SEXUALLY

TRANSMITTED
INFECTIONS
 Definition of STIs
• Sexually transmitted diseases are
infections that are often if, not always
passed from person to person through
sexual contact (Berkow 1997).
 COMMON STIs IN ZAMBIA
• Chancroid
• Chlamydia
• Gonorrhea
• Candidiasis
• Syphilis
• Trichomoniasis
• Warts
• Lympho granuloma venerium (LGV)
• Granuloma inguinale
• Herpes Genitals
• HIV/AIDS
 SITUATIONAL ANALYSIS
• Sexually transmitted infections are among the
most common causes of illness in the world and
have a far reaching health, social and economic
consequences for many countries.
• STIs remain a major public health problem in
Zambia. Failure to diagnose and treat STIs at
an early stage may result in serious
complications , including serious reproductive
health problems like infertility, urethral
strictures.
 SITUATIONAL ANALYSIS
cont
• STIs can also lead to complications to the
cardiovascular and central nervous system.
• About 10% of adult out patient visits in
Zambia are Sexually Transmitted Infection
(STI) –related.
• Surveys in antenatal clinics have shown a
high prevalence of syphilis (10% -15%) in
expectant mothers. The prevalence is also
high among young adults and adolescents
 SITUATIONAL ANALYSIS
cont
• However the full extent of the STI problems is
hidden.
• Most people with STIs seek treatment from
informal health care providers such as
traditional healers or drug traders and are
therefore not captured in the official
information systems.
• In addition, there is growing antibiotic
resistance.
• The 2001-2002 ZDHS shows that 7 % of
women and 8% of men in the 15-49 age
groups have Syphilis
 SITUATIONAL ANALYSIS
cont
• The social – economic disadvantages that
women face make them especially vulnerable
to STIs/HIV/AIDS, e.g. through their inability
to refuse having sex with their husbands even
when they know that their husbands have other
partners.

• For women, STIs are often asymptomatic,

making them more difficult to diagnose than in
men therefore, the consequences are often
greater. The risk of transmission from infected
men to women is greater than from infected
women to men.
 TRICHOMONIASIS
• Definition: It is a protozoa infection
caused by trichomonas vaginalis
(Phipps et al 2003).
• Incubation period : 4-28days
 Transmission
• The parasite is usually transmitted
through;
 anal sex
 Mutual masturbation when fluid come in
contact with other person’s genitals
 Oral sex
 Vaginal sex
• The parasite is mostly contracted from;
 body fluids
 Contaminated beddings
 Damp towels
 Toilet seats
 TRICHOMONIASIS cont
• Signs and symptoms: The infection may
be asymptomatic and usually coexists with
gonorrhea ;
 Copious greenish-yellow frothy vaginal
discharge associated with the following:
 irritation and soreness of the vulva,
perineum and thighs.
 Dyspareunia (discomfort or painful
intercourse)
 Dysuria
 Edema of the labia
 Swelling in the groin
 Musty vaginal odour
• In men
 Infection of the urethra or prostate
gland
 Painful micturation
 Thin, whitish discharge from the
penis
Tingling sensation inside the penis
NB: in most cases men do not show
symptoms
Discharge on the vulva
Infected cervix
 TRICHOMONIASIS cont
• Diagnosis –investigations ;
 Good history taking and proper
physical examination
 High vaginal swab (HVS). This will
reveal the lashing movement of the
flagella and striking motility of the
pearl-shaped organisms.
 TRICHOMONIASIS cont
• Medical management
 Drug of choice is Metronidazole 2g
orally once, however in lactating
mothers stop lactation, treat and
resume lactation in 48hrs after drug
completed. OR
Flaggyl 400mg bd for 7 days
 CANDIDIASIS /THRUSH
• Definition:
Candidiasis, commonly called yeast
infection or thrush, is a fungal infection of
any of the Candida species, of which
Candida Albicans is the most common.
• Incubation Period: 1-90 days
 Candidiasis cont
• PREDISPOSING FACTORS:
Generally the predisposing factors are
factors which disturb the normal
commensal relationship between host and
Candida. These are:
• Hot humid whether
• Oral contraceptives
– Estrogens have been implicated
• Pregnancy
 PREDISPOSING FACTORS of
candidiasis cont
• Metabolic disorders:
– especially diabetes mellitus
– also Cushing's disease, Addison's
disease, hyper or hypothyroidism
• Broad spectrum antibiotic treatment
– Ampicillin and many others have been
implicated
• Immuno-suppressant therapy
• Corticosteroid therapy
• Pernicious anaemia
• Immuno compromised patients (AIDS)
 Clinical features of
candidiasis
• A thick vaginal discharge which has a white
cheese consistency (Curd like) and it has a
slightly offensive odor and covers the vaginal
walls in thick white plagues with raw areas
present
• irritation or itching in the vulvo vaginal area,
may be worsened in the pre-menstrual period
• vulva excoriation and edema
• Dysuria
• Dyspareunia
Vaginal candidiasis
Vaginal candidiasis
Vaginal candidiasis
 Candidiasis cont
• Diagnosis
• 1. Vaginal swab- findings reveal
Ph less than 4.5
Gram negative spores (oval-like cells
with elongated pseudohyphae)
• 2. Clinical examination
 Medical Management of
candidiasis
• Creams and pessaries
• Nystatin cream/pessaries:100,000 I.U
twice a day (bid) for 10 days
• Clotrimazole pessaries: 200mg vaginally
inserted at night for 3 days.
• A less expensive, although highly controversial
treatment, still used in certain areas is Gentian
violet paint: half to 1%. The vagina is flooded
or thoroughly swabbed with the G.V paint 1-
2 times weekly until cured
 Medical Management of
candidiasis cont
• N.B G.V paint is cheap and gives rapid
relief but it is messy and stains, protective pads
need to be worn
• Babies born from infected mothers may be
infected too. The baby will have neonatal
Candidiasis and may present with stomatitis,
diarrhoeal, vulva vaginitis and nappy rash can
occur. The baby may be given tetracycline eye
ointment and erythromycin syrup 50mg/kg body
weight in 4 divided doses for 14 days.
 Prevention of candidiasis
• 1. Health education
• Avoid tight clothing or nylon underwear
• Use of bland soap and plain clean
water for bathing
• Wearing of cotton underwear
• 2. Treat partner if patient has recurrent
infections
 CHLAMYDIA
• Chlamydia infections are caused by
Chlamydia trachomatis a gram negative
bacterium (Phipps 2003).
• Chlamydia can be transmitted during
vaginal, anal or oral sex.
• Numerous strains of the bacterium cause
urogenital infections. E.g. Non–gonococcal
urethritis (NGU) in men and Cervicitis in
women
• Incubation :7-21days
 Chlamydia
• Chlamydia is largely under reported
because most people who are infected are
asymptomatic and do not seek health care.
By the age of 30 it is estimated that at
sometime during their lives 50% of all
sexually active women have had a
Chlamydia infection (Lewis et al 2004)
 Chlamydia cont
• Clinical Manifestations
• 70% of infected females and 25% infected
males are asymptomatic (Lewis et al 2004). The
common features are:
• Cervicitis (Mucopurulent discharge and the
area is edematous and easily bleeds)
• Urethritis (Dysuria, frequent urination and
pyuria)
• Bartholinitis (purulent exudate)
• PID (abdominal pain, nausea, vomiting,
menstrual abnormalities, fever, malaise)
• Most women found with Chlamydia Cervicitis
have been found to have a male partner with
Non gonococcal urethritis
Chlamydia vaginitis
Chlamydia
 Chlamydia
• Diagnosis
 Urine for microscopy , culture and sensitivity
 cervical swab
• Medical Treatment
 Erythromycin, 500mg four times daily for
seven days, is the treatment of choice during
pregnancy and lactation.
 This is because tetracycline, the usual drug of
choice for Chlamydia, may cause fetal
abnormality
Treatment of chlamydia cont
 If Erythromycin cannot be tolerated then
amoxicillin 500mg tds for 7 days may be
used
 Doxycycilin 100mg two times a day for
7 days
 Follow up care is advised, patient
should return if symptoms persist or
occur
 Treatment of sexual partners and
encourages use of condom
 SYPHILIS
• Definition: This is a sexually transmitted
infections caused by an organism called
Treponema Pallidum (Berkow et al
1997).
• Mode of Transmission:
Transmission is thought to be by entry in
the subcutaneous tissue through
microscopic abrasions that can occur
during sexual intercourse. The disease can
also be transmitted through kissing, biting
or oral genital-sex .
Mode of transmission continues
• Trans placental transmission may also occur at
any time during pregnancy, the degree of risk is
related to the quantity of spirochetes in the
maternal blood stream.
• It can also be transmitted through
unscreened blood transfusion.
• Signs and Symptoms
Infection manifests itself in distinct stages
with different symptoms and clinical
manifestations
 Sign and symptoms cont
• Primary syphilis; is characterized
by: Primary lesion, chancre that appears
5-90 days after infection and this
lesion often begins as a primary papule
at the site of inoculation and then
erodes to form a non tender, shallow,
clean ulcer.
 Primary syphilis contd
• The ulcer appears on the vulva, cervix
anus, penis or mouth
• Internal lesions in women may not be
detected
• It may disappear within few weeks
without treatment.
 Sign and symptoms cont
• Secondary syphilis;
• Occurs 6 weeks to 6 months after the appearance
of the chancre and is characterized by a
widespread, symmetric maculo-papular rash on
the palms and soles and generalized
lymphadenopathy.
• The infected individual also may experience
fever, headache and malaise.
• Condylomata lata [broad, painless, pink-
gray, wart like infectious lesions] may
develop on the vulva, perineum, or anus.
 Sign and symptoms cont
• Latent Phase
• If the secondary phase is left untreated the
person enters the latent phase which is
asymptomatic for the majority of the
individuals.
• Tertiary Syphilis
• Tertiary syphilis will develop in about one
third of the infected person. (Parry et al
2004) Neurological, cardiovascular,
musculoskeletal or multi-organ system
complications
Primary syphilis cont
Primary chancre- penis
Primary chancre
Primary chancre
Primary chancre- vulva
Primary chancre – anus
Primary chancre (multiple)
Primary chancre- mouth
Secondary syphilis
Secondary syphilis
Secondary syphilis
Secondary syphilis
Condylomata lata
Latent
Latent
Neurosyphilis
Congenital syphilis
Congenital syphilis
 Screening and Diagnosis
• All women diagnosed with other types of STIs
or HIV should be screened for syphilis as well.
• All pregnant women should be screened for
syphilis at the first prenatal visit and again in
the third trimester.
• Diagnosis is dependent on microscopic
examination of primary and secondary lesion
tissue and serology during latency and late
infection.
• Rapid Plasma Reagin [RPR] test is used as a
screening test.
 Treatment of syphilis
• The new approach to the management of
sexually transmitted diseases [STIs] is known as
Syndromic approach. This approach involves
classification of STIs into syndromes.
• Benzathine penicillin 2.4 mega units’ stat IM
• For those who are reactive to penicillin, they are
given Erythromycin 500mg 6 hourly for 15 days
 Other drugs
• Doxycycline 100mg orally twice daily
for 2 weeks
• Teytracycline 500mg 6 hourly for 2
weeks.
• Ciprofloxacin 500mg twice for 3 days
 Effects of syphilis on
pregnancy
• Syphilis can be transmitted from an
infected pregnant woman to her baby
causing abortion, still birth, premature
delivery, low birth weight, serious
deformities in babies and early neonatal
death.
 Syphilis continues
• NEONATAL SYPHILIS
• The baby may seem healthy in the initial
phases, and then soon develops bulbous
eruptions on the palms, sore and other
areas. These are most commonly found
on the skin and mucous membranes. A
maculo- papular rash with highly
infectious condylomatous lesions is
present.
 Treatment
• 50,000 IU per kg body weight of
Benzathine penicillin in single dose IM or
procaine penicillin can be used 50,000 IU
per kg body weight daily IM for 10 days
 GONORRHEA
• Definition
Gonorrhea is a bacterial infection of
the mucous membranes of the
genitourinary tract, rectum, and
pharynx (Luckmann 1997)
 Gonorrhea cont
• Incidence
• Gonorrhea is the most commonly reported STD.
• The incidence is highest among individuals 15 to 29
years old.
• An increasing number of 10 to 14 year olds are
infected with Gonorrhoea.
• The highest incidence is reported among non-
whites.
Etiology
• Gonorrhoea is caused by neisseria Gonorrhoea
 Mode of transmission
• The primary site of infection is the
genitourinary tract.
• The gonococcus attaches to non- Squamous
epithelium –lined mucosal membranes. In
women, the columnar epithelium is located at
the cervical os. Gonorrhea can also be passed
transvaginally from infected mother to new
born during delivery
 Clinical manifestations
• Approximately 40% of infected women develop the
following symptoms:
• Vaginal discharge (muco-purulent discharge)
• Dysuria
• Abdominal or pelvic pain
• Cervical erythema and edema
• Bartholinitis
• Sporting after sexual intercourse
• Painful menses
• penile discharge
• Vaginal discharge
 Clinical manifestations cont
• other clinical manifestations include the following:
• Anorectal
• Itching or burning
• Bleeding
• Painful bowel movements
• Mucopurulent discharge
• Pharyngeal
• Sore throat
• Redness and swelling
• Horse voice
• Conjunctival
• Redness and swelling
• Mucopurulent discharge
 Investigations
– Sexual health history and physical
examination
– Gram stain and culture –standard
method for diagnosis of Gonorrhea
with results available within 48-72
hours.
– Specimen is taken from the throat
and female end cervical canal
 Clinical management
• Goals of clinical management include
aggressive treatment with antibiotics.
• Careful consideration of
the anatomical site of
infection.
• Drug therapy: Ciprofloxacin 500mg
start or
• Gentamycin 240mg stat IM or
• Kanamycin 2g IM stat or
• Spectinomycin 2g IM stat
 Clinical management cont
• presumptive treatment for sexual contacts
of an infected patient in order to break the
transmission chain, prevent
complications, especially pelvic
inflammatory disease(PID) and to
eliminate additional hospital visit
 Complications
• 1.Disseminated gonococcal infection has 2
stages.
• Early bacteremic stage is characterized by the
following;
• chills
• fever
• skin lesions that resolve spontaneously
• bacterial endocarditis
• meningitis
• Septic arthritis stage: purulent synovial effusion,
most commonly affecting the knees ankles, and
wrists
• 2. Pelvic inflammatory disease
 Prognosis
• cure is possible for all types of
Gonorrhea
• cure is indicated by resolution
 IMPLICATION FOR
CHILDBEARING
• Infection at birth may result in ophthalmic
neonatorum. This is inflammation of the conjunctiva
in the neonatal period (day 1 to day 28) due to
infection with neisseria Gonorrhea. The infection is
acquired during birth when passing through the
birth canal.
• The incubation period is 3 to 5 days
• The neonate may also present with septicemia with
fever, rash and joint swelling
 Clinical features

• It commonly presents with purulent,

copious eye discharge usually in both
eyes. Itching and redness are also
present.
• Diagnosis
This is confirmed by taking an eye
swab for culture and sensitivity
 Treatment
• Tetracycline eye ointment 1% applied
four times a day for 5 days or
• Chloramphenicol eye drops 0.5%, 1-2
drops every 3-4 hours for 5 days or
• Gentamycin eye drops 0.3%, 1-3
drops every 3-4 hours for 5 days
• Systemic treatment should be used for
generalized septicemia
 Treatment cont
• Ceftriaxone intravenously 250mg daily
for 5 days or
• Cefotaxime 50mg/kg intravenously or
intramuscularly as a single dose or
• For known penicillin-sensitive infection;
Ampicillin 100-200mg/kg intravenously or
intramuscularly every 6 hours for 5 days
 CHANCROID
Definition
• This is an acute sexually transmitted
localised, contagious disease
characterised by painful genital ulcers
and suppurative inguinal lymph nodes
(CBOH 2004).
 The organism
• It is caused Haemophilus Ducreyi
• Anaerobic
• Grows best at 30 – 33°c (Carbon
dioxide atmosphere
• Incubation period – 3 to 7 days
• prevalence
• More in men than in females
• More common in people with poor
hygienic conditions
 Sites of lesion in females
• Vagina
• Peri- urethral area
• Fourchettte
• Labia
• Vestibule
• Clitoris
 Diagnosis
• Dark field examination

• Culture on special media

Typical Chancroid ulcer
Early chancroid
 Management
• Keep the ulcer clean

• Use of antibiotics like Ciprofloxacin

5oomg stat orally

• Or use Erythromycin 500mg for

pregnant women
 Complications
• Destructive lesions leading to:

• fistula formation

• gangrene and

• secondary infections
Lymphogranuloma venereum
(LGV)
Definition :
It is a sexually transmitted disease which is
caused by Chlamydia trachomatis especially
type 2
 Causes
• The causal organism is Chlamydia
trachomatis, serovars L1, L2, and L3.
• Serovar L2 is the most common
cause.
• Risk factors:
– Unprotected sex
– Anal intercourse
– Prostitution
 Pathophysiology
• It gains entrance through skin breaks and
abrasions, or it crosses the epithelial cells of
mucous membranes.
• The organism travels via the lymphatics to
multiply within mononuclear phagocytes in
regional lymph nodes.
• Transmission is predominantly sexual.
• LGV occurs in 3 stages. The majority of LGV
infections in the primary and secondary stages
may go undetected.
 Pathophysiology cont
• The primary stage is marked by the
formation of a painless herpetiform
ulceration at the site of inoculation.
• The secondary stage is classically
described as the inguinal syndrome
characterized by painful inguinal
lymphadenitis and associated
constitutional symptoms.
 Pathophysiology cont
• Tender inguinal lymphadenopathy,
usually unilateral, is the most common
clinical manifestation.
• Lymphatic drainage from the penis is
through the inguinal lymph nodes; thus,
heterosexual men are affected most
often in the inguinal lymph nodes.
 Pathophysiology cont
• Homosexual men and women who are
receptive to anal sex may develop peri-
rectal and pelvic lymph node
involvement.
• In women, these nodes may also
become involved as a result of
lymphatic spread from the cervix and
posterior vaginal wall.
 Pathophysiology cont
• Early in the course of the disease, the
nodes appear fleshy and diffuse.
• Later, suppurative granulomatous
lymphadenitis and peri-lymphadenitis
occur with matting of the nodes.
Frequently, these nodes coalesce to form
stellate abscesses.
 Pathophysiology cont
• The tertiary stage of LGV occurs years
after the initial infection. In this stage,
genitorectal syndrome may occur with
resultant rectal stricture or elephantiasis of
the genitalia.
 Pathophysiology cont
• This syndrome is found predominantly in
women and homosexual men, because of
the location of the involved lymphatics.
• This late stage is characterized by
proctocolitis, which is caused by
hyperplasia of intestinal and perirectal
lymphatic tissue.
 Pathophysiology cont
• This inflammation forms perirectal
abscesses, ischiorectal abscesses,
rectovaginal fistulas, anal fistulas, and
rectal stricture.
• In very late stages, fibrosis and
granulomas are characteristic.
• Chlamydial organisms are scarce at
this stage.
 Pathophysiology cont
• Extragenital inoculation sites can produce
regional lymphadenopathy. Examples are
of mediastinal lymphadenopathy from
inhalation of C trachomatis, or
submandibular and cervical chain
lymphadenopathy following inoculation
after oral sex.
 Clinical picture
• The clinical picture is in stages i.e.;
Primary
• Secondary and tertiary
 Primary lymphogranuloma
venereum (LGV)
– The primary lesion of LGV occurs after an
incubation period of 3-21 days following
an exposure.
– The initial lesion may be a painless
papule, shallow erosion, ulcer, or
grouping of lesions with a herpetiform
appearance(having clusters of vesicles).
 Primary lymphogranuloma
venereum (LGV) cont
– If the primary lesion is in the urethra,
symptoms of a nonspecific urethritis may
occur.
– The most common sites of primary
infection in men include the coronal sulcus,
frenulum, prepuce, penis, urethra, glans,
and scrotum.
 Primary lymphogranuloma
venereum (LGV) cont
– In women, the most common sites of the
primary lesion include the posterior
vaginal wall, fourchette, posterior lip of
the cervix, and vulva.
– The primary lesion is noticed in one third
of affected men but rarely is observed in
affected women.
– Primary lesions of the mouth can result
from oral sexual exposure.
A painless open sore in the first stage of
lymphogranuloma venereum
 Secondary LGV
– The secondary stage of LGV occurs after
a usual incubation period of 10-30 days,
but it may be up to 6 months.
– This stage is characterized by the
formation of enlarged, tender regional
lymph nodes known as buboes.
Enlarged lymph node in the
groin in secondary LGV
 Secondary LGV cont
– Patients may experience constitutional
symptoms, which can include fever, headache,
malaise, chills, nausea, vomiting, and
arthralgias.
LG
V
 Tertiary LGV
– This late stage is characterized by
proctocolitis.
– Symptoms include anal pruritus, bloody
muco-purulent rectal discharge, fever,
rectal pain, tenesmus, constipation,
pencil-thin stools, and weight loss.
 Medical Treatment
• Erythromycin, 500mg four times daily for
seven days, is the treatment of choice
during pregnancy and lactation. This is
because tetracycline, the usual drug of
choice for Chlamydia, may cause fetal
abnormality.
 Medical Treatment
• If Erythromycin cannot be tolerated then
amoxicillin 500mg tds for 7 days may be
used Doxycycilin 100mg two times a
day for 7 days
• Follow up care is advised, patient
should return if symptoms persist or
occur
• Treatment of sexual partners and
encourages use of condom
 Genital warts ( Condylomata
acuminata)
• Genital warts, are common STIs that are
caused by a virus called Human
Papilloma Virus(HPV) and is
characterized by flesh-colored or gray
growths found in the genital area and
anal region of both men and women.
Warts
Penile warts
Penile warts
Warts
Warts
Warts
Warts on the anus
 Signs and Symptoms
• Although genital warts are painless,
they may be bothersome because of
their location, size, or due to itching.
• The size may range from less than one
millimeter across to several square
centimeters when many warts join
together.
 Signs and Symptoms cont
• Men and women with genital warts will
often complain of painless bumps,
itching, and discharge.
• Rarely, bleeding or urinary obstruction
may be the initial problem when the wart
involves the urethral opening (the
opening where urine exits the body.)
 WARTS CONTD
• Warts in more than one area are
common.
• There may be a history of previous or
concurrent sexually transmitted diseases
(STDs).
 Specific descriptions
– In men, genital warts can infect the
urethra, penis, scrotum, and rectal area.
– The warts can appear as soft, raised masses
with a surface that can be smooth (on
the penile shaft) or rough with many
fingerlike projections (anal warts).
 Specific descriptions on men
cont
 Others may appear pearly, cauliflower-
like, or rough with a slightly dark surface.
 Most lesions are raised, but some may be
flat with only slight elevation above the
skin surface.
 Infection with HPV may be dormant or
undetectable, with some lesions hidden by
hair or in the inner aspect of the
uncircumcised foreskin in males.
 Specific descriptions in
women
• In women, genital warts have a similar
appearance and usually occur in the moist
areas of the labia minor and vaginal opening.
• Lesions visible on the outer genitals warrant a
thorough examination of the vaginal canal,
cervix, and anorectal area.
 Specific descriptions in
women cont
• Most vaginal warts occur without
symptoms.
• Rarely, women may experience
bleeding after sexual intercourse,
itching, or vaginal discharge
 Diagnosis
• Diagnosis is often based on findings from
the history and appearance of the genital
warts.
• Clinical picture may show lesions
(warts)
• History may reveal onset of symptoms
after sexual contact
 Diagnosis cont
• An enhancing technique called
acetowhitening may be done. This
technique involves the application of
5% acetic acid solution to the area of
suspicion for about 5-10 minutes.
Infected areas will turn white.
• Colposcopy may show the site of the
lesions especially inside the vagina.
 Diagnosis cont
• A Pap smear should always be done in
order to look for evidence of HPV
infection and abnormal cells on the
cervix.
• A biopsy can be performed if the lesion
appears unusual or recurs after treatment.
 Treatment
• There is no treatment that can
completely eliminate genital warts
once a person has been infected.
• Podophyllin resin – a brown liquid which
is painted on to the wart(s) by a doctor or
nurse and must be washed off 4 hours
later.
 Treatment cont
• Podophyllin resin and podofilox lotion remove
genital warts by stopping cell growth and may
require several applications to work effectively.
• Podopfilox lotion/gel – can be applied to the
wart(s). The usual schedule is twice a day for 3
days, followed by 4 days without any lotion.
This cycle is repeated for 4 weeks
 Treatment cont

• NOTE. Podophyllin treatment could

harm the developing baby and an
alternative treatment should be used.
 Treatment cont
• Cryocautery (also called cryotherapy) –
uses liquid nitrogen to freeze more
persistent warts every 1 to 3 weeks for a
short period.
• It may cause some discomfort and is not
recommended for young children.
 Treatment cont
• Laser treatments – this approach, which uses an
intense beam of light, can be expensive and is usually
reserved for very extensive and tough-to- treat warts.
• Electrocautery – an electrical current is used to super-
heat a needle which burns the wart cells and cauterizes
the blood vessels. This is used only after other
treatments have failed.
 Treatment cont
• Surgical excision – the doctor will
perform minor surgery to remove the
wart under local anesthetic.
 GENERAL PREVENTION
• Abstinence until one gets married.
• Being faithful to one partner who is
also faithful
• Condom use
• Screening and early treatment of STIs
• Partner tracing.
• The five Cs (counselling, contact tracing, compliance,
condom use and confidentiality)
 Prevention contd
• Counselling – on the dangers of STIs,
importance of having one sexual partner,
the process of STI care and the link
between HIV and STIs.
• Confidentiality – information regarding
the patient should never be
communicated to other person without
consent from the patient.
 Prevention contd
• Compliance – emphasize the danger of
defaulting whilst on treatment
• Contacts – encourage patient to bring all
sexual contacts for treatment.
• Condoms – should be promoted for those
who choose not to abstain from sexual
intercourse.
 CLINICAL APPROACH
• Treatment of suspected pathogen(s)
based on clinical diagnosis.
 ADVANTAGES OF CLINICAL
APPROACH
• Conforms to traditional clinical practice
• Saves time for the patients
• Reduces on the laboratory expenses for
the patient
• Patient receives treatment on first
contact
•
•
LIMITATIONS OF CLINICAL
APPROACH
• Atypical presentations of STI’s nowadays when
occurring concurrently with HIV infection may be
difficult to identify
• In many instances it is not possible to differentiate
clinically between the various infections.
• It is common for mixed infections to occur.
• Asymptomatic persons not catered for
 AETIOLOGICAL
APPROACH
• Using laboratory tests to identify the
causative pathogen(s) followed by
pathogen specific treatment.
•
 ADVANTAGES OF
AETIOLOGICAL APPROACH
• Avoids over treatment
• Can be extended as screening to identify
asymptomatic STI’s
• Satisfies patients who feel not properly
attended to
without laboratory investigations
• Conforms to traditional clinical training
• More appealing to clinicians
LIMITATIONS OF AETIOLOGICAL
APPROACH
• Requires both skilled personnel and
sometimes sophisticated laboratory
equipment.
• Not available at primary health care
level where large numbers of patients
seek care for STI’s.
• Expensive and time consuming.
LIMITATIONS OF AETIOLOGICAL
APPROACH
• Mixed infections often overlooked.
• Lab results often not reliable due to
lack of quality control and motivation
among staff.
• Delays in reporting test results and
hence in treatment of STI’s.
 SYNDROMIC APPROACH
• Syndromic approach (used in
Zambia): Identification of consistent
group of symptoms and easily recognized
signs (syndromes), and providing
treatment which treats majority of
organisms responsible for each syndrome.
Treatment occurs on 1st encounter with
health care system.
• It involves the identification of clinical
syndromes followed by syndrome
specific treatment targeting all
pathogens which can cause the
syndrome
Common STI syndromic case
definition
• Genital ulcer syndrome – non
vesicular, ulcers are found on the penis,
vagina, labia, scrotum with or without
inguinal lympadenopathy.
• Genital ulcer syndrome – vesicular:
Caused by herpes simplex virus
infection. Lesions are usually on the
anal region or genitalia
 Common STI case definition
• Urethral discharge in men with or
without dysuria
• vaginal discharge syndrome
• Lower abdominal pain in women
• Pain in the scrotum
• Inquinal buboes
• Growths/warts
• Congenital STIs
 MAIN FEATURES OF SYNDROMIC CASE
MANAGEMENT

• Classifying the main causative agents by

the clinical syndromes to which they give
rise
• Using flow-charts which help the service
provider to identify causes of a given
syndrome.
 MAIN FEATURES OF SYNDROMIC
CASE MANAGEMENT
• Treating the patient for all the
important causes of the syndrome.
• Ensuring that partners are treated,
patients educated on treatment
compliance and risk reduction, and
condoms provided.
 ADVANTAGES OF SYNDROMIC
MANAGEMENT
• Can be used in peripheral health institutions.
• Offers promptness of treatment, because STI
services can be made available at any first-line
health facility
• Patients are treated at their first visit.
• Renders patients non-infectious as quickly as
possible thereby reducing the disease burden in
communities.
 DISADVANTAGES OF SYNDROMIC
APPROACH
• Requires special attention to periodical
monitoring of microbial drug sensitivity.
• Does not identify asymptomatic STI’s.
• Poor compliance as the patient has to
take a lot of drugs.
 DISADVANTAGES OF
SYNDROMIC APPROACH
• Entails over treatment of patients
frequently.
• Requires periodical validation of
syndromes.
• Does not conform to traditional clinical
training
 COMPONENTS OF SYNDROMIC
MANAGEMENT
• Making a Syndromic diagnosis
• Providing appropriate drug therapy
• Providing education
• Promoting/providing condoms
• Treating patient’s sexual contacts
• Providing follow-up care (if possible)
 INFORMATION, EDUCATION AND
COMMUNICATION (IEC)
• Education is an important part of STI
case management. This is an
opportunity to prevent an individual
from having further infections and
understand risk situations. Education
should include:
• The need to return if symptoms persist
 INFORMATION, EDUCATION AND
COMMUNICATION (IEC)

• The need to avoid sex until cured

• How STD is transmitted and its
complications
• The need to use condoms
• How to use condoms
• Where STD services can be
obtained
INFORMATION, EDUCATION AND
COMMUNICATION (IEC)
• It is important to encourage patients to
make sure that sex partners get treatment.
This is particularly
THE END

165