcers or sores called "chancres." These usually
appear on the external genitalia, inside the vagina but they can also appear on the lips,
tongue, and other body parts in cases of oral sex. These chancres generally disappear
within a few weeks, but if left untreated, the disease can progress to chronic stages.
2. Secondary syphilis begins with the syphilis rash. This is an infectious brown skin rash
that typically occurs on the bottom of the feet and the palms of the hand. The patient
may present with constitutional symptoms such as fever, sore throat. Late secondary
syphilis presents with condylomatous smooth snail ulcers on the oral cavity with
generalized lymphadenopathy and associated allopecia (loss of hair).
3. Tertiary stage of syphilis can last for many years ranging from 2 –20 years after
secondary stage, and one may suffer from joint and bone damage, increasing blindness,
numbness in the extremities, or difficulty in coordinating movements and neurosyphillis.
Diagnosis
Darkfield examinations and direct fluorescent antibody (DFA) tests of lesion exudate or
tissue are the definitive methods for diagnosing early syphilis.
A presumptive diagnosis is possible with the use of two types of serologic tests:

Venereal Disease Research Laboratory [VDRL] and RPR);

2) treponemal tests (e.g., fluorescent treponemal antibody absorbed [FTA-ABS] and T.
pallidum particle agglutination [TP-PA]).
Treatment



The management of syphilis is given in Figure 6.3 on genital ulcer disease:
Erythromycin 500mg TID x 7 days and Benzathine Penicillin 2.4mg IM stat.
If Penicillin allergy, use Erythromycin 500mg QID x 14 days
Alternative GUD Treatment
 Ciprofloxacin 500mg single dose
29
Prevention and Control

Contact tracing is vital

Screening of all pregnant mothers

Screening of blood before transfusion
6.4.2 CHANCROID
This is an acute venereal infection that presents as a rugged painful necrotizing ulcer on the
genitalia accompanied by inflammatory swelling and suppuration of the regional lymph
nodes. It is caused by a gram negative Baccili called Haemophilus ducreyi, which is spread
through sexual contact. Chancroid can also be transmitted through direct skin-to-skin
contact with an infected person’s ulcers.
Figure 6.5: Microscopic appearance of haemophilus ducreyi
Epidemiology
Chancroid is the third most common genital ulcer disease in Kenya. Infections typically
occur in clusters, often resulting in an outbreak in small towns or communities. Chancroid is
a cofactor for HIV transmission, as are genital herpes and syphilis. High rates of HIV
infection occur among patients who have chancroid.
30
Clinical presentation
Primarily there is development of painful, pus-filled ulcers in the genital region 3 to 5 days
after sexual contact. The ulcers are painful and soft on palpation and there is swelling and
suppuration of the local lymph nodes. Those infected typically notice the appearance of
raised, red bumps on the genital region. In men, these bumps usually develop on the penis
or perianal region. In women, bumps generally appear on the labia, cervix, vagina, or
rectum. Within a few days, these bumps become filled with pus and eventually rupture,
leaving rugged, painful, open sores in the genital region. Ulcers can bleed or ooze pus and
can take weeks to heal without medication.
In 50% of chancroid infections, the infection also presents in the lymph glands in the genital
region. These glands become hard and swollen, and may fill with pus. Known as "buboes,"
these swellings can burst, becoming extremely painful. Buboes are described in subsection
6.4.3.
Diagnosis
The infection can be diagnosed relatively easily by taking a swab from one of the ulcers and
examining it under a microscope for evidence of the chancroid bacteria.
Treatment
Successful treatment for chancroid cures the infection, resolves the clinical symptoms, and
prevents transmission to others. In advanced cases, scarring can result, despite successful
therapy. For the management of chancroid refer to Figure 6.5 on genital ulcer disease.
Recommended Regimens
1. Azithromycin 1 g orally in a single dose;
2. Ceftriaxone 250 mg intramuscularly (IM) in a single dose;
3. Ciprofloxacin 500 mg orally twice a day for 3 days;
4. Erythromycin 500 mg orally three times a day for 7 days.
31
Table 6.2: Comparison of the clinical features of Chancroid and Syphilis
Ulcer
Chancroid
Syphilis
Multiple, Painful,soft irregular
Single
painless,hard
edge with pus and oedema
defined
edge
with
well
clear
discharge
Lymph nodes
Painful,suppurative
swollen
lymph nodes
Lab diagnosis
Incubation period
Gram
Bilateral painless enlargement
without suppuration
negative
small
rods
Spiroachates seen on dark
which form chains
field illumination.
3-5 days
10-90 days
6.4.3. INGUINAL BUBO
Inguinal and femoral buboes are localised enlargements of the lymph nodes in the groin
area, which are painful and may be fluctuant (soft with a feeling of liquid inside). When
buboes rupture, they may appear as ulcers in the inguinal area. As we saw in Chancroid,
buboes are frequently associated with lymphgranuloma venereum and chancroid. In areas
where granuloma inguinale is common, it should also considered as a cause of inguinal
bubo.
If you come across buboes with a genital ulcer, you should use the genital ulcer flow chart to
treat it.
Treatment
The treatment is Erythromycin tablet 500 mg qid for 14 days or Doxyclyline capsules 100 mg
bd for 14 days. Some cases may require longer treatment than the 14 days recommended.
Buboes might require aspiration through intact skin or incision and drainage to prevent the
formation of inguinal/ femoral ulcerations.
6.4.4 LYMPHOGRANULOMA VENEREUM (LGV)
Lymphogranuloma venereum (LGV) is caused by Chlamydia . trachomatis.
32
Epidemiology
Lymphogranuloma venereum occurs throughout tropical Africa and is more common in
towns and seaports and among promiscuous people.
Clinical Presentation
After the initial ulcer or vesicle (which may be missed) the next signs and symptoms are
swelling of the inguinal lymph glands in males. The primary lesion is a papule, a shallow
ulcer or an erosion. This may disappear all together or become an ulcer. The common site
for this presentation in males is the prepuse, coronal sulcus, scrotum, frenulum or shaft of
the penis. In females, the common sites are the vulva, fourchette and cervix. In both males
and females, the disease leads to a chronic inflammatory reaction along lymph vessels,
lymph glands and surrounding tissue which heals by fibrosis after many months if untreated.
Discharging sinuses in the skin are common. The destruction of the lymphatic of the genital
and inguinal areas results in fibrotic malformation of the genitals and in females may also
cause rectal stricture. The damage to the lymphatics and lymph glands causes
elephantiasis of the external genitals and in severe cases this may extend to the lower
limbs.
Diagnosis
Genital and lymph node specimens (i.e., lesion swab or bubo aspirate) may be tested for C.
trachomatis by culture, direct immunofluorescence, or nucleic acid detection. A biopsy of
the inguinal lymph nodes can also be done.
Treatment
The main aim of treatment is to relieve pain, cure infection and prevents ongoing tissue
damage, although tissue reaction to the infection can result in scarring. For the
management, follow the treatment given in Figure 6.3 on genital ulcer disease.
6.4.5 GENITAL HERPES SIMLEX VIRUS (HSV) INFECTION
Genital herpes is a chronic, life-long viral infection. Two types of HSV have been identified,
HSV-1 and HSV-2. The majority of cases of recurrent genital herpes are caused by HSV-2.
33
Diagnosis of HSV Infection
It presents with multiple shallow and tender ulcers. These may start as itchy vesicles
grouped. The incubation period of HSV is 1 week. Isolation of HSV in cell culture is the
preferred virologic test. PCR assays for HSV DNA are more however sensitive and have
been used instead of viral culture.
Treatment

Acyclovir 400 mg orally three times a day for 7–10 days

Acyclovir 200 mg orally five times a day for 7–10 days OR

Famciclovir 250 mg orally three times a day for 7–10 days
6.4.6 GENITAL WARTS
Genital warts is caused by the human papilloma virus (HPV). HPV is a DNA virus of the
papova group of viruses. There are several serological types of HPV:
HPV 16, 18, 31, 33 and 35. These are associated with genital warts. HPV 6, 11 and 12 are
associated with skin warts. HPV is a very common infection among the general public and
is spread through sexual contact.
Symptoms:
Genital warts look like miniature cauliflower florets, which are usually flesh-coloured, soft
and moist. They can develop on the vulva, cervix and in or around the vagina. In men
genital warts develop on the frenulum, scrotum or penis. One important observation about
genital warts in females is that they tend to grow bigger during pregnancy. This is due to
stimulation by homones. Cervical warts are caused by certain strains of HPV, notably 16,
18 and 3, which are known to predispose to carcinoma of the cervix.
Diagnosis
The diagnosis of warts is mainly by clinical observation of the lesions. Specialised tests in
the laboratory such as biopsy of the wart, pap smear and colposcopy may be done.
Treatment:
There is no cure for HPV as well as no HPV treatment. However genital warts can be
treated by medication or by burning the warts off.
34
Complications:
There is a significantly increased risk of developing cervical cancer and some other types of
cancer including, vulvar cancer, anal cancer, or cancer of the penis.
6.4.7 MOLLUSCUM-CONTAGIOSUM
Molluscum contagiosum is a skin infection that is caused by a virus called the Poxvirus. It
causes a rash of tiny sores that can appear on areas of the skin or on the mucus glands of
eyes, mouth, nose, or genitals.
Epidemiology
Affects almost 8% of the world’s population, molluscum contagiosum can affect men,
women, and children. The highest incidences occur in tropical and warm climates around
the world. Overall infection rates are approximately 5% to 8% of the population. Additionally,
up to 20% of people with HIV/AIDS have the disease. In individuals co-infected with HIV,
the lesions may be severe and more widespread. Molluscum contagiosum is contracted by
skin-to-skin contact with an infected person. In adults, this skin-to-skin contact is generally in
the form of sexual activity.
Treatment
Molluscum contagiosum usually resolves without any type of treatment. However, it can take
a while for the virus to disappear. Treatment usually involves removing the molluscum in
order to prevent it from spreading.
6.4.8 BALANITIS
Balanitis is inflammation of the glans penis. Balanitis involving the foreskin and prepuce is
termed balanoposthitis. The most common complication of balanitis is phimosis, or inability
to retract the foreskin from the glans penis. Patients usually present with the following
complaints: Penile discharge; inability to retract foreskin; Impotence; difficulty in urinating or
controlling urine stream;Tenderness of the glans penis.
On physical examination there is:
35

Erythema and oedema of glans penis or foreskin;

Inability to visualize glans penis or urethral meatus;

Discharge;

Ulceration and plaques;

Phimosis and meatal stenosis.
Causes:

Diabetes is the most common underlying condition associated in adult balanitis.

Other causes include poor personal hygiene; chemical irritants (eg, soap, petroleum
jelly); penile cancer

Several organisms and viruses cause balanitis, including the following:
o
Candidal species :
o
Anaerobic infection;
o
Human papilloma virus;
o
Gardnerella vaginalis;
o
Trichomonal species;
o
Group B and group A streptococci
Diagnosis
This may include careful identification of the cause with the aid of a good patient history,
swabs and cultures, and pathologic examination of a biopsy
Treatment
This will depend on the cause and maintenance of good hygiene.
6.4.
Prevention and Control of STIs
Like all the other communicable diseases, STIs are preventable. And the best approach to
the prevention of STIs is to avoid exposure. As you have noticed, STIs are transmitted from
person to person through specific preventable behaviours, which bring a person into contact
with secretions or blood of an infected sexual partner.
36
ACTIVITY
What kind of behaviour determines the risk of getting an STI
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Well, I am sure you mentioned sexual behaviour such as the following:

Having many sexual partners;

Changing sex partners frequently;

Having sex with casual partners, clients of commercial sex workers or commercial sex
workers;

Sexual practices such as anal sex.
In addition, the following health behaviour increases the risk of getting STIs. These are:

Failure to use condoms correctly and consistently;

Delay in getting STI treatment;

Failure to bring in sexual contacts for treatment;

Not taking full treatment for STIs.
You should advice your clients to reduce the likelihood of exposure to STIS by:

Practicing abstinence

Delaying sexual activity among adolescents and young people;

Decreasing the number of sexual partners

Using condoms correctly and consistently

Faithfulness to one uninfected partner.
Another way in which STIs are transmitted is through medical procedures that involve
passing instruments through the cervix.
Women who harbour pathogens such as N.
37
gonorrhoea or C. trachomatis in their cervix are at risk of upper genital tract infection after
such a procedure. You can prevent this by adopting appropriate infection prevention
procedures and aseptic techniques, stopping the spread of infection to the upper genital
tract by treating any cervical infections prior to performing any procedure.
How can you control the spread of STIs?
Well, communities with good access to effective prevention and treatment services have
lower rates of STIs than communities where services are poor, disrupted or not used by
people at risk. As you now well appreciate, STIs are transmitted in the community and thus
its control cannot be limited to the clinical setting alone. Further, the control of STIs for a
long time has been quite a tricky business. This is because people with STIs may refuse to
come for treatment for fear of stigmatisation. Also the cost of STI treatment may be a barrier
to seeking medical care for those who do not have sufficient funds. In addition, 70-80% of
women may be asymptomatic and thus may not seek medical treatment. Other reasons
include ignorance, social stigma, traditional sexual practices, and failure to take the full
prescribed course of treatment, all make it difficult to control STIs. Since all STIs including
HIV are preventable, as health workers we need to promote primary prevention while at the
same time we provide effective treatment and care for those who are infected.
We can do this by:

improving our knowledge and skills in the management of STIs;

improving access to STI services;

integrating STI services within primary care rather than having centres dedicated to STI
treatment;

promote prevention; and

detect and manage existing infections.
There are three main ways that can be used to prevent STIs. Before you proceed further
do the following activity.
38
ACTIVITY
List the three methods of STI prevention that can you apply.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Now read through the text below and see if your ideas are included.
The three main methods of STI prevention are:

primary;

secondary; and

tertiary prevention.
Primary prevention means protecting a person from becoming infected. It has been shown
that most STIs are transmitted from a reservoir of infected individuals and their sexual
partners. In you target control measures to this group you intervention will be highly effective,
As you have seen, everybody is susceptible to acquiring STIs, however, some behaviour
exposes some individuals more than others. Secondary prevention means the prompt
detection, treatment, and contact tracing of asymptomatic cases. Tertiary prevention is the
treatment of disease and management of complications,
The emphasis on primary prevention results in reducing the prevalence and duration of STIs
and is thus the most cost effective in terms of money and manpower. Strategies to effect
these three levels of prevention have the following components:

Health education and promotion;
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High degree of disease suspicion;
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Clinical service and laboratory evaluation;
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Appropriate treatment;
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Partner tracing/patient counselling;

Training and research.
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Summary
You have now come to the end of this Unit on STIs.
I hope you found it useful and
informative. Go back to the beginning of this unit and review the objectives we set. Did you
achieve them? If not, review the relevant sections again. If you feel confident that you have
mastered the content in this unit, take a well earned break and then complete the attached
assignments. Good luck!
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DIRECTORATE OF LEARNING SYSTEMS
DISTANCE EDUCATION COURSES
Student Number: ________________________________
Name: _________________________________________
Address: _______________________________________
_______________________________________________
COMMUNICABLE DISEASES COURSE
Tutor Marked Assignment
Unit 6: Sexually Transmitted Diseases
Instructions: Answer all the questions in this assignment.
1. List the main Sexually Transmitted Infections of public health importance.
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2. A woman comes to your clinic complaining of a vaginal discharge.
a. What are the important questions you need to ask?
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b. What differential diagnosis should you run through your mind?
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3. Describe the sign and symptoms of gonorrhoea.
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4. What treatment would you give for acute gonorrhoea infection?
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5. As a good health worker what advise would you give to patient having gonorrhoea?
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6. A man comes in complaining of a sore in his penis.
a. What four conditions could this man be suffering from?
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b. On examination you find that he actually has rugged, painful, and necrotic multiple
ulcers which bleed easily. What would be your diagnosis?
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c)
Which syndromic management chart would you use to treat this patient?
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7. Name the common sites where ulcers due to LGV occur in males.
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8. A young woman complains of a sore. Upon examination you notice an ulcer on the outer
labia.
a. How would you classify this patient under the syndromic management approach?
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b. What are the main causes of this ulcer?
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c. How would you treat this patient?
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9. A young woman complains of a pain in her stomach, low down. You take her history and
examine her. She tells you that her periods are normal and she has never been
pregnant. She has no rebound tenderness but clearly feels pain when you palpate her
abdomen.
a) What syndromic management flowchart should you use?
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b) How would you manage this woman?
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A week later, the same woman returns. She tells you that she feels no better, though she is
taking all the tablets you gave her as you suggested. Upon examination, you discover that
she has a temperature of 38.2°C.
c) How would you manage her this time?
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10. A middle-aged man tells you that he has felt pain in his groin for a week or so. Upon
examination, you confirm that he has a painful fluctuating mass in the right groin. The
patient winces when the mass is touched. There are no ulcers on his penis.
a) What is the man suffering from?
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b) How would you treat him?
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11. What practical steps could you take to reduce the incidence of STI in your community
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Congratulations! You have now come to the end of this unit. Remember to indicate your
Student number, names and address before sending the assignment. Once you complete
this assignment, send it to AMREF Training Centre. We will mark it and return it to you with
comments.
Our address is:
AMREF Distance Education Project
Directorate of Learning Systems
P O Box 27691-00506
Nairobi, Kenya
Email: [email protected]
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