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1. Sexually transmitted infections that cause urethral discharge. By Group 2 Nasasira C olline 2022/U/MMU/BNSD/002 Ajuna Charles 2022/U/MMU/BNSD/005 Ainebyoona Silver 2022/U/MMU/BNSD/011

2. 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.

3. STIs that can lead to urethral discharge Chlamydia Gonorrhea Trichomoniasis Mycoplasma genitalium Ureaplasma

4. Gonorrhea It’s caused by Neisseria gonorrhoeae , a gram-negative coccus. Most particularly among those aged 15-24 years

5. Signs and symptoms – gonorrhoae In men. Purulent or mucopurulent urethral discharge (white, yellow or green) Dysuria Urinary frequency or urgency Epididymitis; unilateral scrotal pain or swelling. Tenderness over the epididymis.

6. Symptoms continued… In women. Mucopurulent vaginal discharge Intermenstrual or postcoital bleeding. Cervical friability. Dysuria Increased urinary frequency Absence of significant pyuria. Lower abdominal pain Cervical motion tenderness. Vulvo -vaginitis (pre-pubertal girls )

7. Extra-genital symptoms (both sexes) Pharyngeal gonorrhea (oral infection) e.g. sore throat, swollen lymph nodes, Rectal gonorrhea; proctitis , mucopurulent discharge, pain or bleeding, tenesmus Occular gonorrhea (gonococcal conjunctivitis); eye redness, purulent discharge , pain, DGI; skin (painless pustules with erythematous base); joints (migratory polyarthritis); systemic (fever, malaise, septic arthritis.) Rare complications; meningitis and endocarditis.

8. Investigations 1. direct detection. ** Nucleic Acid Amplification Test (NAAT) – gold standard (highly sensitive & specific) Sample; urine (men) endocervical /vagina swab (women). ** gram stain (for symptomatic men). Sample; urethral discharge. Findings; gram – ve intracellular diploccoci Less sensitive in women. ** culture (for ABX susceptibility test). Sample; urethral, endocervical , rectal swabs. This is required in suspected antibiotic resistant cases.

9. Investigations continued. . . 2. serological and other tests. ** PCR for co-infections – test for Chlamydia trachomatis which often coexists. ** urinalysis – rule out UTI. ** blood cultures – if DGI is suspected. Synovial analysis – if gonococcal arthritis is suspected.

10. Management First line (uncomplicated gonorrhea) Ceftriaxone 500mg IM (single dose) Doxycycline 100mg PO BID for 7 days (if Chlamydia not ruled out). alternative (allergy or cef unavailable) Gentamicin 240mg IM + azithromycin 2g PO [single doses] Complicated infections Cef 1g IM+ doxy + metro (14 days) Individuals diagnosed with gonorrhoea should undergo a full sexual health screen. Contact tracing and partner notification need to be undertaken. All forms of sexual intercourse need to be  avoided  until all parties are tested and have completed treatment.  A test of cure should be routinely performed at least 14 days after completing treatment (if diagnosed via NAAT). 

11. Complications Pelvic inflammatory disease (PID ) (in women) Epididmyo-orchitis and balanitis (men) Chronic prostatitis(men) Disseminated gonococcal infection ( DGI) Ophthalmia neonatorum Infertility (both sexes). Chronic infection = scarring of R organs (epididymis, fallopian tubes) = infertility. Increased HIV transmission Perihepatitis (women) Endocarditis and meningitis (rare)

12. Chlamydia Cause • Chlamydia trachomatis

13. Chlamydia – signs and symptoms In men. Clear (watery) or mucoid urethral discharge Dysuria Urinary frequency or urgency Epididymitis; unilateral scrotal pain or swelling. Tenderness over the epididymis.

14. Signs and symptoms cont … In women. Mucopurulent vaginal discharge Intermenstrual or postcoital bleeding. Cervical friability. Dysuria Increased urinary frequency often without significant pyuria. Lower abdominal pain Cervical motion tenderness. Vulvo -vaginitis (pre-pubertal girls ) less common compared to gonorrhea. Sexual abuse must be considered if chlamydial infection is confirmed in prepubertal girls as per WHO and CDC guidelines.

15. Continued Symptoms affecting neonates • Conjunctivitis ( ophthalmia neonatorum ) and pneumonia

16. Investigations ** NAAT – gold standard. (most sensitive and specific test >95%) Sample sources; first catch urine or urethral swab for men. Vaginal or endocervical swab for women. Detects both C. trachomatis and co-infections e.g. gonorrhea. ** Chlamydia culture used in legal cases e.g. sexual abuse in children or when antibiotic resistance is suspected. Less sensitive than NAAT. ** Direct Flouroscent Antibody (DFA) Test; detects chlamydial antigens in Urethral or vaginal swabs; less sensitive than NAAT. ** ELISA; detects antigens but less sensitive & not commonly used in clinical settings. ** Serology (IgG, IgM antibodies). Used in chronic infections (e.g. Chlamydia associated infertility or reactive arthritis), not useful in acute genital infections.

17. Management The first-line management for chlamydia  (uncomplicated urogenital, rectal & pharyngeal) Doxycycline   100mg orally twice daily for 7 days (contraindicated in pregnancy)  Alternatives Azithromycin 1g oral, followed by 500mg daily for 2 days Levofloxacin 500mg orally once daily for 7 days. Pregnant women; Azithromycin 1g orally in a single dose. Amoxicillin 500mg orally 3 times daily for 7 days. Neonates ( ophtalmia neonatorum & pneumonia) Erythromycin base or ethylsuccinate 50mg/kg/day orally divided into 4 doses daily for 14 days. Individuals diagnosed with chlamydia should undergo a full sexual health screen. Contact tracing and partner notification need to be undertaken. All forms of sexual intercourse need to be  avoided  until all parties are tested and have completed treatment.  A test of cure at around 5 weeks should be offered in cases of rectal infection or pregnancy. 

18. Complications Pelvic inflammatory disease (PID): increases the risk of  ectopic pregnancy  and infertility Epididmyo-orchitis (leading to scrotal pain and swelling) Prostatitis Reactive arthritis(due to AI response causing join pain, conjunctivitis, urethritis (Reiter’s syndrome). Neonatal infections (conjunctivitis and pneumonia)

19. TRICHOMONIASIS Caused by a protozoan parasite called Trichomonas vaginalis . It's typically transmitted through sexual contact. Can lead to frothy, yellow-green discharge and discomfort. Sometimes referred to as ‘ trich ’, trichomoniasis

20. Signs and symptoms Typical   clinical features  in females include: Vaginal discharge (thin, frothy yellow coloured ) “Strawberry cervix” on speculum examination - punctate hemorrhages on cervix. Hallmark finding. Vulval pruritus Vulvovaginitis Vaginal and vulvular itching, and irritation. Dysuria Dyspareunia Up to 50% of women have no symptoms Typical   clinical features  in males include: Urethral discharge (mild, clear, or mucopurulent) Urethral irritation/itching Dysuria Balanitis

21. Investigations **NAAT - gold standard. Detects T. vaginalis DNA, used in asymptomatic or low parasite load cases. **Wet mount microscopy (simple & rapi ). Detects motile trichomonads . ** culture – alt for NAAT. More sensitive than wet mount but takes 3-7 days. ** Rapid antigen test (point-of-care testing) – detects T. vaginalis antigens in swabs. Useful in resource limited settings. ** Urine microscopy (Men, less reliable). Show trichomonads in first void urine but low sensitivity.

22. Management First line treatment; Metronidazole 2g orally, single dose OR tinidazole 2g orally single dose (more expensive but better for resistant cases). Alcohol should be avoided during treatment and for 72 hours afterwards If single dose not tolerated metronidazole 500mg orally twice daily for 7 days is used. Individuals diagnosed with trichomoniasis should undergo a full sexual health screen. Contact tracing and partner notification need to be undertaken. All forms of sexual intercourse need to be avoided until all parties are tested and treated.

23. Complications Pelvic inflammatory disease Infertility Altered vaginal flora Prostatitis Epidydimitis In pregnancy, there is an increased risk of premature rupture of membranes and preterm birth.

24. Mycoplasma genitalium Another cause of non-gonococcal urethritis (NGU), leading to discharge and discomfort. Caused by the bacterium Mycoplasma genitalium .

25. Signs and symptoms In men. urethritis (major cause of NGU) Scanty, mucoid, or watery urethral discharge Dysuria Epididymitis (rare) In women. Post-coital bleeding Mild vaginal discharge Lower abdominal pain Dyspareunia Fever (in severe cases)

26. Investigations Testing for  Mycoplasma genitalium  does not form a part of a routine asymptomatic sexual health  screen. Testing should occur in patients with symptoms . ** NAAT – gold standard. First catch urine (men) or cervical/vaginal swabs (women) Other tests. ** mycoplasma culture (difficult, not routine) ** antibiotic resistance testing (if treatment fails)

27. Management Initial therapy. Doxycycline 100mg orally twice daily for 7 days followed by moxifloxacin 400mg orally once daily for 7 days. This sequential regimen is recommended due to the high prevalence of macrolide resistance. Doxycycline reduces the bacterial load and moxifloxacin targets the remaining bacteria. Different treatment regimens are used in pregnancy . Individuals diagnosed with  Mycoplasma genitalium  should undergo a full sexual health screen. Contact tracing and partner notification need to be undertaken. All forms of sexual intercourse need to be avoided until all parties are tested and treated. A test of cure is performed at 5 weeks following initiation of treatment. 

28. Important considerations No β - lactam ABX (resistant due to lack of cell wall) Macrolide resistance (azithromycin failure) is rising. Test of cure recommended after 3-4 weeks due to high reinfection rates. Treat sexual partners to prevent reinfection.

29. Complications In men. Persistent NGU Epididymitis Prostatitis In women. Cervicitis PID > can lead to infertility; ectopic pregnancy; chronic pelvic pain. Miscarriage Preterm labor PROM Low birth weight.

30. Ureaplasma Caused by the bacterium Ureaplasma urealyticum and ureaplasma parvum (commensals of genital tract) It can lead to non-gonococcal urethritis (NGU) with symptoms like discharge (mucoid).

31. .

32. Signs and symptoms In men. Urethritis Dysuria Mucoid discharge Prostatitis Epididymitis In women Cervicitis Vaginal discharge Pelvic pain. Endometriosis PID Preterm birth and low birth weight. ( preg women)

33. Transmission. Sexual transmission is the primary route. Vertical transmission can also occur hence neonatal infections e.g. conjunctivitis or pneumonia.

34. Investigations. ** NAAT – gold standard. Culture – less commonly used due to difficulty and slow growth. Serological tests; less reliable and not routinely used.

35. Treatment. First line. Doxycycline 100mg orally twice daily for 7 days. Alternatively, Azithromycin can be used for single dose therapy if doxycycline is not suitable. Other options if resistance or treatment failure occurs. - fluoroquinolones e.g. moxifloxacin 400mg orally once daily for 7-10 days.

36. Complications. Infertility Ectopic pregnancy PID Chronic pelvic pain. Neonatal infection including pneumonia and conjuctivitis (if vertical transmission occurs) Increased risk for HIV acquisition and transmission.

37. Syndromic management (urethral discharge syndrome) ** treatment regimen. Ceftriaxone 250mg IM as a single dose. Doxycycline 100mg orally twice daily for 7 days to address potential co-infection with Chlamydia trachomatis. Pregnant women; erythromycin 500mg orally 4 times daily for 7 days. If symptoms persist after treatment; reassess for other causes, ensure partner treatment, and consider testing for T. vaginalis and M. genitalium . ** partner management. Sexual individuals notified, evaluated, and treated to prevent reinfection and further transmission. ** health education. Counselling on safe sexual practices, including consistent use of condoms, to reduce risk of acquiring or transmitting STIs.

38. 4 Cs general management Contact tracing and partner management Condom use - Safe sex Compliance and adherence to treatment regimen Counselling and testing, and prevention.

39. General prevention Use Condoms : Consistently using condoms during vaginal, anal, and oral sex reduces the risk of transmission. Regular Testing : Get regularly tested if you're sexually active, especially with multiple partners. Limit Sexual Partners : Reducing the number of sexual partners decreases the risk of exposure. Mutual Monogamy : Engage in a mutually monogamous relationship with a partner who has tested negative .

40. Continued Avoid Sharing Sex Toys : If sharing, ensure they are thoroughly cleaned or use a new condom for each partner. Use Condoms : Condoms can reduce the risk but not eliminate it entirely, as herpes can affect areas not covered by a condom . Regular Testing : Regular STI screenings can help detect herpes early.

41. References Centers for Disease Control and Prevention (CDC). (2021). Sexually transmitted infections treatment guideline, 2021. Ministry of Health, Uganda. (2022). Uganda Clinical Guidelines 2022: National guidelines for management of common conditions. World Health Organization (WHO). (2021). Guidelines for management of symptomatic sexually transmitted infections. WHO press. Workowski , K, A. & Bolan, G, A. (2021 ). Sexually transmitted infections treatment guidelines, 2021. Bradshaw, C, S., Jensen, J. S., & Waites , K. B. (2020). New horizons in Mycoplasma genitalium treatment. Clinical Microbiology Reviews, 33(3), e00043-19