Syndromic approach

Syndromic approach to STI

1. Syndromic Approach Syndrome – is group of symptoms patient complains about and clinical signs you observe during examination Different organisms that cause STIs give rise to only limited number of syndromes Although many different pathogens cause STIs, some of them give rise to similar or overlapping clinical appearances WHO recommendation

2. Syndromic Approach cont’d The syndromic approach using flowcharts to guide diagnosis and treatment is more accurate than diagnosis based on clinical judgment alone

3. The main syndromes of common STIs : SYNDROME MOST COMMON CAUSE Vaginal discharge Vaginitis ( trichomniasis,candidisis ), Cervicitis( gonorrhea , chlamydia ) Urethral discharge Gonorrhea, chlamydia Genital ulcer Syphilis, chancroid, herpes Lower abdominal pain Gonorrhea, chlamydia , mixed anaerobes Scrotal swelling Gonorrhea, chlamydia Inguinal bubo LGV, Chancroid Neonatal conjunctivitis Gonorrhea, chlamydia

4. Key Features of Syndromic Management Problem oriented (responds to patient’s symptoms ) Highly sensitive and does not miss mixed infections Treats the patient at first visit Can be implemented at primary health care level Use flow charts with logical steps Provides opportunity and time for education and counseling

5. The Five Steps in Syndromic STI Case History taking and examination Syndromic diagnosis and treatment, using flow charts Education and counseling on HIV testing and safer sex, including condom promotion and provision Management of sexual partners Recording and reporting

6. Criteria for the selection of STI drugs Availability Low cost High efficacy (at least 95%) Acceptable toxicity and tolerance (safety) Organism resistance unlikely to develop or likely to be delayed Single dose Oral administration Not contraindicated for pregnant or lactating

7. . Urethral discharge and/or burning Common symptoms of urethritis in men History taking and examination: Take history and examine the patient. Inspect genital organs. Do not forget to inspect the interior part of the prepuce and the covered part of glans penis.

8. Reasons for medical examination: To confirm the presence of urethral discharge To rule out existence of other STIs

9. Major pathogens causes urethral discharge: Neisseria Gonorrhoea and Chlamydia trachomatis (2 nd in Ethiopia) Rarely other causes mycoplasma genitalium Occur in NGU (Chlamydia trachomatis the most common)

10. Treatment Regimen for Urethral Discharge in Men

11. Persistent (Recurrent Urethral discharge Pt present with persistent or recurrent burning sensation on urination with or with out discharge Cause can be: In adequate Rx Re infection Infection by drug resistance

12. Genital Ulcer /vesicular or non vesicular ulcer) History taking and examination: Take the client’s history and conduct an examination. Inspect the genital organs. Do not forget to inspect the interior part of the prepuce and the covered part of the glans penis in men and the skin of the external genitalia, including the mucous surfaces of the labia and anus in women.

13. Reasons for medical examination: To confirm the presence of ulcer(s) To ensure no other STIs are present

14. Special Circumstances If there are no ulcers, the patient may have grouped vesicular lesions with a history of recurrence that require the management of Herpes Ulcers due to drug intake (fixed drug eruption), scabies and trauma can be excluded by determining the patient’s history and through a urine analysis If you have not been able to confirm the presence of STIs, reassure your patient, educate him/her and promote the use of condoms

15. Major Pathogens Treponema pallidum (Syphilis) Hemophilus ducreyi (Chancroid) Herpes simplex virus (Genital herpes) Chlamydia trachomatis (LGV) Calymmato bacterium granulomatis (Donovanosis)

16. Vaginal discharge syndrome Most cases of vaginal discharge are not of an STI origin, Candidiasis and bacterial vaginosis are the most common causes. History taking and examination: Take history and try to assess clients STI risks. An STI risk assessment is considered positive if the patient or her partner has an STI or a high-risk behavior. Examine the patient.

17. Vaginal discharge syndrome cont’d Remember: Vaginal discharges may be physiological. Using speculum, if available, inspect the cervix and the vagina to locate the origin of the discharge. Do not forget to note the type, color, odor and amount of discharge. Ask whether the patient also has pain in the lower abdomen.

18. Vaginal discharge syndrome cont’d The wet mount/gram stain microscopy of vaginal specimen will help in the diagnosis of: Trichomoniasis : mobile trichomonads Candidiasis : Budding yeasts or pseudohyphae Bacterial vaginosis : presence of Clue cells plus pH > 4.5 or KOH positive

19. Cause Vaginitis Cervicitis

20. Major Pathogens that cause Vaginitis Trichomonas vaginalis Candida albicans Non specific vaginitis ( Gardnella vaginalis )

21. Major Pathogens that cause Cervicitis: Neisseria gonorrhea (Gonorrhea) Chlamydia trachomatis (Chlamydial infection) Bacterial vaginosis (Gardnella vaginalis) is the leading cause of vaginal discharge in Ethiopia. List of cause of vaginal discharge from commonest to less common :- Vaginosis (G.vaginalis) , candidiasis, Trichomoniasis ,Gonorrhoea& Chlamydia

22. Complication of Cervicitis and vaginitis PID PRM pre-term labour Infectivity chronic pelvic pain

23. Risk assessment one or more : Multiple sexual partner in last 3 month New sexual partner in last 3 month Ever traded sex and Age below 25 years

24. Lower Abdominal Pain syndrome in Women All sexually active women presenting with lower abdominal pain should be evaluated for the presence of Pelvic Inflammatory Disease (PID): Salpingitis Endometritis tubo ovarian abscess pelvic peritonitis, inflammation around the spleen and liver. How ever ; PID is a result of polymicrobial- mycoplasma, Bacteroids, streptococcus, E.coli or H. Influenzae.

25. Lower Abdominal Pain syndrome in Women cont’d History taking and examination: Take history and examine the patient. In the history, check for other symptoms, such as a missed or overdue period, recent delivery or abortion, or vaginal bleeding. During examination look for vaginal bleeding, this is a sign of ectopic pregnancy and will require a gynecological referral.

26. Lower Abdominal Pain syndrome in Women cont’d Bimanual Examination: During bimanual examination look for swelling or lumps in the patient's abdomen. Notice tenderness on cervical mobilization

27. Lower Abdominal Pain syndrome in Women cont’d During the examination, keep the following points in mind: Tenderness : superficial palpation Rebound tenderness: deep palpation – severe tenderness when pressed slowly and pressure is suddenly removed Guarding : rigid abdominal muscles  

28. Major Pathogens: Neisseria gonorrhea (Gonorrhea) Chlamydia trachomatis (Chlamydial infection) Anaerobic Bacteria Clinical manifestation Bilateral lower abdominal pain CMT  

29. Complications Ectopic pregnancy Infertility Peritonitis and intera-abdominal abscess Adhesion or intestinal obstruction

30. Note: No pain killers should be used since they may mask serious complications. Patients receiving metronidazole should be cautioned to avoid alcohol. Persistence of lower abdominal pain may be due to: Incorrect diagnosis Complicated infections Incorrect use of anti-microbial drugs

31. Hospitalization should be considered in the following circumstances: The diagnosis is uncertain Surgical emergencies, such as appendicitis and ectopic pregnancy Suspected pelvic abscess Severe illness The patient is pregnant The patient failed to respond to outpatient therapy

32. Scrotal Swelling and Pain syndrome Inflammation of the epididymis (epididymitis) usually manifests itself by acute onset of unilateral testicular pain and swelling . The adjacent testis is often inflamed (orchitis), giving rise to epididymo-orchitis.

33. Scrotal Swelling and Pain syndrome History taking and examination: Take history and examine the patient In the history, check whether the patient has injured himself or whether the patient has had an STI in the last six weeks. Inspect the scrotal skin for bruising. Do not forget to palpate the scrotal sac, comparing the two sides, and check for swelling and pain in the testis, position of the testis in the scrotal sac ( elevation, rotation or torsion).

34. The reasons for examination are: To exclude the presence of swelling and or pain in the testis To exclude rotation or elevation or torsion or trauma to the testis To exclude inguinal hernia To exclude trauma to tests To confirm the presence of urethral discharge To make sure that there are no other STIs

35. Testicular torsion and Epi.orchits Epididymitis/ Orchitis

36. Major Pathogens Neisseria gonorrhea (Gonorrhea) Chlamydia trachomatis (Chlamydial infection) The cause varies according to the age of the pt. If younger than 35 years – the cause likely N. Gonorrhoea or C. Trachomatis If older than 35 year – gram negative organisms Possibly TBC if not involved in unsafe sex Other causes may be Brucellosis, mumps, onchocerciasis, w. Flariasis

37. Complications scrotal swelling by STI Epididymitis Infertility Impotence Prostatis Scrotal edema

38. Inguinal Bubo syndrome ( Inguinal Swelling ) Swelling of inguinal lymph nods as a result of STI Inguinal bubo is an abscess of a lymph node . It presents as a localized enlargement, which is often painful and may be fluctuant . Frequently, inguinal bubo is caused by LGV and chancroid.

39. Inguinal Bubo syndrome ( Inguinal Swelling cont’d Acute infection of either the lower limbs or genital region may cause inguinal Adenophathy. The enlarged lymph nodes may appear in syphilitic or HIV infection. These lymph nodes are not really considered as bubo .

40. Inguinal Bubo syndrome ( Inguinal Swelling cont’d If the patient presents with bubo and associated ulcers, the care provider must refer to the genital ulcer flow-chart. This would include treatment for syphilis and Chancroid. If a patient complains of having bubo without the presence of ulcers, use the inguinal bubo flow chart in determining proper treatment.

41. Inguinal Bubo syndrome ( Inguinal Swelling cont’d History taking and examination: Take history and examine the patient. When taking the history, check to determine whether the patient has groin pain, recent or past genital ulcer or swelling anywhere in the body. Inspect the lymph nodes and examine to confirm whether the enlarged node is painful, warm, and tender to palpation and fluctuant.

42. Inguinal Bubo syndrome ( Inguinal Swelling cont’d If a bubo is present, do not forget to inspect the interior part of the prepuce and covered part of the glans penis in men and external genitalia and mucous surface of the labia in women, to exclude the presence of genital ulcer. If the patient does not have any ulcers, the patient may have vesicular lesions. If this is the case, the care provider should provide treatment for herpes.

43. Inguinal bubo

44. Reasons for the examination: To confirm the presence of bubo To exclude the presence of ulcers To make sure the patient does not have another STI If you have not been able to confirm the presence of STIs, reassure your patient, educate him/her and promote the use of condoms.

45. Major Pathogens: Lymphogranuloma venereum Chlamydia Hemophilus ducreyi (Chancroid) Chlamydia granulomatis Sometimes T.Palladium (does not produce necrosis & abscess)

46. Neonatal conjunctivitis Conjunctivitis in a newborn may be caused by infection, a blocked tear duct, or by irritation produced by the antibiotic eye drops given at birth.

47. Neonatal conjunctivitis cont’d Many organisms can cause infection in the eyes of newborn infants. The most common bacterial infections with potential to cause serious eye damage are gonorrhea and Chlamydia, which can be passed from mother to child during birth. The viruses that cause genital and oral herpes can also cause neonatal conjunctivitis and severe eye damage.

48. Prevention of Neonatal Conjunctivitis : Immediately after delivery, the eyelids are cleaned with hydrophilic cotton; before the eyes are opened 1% tetracycline eye ointment is applied into each inferior conjunctival sac The management of neonatal conjunctivitis must be applied for any baby less than 1 month of age that is suffering from eye suppuration

49. History taking and examination Take history from the mother andexamine the baby. Ask the mother if she or her sexual partner(s) have any STI symptoms. Inspect the baby's eyes for a purulent conjunctival discharge. Do not forget to separate or press the eye lids, to look for pus pouring out from beneath them.

50. Reasons for history taking and examination To confirm the presence of purulent conjunctival discharge frombaby's eyes To make sure that the mother does not have any other STIs

51. Major Pathogens: Neisseria gonorrhea (Gonorrhea) Chlamydia trachomatis (Chlamydial infection)

52. Clinical manifestations Pre-orbital swelling Redness of the eye Purulent discharge from eye

53. Complications Blindness if not treated early

54. Summary STD’s can be transmitted by any sexual activity between opposite sex or the same sex partner Havening one STD does not confirm future immunity except probably hepatitis B Sexual partner of infected person needs treatment STD affects people of all socioeconomic class women bears disproportionate effect of STD

55. Summary cont’d Frustration, anger, anxiety ,fear , shame and guilty are common emission associated with STD diagnose and treatment Different STDs frequently co-exist in the same client There are sexually transmitted enteric infections by oral anal contact. Examples: Shigelosis ,salmunellosis ,ameobiasis and giardiasis