SEXUALLY TRANSMITTED INFECTIONS IN PATIENTS.pptx

Sexually Transmitted Infections (STIs)


Sexually transmitted infections (STIs), also known as sexually transmitted diseases (STDs), are infections passed from one person to another through sexual contact1. These infections are typically spread during vaginal, oral, or anal sex, but can also be transmitted through other forms of sexual contact involving the penis, vagina, mouth, or anus due to skin-to-skin contact, as seen with herpes and HPV1. STIs can be caused by bacteria, viruses, or parasites1.

The impact of STIs is far-reaching, affecting sexual and reproductive health worldwide6. Over one million curable STIs are acquired every day around the world by people aged 15–49, and the majority of these infections are asymptomatic6. In 2020, there were an estimated 374 million new infections of curable STIs, including chlamydia, gonorrhea, syphilis, and trichomoniasis, among people aged 15–496.

STIs can lead to severe reproductive health issues, such as infertility, ectopic pregnancies, and adverse pregnancy outcomes7. They can also cause stigma, discrimination, and psychological distress, leading to delays in diagnosis and treatment because of fear of social consequences7. The economic burden of treating STIs and their complications places a considerable strain on healthcare systems due to direct medical expenses like diagnostics, treatment, and follow-up care7.


STIs have a profound effect on sexual and reproductive health on a global scale6. Each day, more than a million treatable STIs are contracted worldwide8. The World Health Organization (WHO) estimated that there were 374 million new infections of four STIs—chlamydia (129 million), gonorrhea (82 million), syphilis (7.1 million), and trichomoniasis (156 million)—in 20206. In 2016, it was estimated that over 490 million people were living with genital herpes, and an estimated 300 million women have human papillomavirus (HPV), which is the main cause of cervical and anal cancer in men who have intercourse with men6. Furthermore, updated WHO estimates indicate that 254 million people had hepatitis B in 20226.

STIs can have consequences that go beyond the infection's immediate effects6. STIs such as herpes, gonorrhea, and syphilis, can raise the risk of contracting HIV6. Mother-to-child transmission of STIs can result in stillbirth, neonatal death, low birth weight and prematurity, sepsis, neonatal conjunctivitis, and congenital abnormalities6. HPV infection results in cervical and other cancers6. The majority of the just over one million fatalities in 2022 caused by hepatitis B were caused by cirrhosis and hepatocellular carcinoma6. Pelvic inflammatory disease and infertility in women are significantly caused by STIs like gonorrhea and chlamydia6.


There are more than 20 different types of STIs caused by bacteria, viruses, and parasites1. The most common STIs include:

: In 2023, over 1.6 million cases of chlamydia were diagnosed3.

: In 2023, over 600,000 cases of gonorrhea were seen

1. SEXUALLY TRANSMITTED INFECTIONS

2. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS STI/STDs refers to a variety of clinical syndromes and infections caused by pathogens that can be acquired and transmitted through sexual activity. STI/STDs are infections acquired during heterosexual or homosexual intercourse with an infected person.

3. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS Characteristics shared by sexually transmitted diseases/infections STDs can be transmitted by any sexual activity between opposite sex or same sex partners and by any sexual technique (anal, oral, vaginal and shared masturbation toys) Having one STD does not confer immunity against future reinfection with the same STD or with any other STD. Sexual partners of the infected clients are most likely also infected and require assessment and treatment

4. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS Characteristics cont ’ STDs affect people from all socioeconomic classes, cultures, ethnicities, and age groups. Women are more affected by STDs than men because of anatomical makeup Frustration, anger, anxiety, fear, shame and guilt are emotions commonly associated with STDs. STDs commonly coexist in the same client.

5. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS Risky groups Widows Adolescence/youth Long distance truck drivers Displaced persons (internal/external) Drug abusers Prisoners Migrant/police force Prostitutes Beach boys MSM /WSW/ Bisexuals

6. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS Risky behaviors Having multiple sexual partners either casual or for money Wife inheritance Early age at initiation of sexual activity Unprotected sexual contact Alcohol and drug use (ADA)

7. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS Reducing risky behaviors Abstinence Being faithful (Mutual monogamy) Condom use Treatment compliance Contact tracing and follow-up

8. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS AND THE RESPECTIVE CAUSATIVE ORGANISMS Bacterial STDs Gonorrhea Neisseria gonorrhea Chlamydial Chlamydia trachomatis Syphilis Treponema pallidum Cancroid Haemophilus ducreyi Bacterial vaginosis Gardnerella vaginalis and other vaginal anaerobes Non-gonococcal urethritis Mycobacterium genitalium Trichomonas vaginalis Chlamydia trachomatis Lymphogranuloma venereum Chlamydia trachomatis Granuloma inguinale Klebsiella granulomatis

9. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERSAND THE RESPECTIVE CAUSATIVE ORGANISMS b) Viral STDs   Genital herpes Herpes simplex virus type II Genital warts Human papilloma virus Hepatitis B Hepatitis B virus Hepatitis C Hepatitis C virus c) Protozoan STDs   Trichomoniasis Trichomona vaginalis d) Fungal STDs   Candidiasis (vulvovaginal) Candida albicans e) STDs by ectoparasites   Scabies Sarcoptes scabiei Pediculosis pubis Pubic lice

10. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 1. Gonorrhea Gonorrhea is associated with cervicitis in women and urethritis in men. In case of anal sex, the rectum may be infected. Gonococcal infections of the pharynx are associated with oral sex. It can also be transmitted from an infected mother to the newborn during vaginal delivery, hence ophthalmia neonatorum (Neonatal conjunctivitis) The infection may also gain access to the blood stream causing bacteremia a characterized by polyarthritis, dermatitis, endocarditis and meningitis especially in women. Cause : Neisseria gonococci, which is a gram negative diplococci. Incubation period : 48-72 hours

11. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 1. Gonorrhea Signs and symptoms Men Purulent urethral discharge (yellow-green or beige in color) Painful micturition (dysuria); sometimes described as burning pain on urination Frequency micturition Urgency of micturition Dyspareunia (painful intercourse) Painful/swollen testicles

12. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 1. Gonorrhea Signs and symptoms b) Women Lower abdominal pain Dysuria Urinary frequency Purulent yellow-green vaginal discharge Dyspareunia (painful intercourse) Swollen/tender Bartholin’s glands Spotting after sexual intercourse Abnormal/painful menses. Cervical erythema on speculum examination

13. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS 1. Gonorrhea Signs and symptoms c) Rectal inflammation (Proctitis) characterized by; Purulent anal discharge Anal itching Anal soreness Anal bleeding Painful bowel movements

14. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS 1. Gonorrhea Signs and symptoms d) Pharyngeal inflammation (pharyngitis) characterized by; Sore throat Swollen lymph nodes of the neck (cervical lymph nodes) e) Neonatal conjunctivitis (ophthalmia neonatorum) characterized by; Purulent eye discharge Swollen eyelids Red ey es

15. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS 1. Gonorrhea Diagnosis Health history and physical examination Endocervical swab or high vaginal swab or rectal swab or oropharyngeal swab or first catch urine specimen for culture and sensitivity; and Nucleic Acid Amplification Test (NAAT), which is a molecular test that detects the genetic material (DNA) of Neisseria gonorrhea and is more accurate and reliable than culture

16. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS 1. Gonorrhea Management The antibiotic alternatives used are; Ceftriaxone injection or cefixime orally Erythromycin or azithromycin Doxycycline Levofloxacin or ofloxacin

17. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 2. Chlamydia Chlamydial infections primarily affect the cervix, urethra and rectum. It is associated with cervicitis in women and non-gonococcal urethritis in men. The infection may remain asymptomatic for an extended period. Hence clients do not seek medical treatment and the diagnosis is often missed. It may extend beyond the cervix in women causing pelvic inflammatory disease. Involvement and scaring of the fallopian tubes leads to infertility in women. It may cause urethral stricture and also extend to epididymis, hence infertility. Cause : Chlamydia Trachomatis; which is gram negative Incubation period : 4-7 days.

18. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 2. Chlamydia Signs and symptoms. Women Mucopurulent yellow vaginal discharge Lower abdominal pains Red inflamed and edematous cervix Swollen/tender Bartholin’s gland with purulent discharge Spotting after sexual intercourse Mid-cycle menstrual bleeding Dysuria. Urinary frequency

19. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 2. Chlamydia Signs and symptoms. b) Men Dysuria Mucopurulent urethral discharge Urinary frequency and urgency Scrotal pain, tenderness or swelling c) Rectal inflammation (Proctitis) characterized by; Purulent anal discharge Anal itching Anal soreness Anal bleeding Painful bowel movements

20. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 2. Chlamydia Signs and symptoms. d) Pharyngeal inflammation (pharyngitis)characterized by; Sore throat Swollen lymph nodes of the neck (cervical lymph nodes) Diagnosis Health history and physical examination Endocervical swab or high vaginal swab or rectal swab or oropharyngeal swab or first catch urine specimen for culture and sensitivity

21. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 2. Chlamydia Management options Erythromycin or azithromycin Doxycycline Levofloxacin or ofloxacin Amoxicillin especially in pregnancy

22. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 3. Trichomoniasis Trichomoniasis is a protozoal infection causing vulvovaginitis. Treatment of choice is nitroimidazoles such as metronidazole or tinidazole Cause: Trichomona vaginalis (flagellated protozoa). It is sexually transmitted and thrives well in an alkaline environment. Incubation period: 3-28 days

23. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 3. Trichomoniasis Signs and symptoms Women Copious white or yellowish or green vaginal discharge with unusual fishy smell Pruritus of external genitalia and vagina Excoriation of the external genitalia because of itching. Dysuria Frequency of urination Dyspareunia Strawberry cervical appearance due to erythema/edema Red and edematous vaginal mucosa

24. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 3. Trichomoniasis Signs and symptoms. b) Men Dysuria Frequency of urination Burning sensation after ejaculation Urethral discharge Itching sensation inside the penis Anal itching and discharge.   Diagnosis Health history and physical examination findings Wet specimen of vaginal exudate for microscopic examination

25. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 4. Vulvovaginal Candidiasis Candidiasis is a fungal infection causing vulvovaginitis. Cause: Candida albicans (yeasts) Signs and symptoms White curd-like creamy vaginal discharge, which may be frothy. Pruritus (vulva/vagina) Excoriation in the external genitalia because of itching. Valvular edema/swelling Vaginal soreness Dyspareunia Pain in the Valvular area after urination

26. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 4. Vulvovaginal Candidiasis Diagnosis Health history and physical examination findings Wet specimen of vaginal discharge for isolating the yeast Vaginal discharge cultures Management Intravaginal preparations of clotrimazole, or miconazole or triconazole Systemic fluconazole

27. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 5. Syphilis Syphilis is systemic and highly infectious sexually transmitted diseases. The disease is divided into stages based on the clinical findings, and this guides treatment and follow-up. Cause: Treponema Pallidum bacteria. Incubation period : 10-21 days but can be as long as 90 days.

28. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 5. Syphilis Mode of transmission Sexual contact: The infection gains access to the body through sexual contact, and then disseminates to the rest of the body through the lymphatics and blood Transplacental : The infection can also be transmitted transplacentally from the mother to the unborn baby hence congenital syphilis. Direct inoculation: this may be through accidental needle injuries, blood transfusion or open wounds

29. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 5. Syphilis Stages and the respective signs and symptoms Primary chancre (primary stage) Painless oval ulcer (chancre) with hard surface and sharply defined margin Inguinal lymphadenopathy. The nodes are firm and painless. If untreated, the chancre disappears in 1-8 weeks without treatment

30. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 5. Syphilis Stages of Syphilis cont ’ b) Secondary stage Maculopapular rash which is non-irritant and located in most areas. It is bilaterally symmetrical Scalp hair loss (alopecia) and also hair loss from the eyebrows. White mucous patches in the mouth and pharynx General flu-like manifestations such as nausea, anorexia, headache, malaise, muscle and joint pain Condylomata lata lesions in the vulva and around the anus (fleshy moist tissue growths). These are highly infectious. Generalized and non-tender lymphadenopathy The manifestations of the secondary stage may disappear after 2 to 6 weeks.

31. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 5. Syphilis Stages of Syphilis cont ’ c) Tertiary stage (latent) Infection spreads to the bones, joints, eyes, blood vessels, and heart. It can affect the central nervous system and present with cranial nerve dysfunction, meningitis, stroke, altered mental status, auditory and ophthalmic abnormalities. Localized granulomas in any part of the body.

32. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 5. Syphilis Diagnosis Health history and physical examination Blood for serological tests. There are two tests that cane done; Venereal Disease Research Laboratory (VDRL) Rapid Plasma Reagin (RPR) Fluorescent Treponemal Antibody Absorption (FTS-ABS) Blood for PCR tests for detection of Treponema pallidum DNA

33. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 5. Syphilis Management options Benzathine /procaine/ crystalline penicillin Azithromycin Ceftriaxone Complications Neurological deficits – paresis Aortic aneurism/insufficiency

34. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 6. Chancroid Cancroid is a highly infectious sexually transmitted disease. Cause : Haemophilus ducreyi (gram negative bacteria) Incubation period: 2-5 days Signs and symptoms Multiple small papules/vesicles which open up to form painful deep ulcers at the glans/shaft of penis, or vaginal or anal orifice Offensive purulent discharge from the ulcer Ulcer is surrounded by a red zone of congestion and edema Tender inguinal lymphadenopathy

35. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 6. Chancroid Diagnosis Health history and physical examination. a probable diagnosis is made if the client has; One or more painful ulcers Tender inguinal lymphadenopathy No evidence of syphilis from serological tests 2. Wet swab from the ulcers taken for culture to isolate the H. ducreyi.

36. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 6. Chancroid Management options Azithromycin or erythromycin Ceftriaxone Ciprofloxacin Complications Phimosis Fistulae Secondary bacterial infection

37. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 7. Genital Herpes Genital herpes is a chronic, and recurrent lifelong viral infection. The virus is transmitted by both asymptomatic and symptomatic cases via sexual contact either vaginal, oral or anal sex. Newborns can be infected during vaginal delivery in presence of active lesions. Hence caesarian section is recommended in a client with active genital herpes infection.

38. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 7. Genital Herpes The recurrence occurs because after disease remission, the virus lies dormant in the nerve ganglion and cause another episode of infection in case of stress, infection, trauma, menses and sexual activity. Recurrent genital herpes causes localized manifestations. Before the lesions or vesicles appears, the client may experience prodromal features such as burning sensations or pain. The vesicles tend to appear at the site of previous infection.

39. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 7. Genital Herpes Cause : Herpes Simplex Virus type I and II. However, HSV type 2 is the one associated with recurrent genital herpes. HSV type I anogenital herpetic infections is common in MSM. Incubation period : 4-7 days Signs and symptoms Groups of small painful blisters/vesicles on the penile skin/vulva/anus. The vesicles rupture in about 24-48 hours producing painful shallow ulcers. The ulcers may resolve spontaneously after 7 to 10 days.

40. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 7. Genital Herpes Diagnosis Health history and physical examination for clinical diagnosis PCR assays for HSV DNA. This is the diagnosis test of choice. Management options Antiretroviral chemotherapy offers clinical benefits to most clients. The common used drugs are acyclovir or valacyclovir or famciclovir for 5 to 10 days. Complications Disseminated infections Meningitis Encephalitis

41. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 8. Lymphogranuloma Venereum This is a systemic infection that is causes by certain strains of C. trachomatis. It commonly heals spontaneously and may go unnoticed. It is characterized by; Primary lesion is a small, painless papule on the glans or vagina mucosa In case of anal sex, the client may present with mucoid or hemorrhagic rectal discharge and pain, constipation, fever and tenesmus . Tender enlarged and inflamed inguinal or femoral lymph nodes.

42. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 8. Lymphogranuloma Venereum Treatment options are doxycycline for 21 days or erythromycin for 21 days The complications include; Scarring Lymphatic obstruction Marked external genitalia deformity Rectal fibrosis and strictures Diagnosis Health history and physical examination for clinical diagnosis Genital or rectal swabs for culture to isolate the causative organism.

43. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 9. Granuloma Inguinale This is a genital ulcerative diseases caused by Klebsiella granulomatis (gram negative). It is characterized by painless slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy. The lesions are highly vascular and bleed easily. They have beefy-red appearance. Extragenital infection may occur with extension of infection to the pelvis, intra-abdominal organs, and bones .

44. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 9. Granuloma Inguinale Diagnosis is base of on health assessment and staining of Donovan bodies on tissue biopsy. There is no reliable laboratory test because it’s difficult to culture the organism. Relapses are common even after apparently effective treatment Treatment options are doxycycline or ciprofloxacin or erythromycin or septrin for 21 days.

45. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 10. Genital Warts Genital warts are caused by Human Papilloma Virus (HPV) types 6 and 11. The warts are flat, popular or pedunculated growths. They occur commonly around vaginal introitus , under the foreskin of uncircumcised men, and on the shaft of the circumcised penis. They can also occur in the perineum, perianal skin, anus, scrotum, and epithelium of the vagina, cervix, and urethra.

46. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 10. Genital Warts The warts are usually asymptomatic bur in some cases, they can be painful and pruritic. Diagnosis is mainly based on the findings of health history and physical examination. The viruses are also associated with conjunctival, nasal, oral, and laryngeal warts. If untreated, the genital warts may resolve spontaneously, remain unchanged or increases in size and number.

47. SEXUALLY TRANSMITTED INFECTIONS/ DISORDERS: 10. Genital Warts Treatment options are; Removal of visible warts using cryotherapy with nitrous oxide gas; or surgical removal using excisional scissors. Topical therapy applied only to the wart such as trichloroacetic acid or bichloroacetic acid solution usually applied by the health worker. Podofilox solution or gel; or Imiquimod that the client can be given for self-application.

48. STI DIAGNOSTIC AND MANAGEMENT APPROACHES Globally, the health service providers use one of the following approaches in the diagnosis and subsequent management of the clients; Syndromic approach This approach involves identification of group of symptoms associated with particular STIs and then treatment is given targeting all the possible causes of such signs and symptoms. The health workers in all the setting should be able to identify the syndromes outlined in particular flow chart s and put the patient on treatment. However, the challenge is that asymptomatic. This is the approach recommended by the WHO and adopted by many countries, kenya included.

49. STI DIAGNOSTIC AND MANAGEMENT APPROACHES 2. Etiologic approach This approach involves identifying the causative agent using laboratory tests and then the treatment is given to target the agent and achieve cure. The challenge with this approach is that many health facilities may not have laboratories as well as appropriate equipment and reagents to carry out the tests. This may delay treatment as client has to be referred where such services are available. However, the approach is still in use where such services are available.

50. STI DIAGNOSTIC AND MANAGEMENT APPROACHES 3. Clinical approach This approach banks on the clinical experience of the health worker to conduct health history and physical examination; and make implication of the possible causative organism. The treatment is then given based on the clinical judgement. The challenge is that high clinical skills are required and also there is a possibility of overlooking mixed infections.

51. STI SYNDROMES 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. For the purpose of management, the STIs are grouped into 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

52. SYNDROMIC MANAGEMENT Syndromic approach is used to treat/manage the STI especially those caused by organisms that respond to similar treatment For each syndrome a clinical algorithm (flow chart) is developed to be followed in managing STI patients. Algorithm (flow chart) is like a map that guides the health worker to go through a series of decisions and actions. Each decision or action is enclosed in a box, with one or two routes leading out to another box, containing another decision or action.

53. SYNDROMIC MANAGEMENT In each syndrome, the flow chart gives: Clinical problem Decision to be taken The action to be carried out What to do if symptoms persist Reminders to educate the client about partner referral, sexual practices, treatment compliance and condom use Benefits of using flow-charts The flow chart simplifies the treatment regimes They can be used at any time in all types of health facilities They suggest clear decisions

54. 4 Cs of STI Management 1. Counseling Empathize with the patient Counsel on behavior change and adoption of less risky sexual behaviors Counsel on circumcision for uncircumcised males Counsel on need for HIV testing and possibly test Counsel on family planning with a focus on dual protection.   2. Condoms Proper condom use is the only often alternative to abstinence. Explain and demonstrate the proper use of condoms Give condoms to the patient

55. 4 Cs of STI Management 3. Compliance Patient to comply with treatment Avoid self medication Avoid sharing medication Abstain from sexual intercourse for 7 days after completion of treatment and resolution of symptoms to prevent reinfection. Follow instructions   4. Contact treatment Encourage patient to inform all his/her sexual partners to seek medication especially if they had sex with the partner during the 60 days preceding the patient’s onset of the chlamydial infection symptoms.

56. STI SYNDROMES

57. STI SYNDROMES

58. I: URETHRAL DISCHARGE SYNDROME Urethral discharge is the presence of abnormal secretions from the distal part of the urethra and it is the characteristic manifestation of urethritis. Urethritis is usually due to sexually transmitted infections although urinary tract infections may produce similar symptoms. Urethral discharge is one of the commonest sexually transmitted infections among men in our country.

59. I: URETHRAL DISCHARGE SYNDROME Urethral discharge can be caused by different causative micro-organisms. It can be caused by a single microorganism or mixture of micro-organisms. In some rare cases it can be also the result of non-infectious causes. Due to these reasons urethral discharge is a syndrome of many causes rather than a single disease to be dealt with and it needs to be dealt with as a syndrome while it is being managed. Urethral discharge syndrome needs to be treated as soon as possible because if it is not treated on time it can cause serious complication.

60. I: URETHRAL DISCHARGE SYNDROME Etiology of urethral discharge syndrome The causative agents of urethral discharge syndrome are many; but the two most common causative agents of the syndrome are: Neisseria gonorrhea Chlamydia trachomatis. Most of the time urethral discharge is due to mixed infection of Neisseria gonorrhea and Chlamydia trachomatis Some of the other causative micro-organisms are: Mycoplasma genitalium Trichomonas vaginalis Ureaplasma urealyticum

61. I: URETHRAL DISCHARGE SYNDROME Clinical manifestations of urethral discharge syndrome Profuse and purulent discharge in case of gonorrhea Scanty mucopurulent discharge in case of chlamydial infection. Burning sensation during micturition, Urgency and frequency of urination Itching sensation of the urethra. The signs and symptoms of complications of the syndrome are testicular pain and swelling, polyarthralgia , tenosynovitis, arthritis, skin lesions and constitutional symptoms.

62. I: URETHRAL DISCHARGE SYNDROME Complications of urethral discharge syndrome Untreated UDS can cause some important acute and chronic complications. Early and prompt treatment of the syndrome is very important to avoid the possible complications. Some of the common complications of UDS are: Disseminated gonococci syndrome Acute epididymo-orchitis characterised by testicular pain and swelling Urethral stricture Infertility

63.   II: VAGINAL DISCHARGE SYNDROME Physiologically women have vaginal discharge which is white mucoid, odor less and nonirritant, thin or thick based on menstrual cycle. There is individual variation in the amount of normal vaginal discharges. Abnormal vaginal discharge which is STI-related is abnormal in color, odor and amount. The syndrome is associated with vaginitis and or cervitis depending on the causative organism.

64. II: VAGINAL DISCHARGE SYNDROME Etiology of vaginal discharge syndrome The most common causes of vaginal discharge syndrome are Neisseria gonorrhea Chlamydia trachomatis Trichomonas vaginalis Gardnerella vaginalis Candida albicans

65. II: VAGINAL DISCHARGE SYNDROME Clinical manifestations The classical manifestation of vaginal discharge is discharge from the vagina. The discharge can be; Thin, homogenous whitish discharge with fishy odor Thick, profuse, malodorous, yellow-green, frothy itchy Purulent exudate from the cervical Os White , thick and curd like discharge coating the walls of the vagina

66. II: VAGINAL DISCHARGE SYNDROME The other manifestations are: vulvo -vaginal pruritus (itching) Redness/irritation and edema of vulva Bartholin’s glands are swollen Redness of the cervix Cervical bleeding Dyspareunia Spotting after intercourse Dysuria and frequency of urination.

67. II: VAGINAL DISCHARGE SYNDROME Complications Untreated vaginal discharge can cause reproductive, sexual and other health complications. Some of the complications are: Pelvic Inflammatory Disease (PID) Peritonitis and intra-abdominal abscess Adhesions and intestinal obstruction Ectopic pregnancy Premature Rupture of Membrane (PROM) in case of pregnant women Chorioamnionitis Post-partum endometritis (puerperal sepsis) Preterm labor in case of pregnant women leading to preterm baby/low birth weight Infertility Chronic pelvic pain

68. III: LOWER ABDOMINAL PAIN SYNDROME Lower abdominal syndrome refers to a clinical syndrome resulting from ascending infection from the cervix and/or vagina. It comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis , salpingitis , tubo -ovarian abscess and pelvic peritonitis. The inflammation may also spread to the liver, spleen or appendix. The vast majority of LAP syndrome with or without pelvic abscess improves with antibiotics alone and the fever usually subsides in less than 72 hours.

69. III: LOWER ABDOMINAL PAIN SYNDROME Etiology LAP syndrome is frequently poly-microbial. The commonest pathogens associated with LAP syndrome, which are transmitted sexually, are: Chlamydia trachomatis Neisseria gonorrhea. Other causes which may or may not be transmitted sexually include: Mycoplasma genitalium Bacteroides species E. coli H. influenza Streptococcus

70. III: LOWER ABDOMINAL PAIN SYNDROME Clinical manifestation The commonest manifestations of LAP syndrome include Lower abdominal pain Abnormal vaginal discharge Inter-menstrual or post coital bleeding Dysuria Backache Fever Nausea and vomiting Cervical excitation tenderness Adnexal tenderness Rebound tenderness Adnexal mass

71. III: LOWER ABDOMINAL PAIN SYNDROME Complications of lower abdominal pain syndrome If patients with LAP syndrome are not treated appropriately and adequately the following life threatening complications may occur. Peritonitis Intra-abdominal abscess Adhesions and intestinal obstruction Ectopic pregnancy Infertility Chronic pelvic pain Recurrent PID

72. IV: GENITAL ULCER DISEASE SYNDROME Genital ulcer is an open sore or a break in the continuity of the skin or mucous membrane of the genitalia as a result of sexually acquired infections. Commonly genital ulcer is caused by bacteria and viruses. Genital ulcer facilitates transmission of HIV more than other sexually transmitted infections because it disrupts continuity of skins and mucous membranes significantly. Common sites for genital ulcers in male are glance penis, prepuce and penile shaft Common sites for genital ulcers in women are vulva, perineum, vagina and cervix and can cause occasionally severe vulvo - vaginitis and necrotizing cervicitis

73. IV: GENITAL ULCER DISEASE SYNDROME Etiology of genital ulcer syndrome There are different kinds of bacteria and viruses which cause genital ulcer. The common etiologies of genital ulcer syndrome are: Herpes simplex virus (HSV-2) Treponema pallidum Haemophilius ducreyi Other causes include; Herpes simplex virus (HSV-1) Chlamydia trachomatis Klebsiella granulomatis (donovanosis)

74. IV: GENITAL ULCER DISEASE SYNDROME Clinical manifestation Genital ulcer is caused by different causative agents and due to this fact genital ulcer has different kinds of clinical manifestations. Common clinical manifestations of genital ulcer are: • Constitutional symptoms such as fever, headache, malaise and muscular pain • Recurrent painful vesicles and irritations • Shallow and non-indurated tender ulcers . • Painless indurated ulcer(Chancre) • Regional lymph adenopathy

75. IV: GENITAL ULCER DISEASE SYNDROME Complications of genital ulcer syndrome Locally destructive granulomatous lesions occur ( Gummas ) on the skin, liver, bones, or other organs Dementia, often with paranoid features Optic atrophy General paresis Aortic aneurysm and aortic valve insufficiency Asymptomatic aortitis Angina pectoris Recurrent disease Aseptic meningitis Encephalitis Phimosis in men Destruction of the penis or auto amputation Extra genital lesions

76. V: NEONATAL CONJUNCTIVITIS (OPHTHALMIA NEONATORUM) Neonatal conjunctivitis (ophthalmia neonatorum) is an ocular redness, swelling and drainage which can be sometimes purulent due to pathogenic agents or irritant chemicals occurring in infants less than 4 weeks of age. In cases of neonatal conjunctivitis due to pathogenic agents, the neonates get the infections from their infected mothers. Neonatal conjunctivitis can cause loss of sight if it is not managed properly and promptly. Neonatal conjunctivitis due to sterile chemical irritants can be resolved by itself within 48 hours without any intervention.

77. V: NEONATAL CONJUNCTIVITIS (OPHTHALMIA NEONATORUM) Etiology of neonatal conjunctivitis The etiology of neonatal conjunctivitis can be disease causing micro-organisms or sterile chemicals which are irritant and applied for preventive purposes. The common causative organisms of neonatal conjunctivitis are: N. gonorrhea C. trachomatis S. pneumoniae H. influenzae S. aureus The commonest irritant chemical that causes neonatal conjunctivitis is silver nitrate solution, which is applied to the eye of the neonate for prophylactic purposes.

78. V: NEONATAL CONJUNCTIVITIS (OPHTHALMIA NEONATORUM) Common risk factors of neonatal conjunctivitis Maternal infection with STI Exposure of the infant to infectious organisms Inadequacy of ocular prophylaxis immediately after birth Premature rupture of membrane Ocular trauma during delivery Mechanical ventilation Prematurity

79. V: NEONATAL CONJUNCTIVITIS (OPHTHALMIA NEONATORUM) Clinical manifestations The common clinical presentations of neonatal conjunctivitis (ophthalmia neonatorum) are: Red and edematous conjunctiva Edematous eyelids Discharge which may be purulent Orbital cellulitis in more serious cases

80. V: NEONATAL CONJUNCTIVITIS (OPHTHALMIA NEONATORUM) Complications of neonatal conjunctivitis Neonatal conjunctivitis can lead to some serious ophthalmic complications if it is not managed promptly. Some of the complications of neonatal conjunctivitis (ophthalmia neonatorum) are: Pseudo membrane formation Corneal edema Corneal opacification Corneal perforation Blindness

81. V: NEONATAL CONJUNCTIVITIS (OPHTHALMIA NEONATORUM) Prevention of ophthalmia neonatorum The best way of managing neonatal conjunctivitis is preventing it from happening. It can be prevented if effective preventive actions are taken by healthcare providers. Prevent neonatal conjunctivitis by: Wiping the baby’s both eyes with dry and clean cotton cloth as soon as the baby is born. Apply 1% tetracycline eye ointment into the eyes of the newborn infant. Properly open the eye of the infant and place the ointment on the lower conjunctival sacs and avoid placing on the eyelids Daily cleaning of the eyes

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