MODIFIED SYNDROMIC APPROACH

ANOGENITAL ULCER DISEASE SYNDROME URETHRAL DISCHARGE SYNDROME ANORECTAL DISCHARGE SYNDROME
1. Take medical, sexual history and assess risk for STI

Resistant or persistent urethral discharge

Ref: Malaysia STI Guideline 5th Edition 2024 © Sharing Kak Amie 2024
 VAGINAL DISCHARGE SYNDROME LOWER ABDOMINAL PAIN SYNDROME
1. Take medical, sexual history and assess risk for STI
**MSA has low sensitivity and specificity for cervical gonococcal and chlamydial infection in women

Flowchart for the syndromic approach to management of women presenting with vaginal discharge based on risk assessment.

Flowchart for the syndromic approach to management of women presenting with vaginal discharge based on speculum examination

Ref: Malaysia STI Guideline 5th Edition 2024 © Sharing Kak Amie 2024
 VAGINAL DISCHARGE
URETHRAL DISCHARGE GENITAL ULCER
VAGINITIS CERVICITIS
VULVO-VAGINAL
1ry SYPHILIS BACTERIAL GONORRHEA
GONORRHEA CHLAMYDIA NGU HERPES CHANCROID LGV TRICHOMONIASIS CANDIDIASIS
(CHANCRE) VAGINOSIS CHLAMYDIA
st
RX IM Ceftriaxone T Doxycycline 1st episode of NGU: IM Benzathine 1 episode: T Azithromycin T Doxycycline T Metronidazole spontaneous cure Clotrimazole pessary IM Ceftriaxone
50mg STAT 100mg BD x - T Doxycycline Penicillin 2.4MU T Acyclovir 1g STAT 100mg BD 400mg BD x 5days rate in 20-25%. 500mg STAT 50mg STAT
** If chlamydia 7days 100mg BD x 7days STAT 400mg TDS x 1 x 21 days or 2g STAT,
infection has week T Metronidazole Recurrent vaginal PLUS
not been ruled Recurrent/ Surgical 400mg BD x5days candidiasis
out, all non- persistent NGU: Recurrent: treatment or 2g STAT •4 or more episodes T Doxycycline
pregnant - T Metronidazole T Acyclovir → Needle in a 12-month 100mg BD x
patients should 400mg BD x5days 800mg TDS x 2 aspiration of period (may occur in 7days
receive oral + T Azithromycin days fluctuant buboes nearly 10% of
doxycycline 500mg STAT, then OR women).
100mg BD for 7 250mg OD x4days T Acyclovir •Infection should be
days. (if treated w doxy 800mg BD x5 confirmed by culture
1st line) days on at least one
occasion.
•Predisposing
factors: DM, HIV or
other causes of
immunosuppression,
corticosteroid use,
frequent broad
spectrum antibiotic
use and non-
compliance to
antifungal therapy.

- T Fluconazole 150-
200mg q72h for 3
doses, then weekly
for 6 months
OR
Canesten 500mg
weekly for 6months

Ref: Malaysia STI Guideline 5th Edition 2024 © Sharing Kak Amie 2024
 1ry SYPHILIS BACTERIAL VULVO-VAGINAL
GONORRHEA CHLAMYDIA NGU HERPES CHANCROID LGV TRICHOMONIASIS
(CHANCRE) VAGINOSIS CANDIDIASIS
Pathogen Neisseria Chlamydia - Chlamydia Treponema 1.HSV-1 Haemophilus C. trachomatis the most common Trichomonas vaginalis Candida albicans in
gonorrhoeae trachomatis trachomatis (11- pallidum 2.HSV-2 ducreyi serovars L1-L3 cause of vaginal - flagellated protozoan, 90% of cases
50%) discharge in women parasite of genital tract
•Mycoplasma * Most have of reproductive - almost exclusively C. glabrata in 8% of
genitalium (6-50%) associated HIV years sexually transmitted cases
•Ureaplasma spp. infection Gardenella - infection can only
(11 - 26%) vaginalis, follow intravaginal or
•Trichomonas Mobiluncus spp and intraurethral inoculation
vaginalis (1- 20%) Bacteroides spp. of the organism
Incubation 1-14 days 7-21 days • Variable, often 9-90 days 2 - 14 days 3 to 10 days 3 to 30 days 4 days to 4 weeks
period -Men become (usually shorter longer
symptomatic 2-5 5-15 days) •1 week to 3 weeks
days (up to 6 weeks)
- women become
symptomatic
within 10 days
Common In males: MAJORITY ARE •Urethritis is Single, painless, Multiple The ulcers are 1.Primary stage: - offensive fishy In male: Symptoms
C/P •Asymptomatic ASYMPTOMATIC characterised by indurated, well PAINFUL classically •A small painless smell (in 15-50% NO Sx. Infected •Vulvar itchiness or
•Purulent or urethral circumscribed vesicles ± described as: papule or pustule approximately 50% men usually present as burning sensation
mucopurulent In males: inflammation, ulcer + regional shallow ulcers •Multiple, that erode to form of cases) sexual partners of •Vaginal soreness or
urethral •Asymptomatic which results from LNs painful a small - watery infected women. irritation
discharge •Mucopurulent infectious & non- *Chancre may be Tender inguinal •Not indurated herpetiform ulcer homogeneous Common Sx: •Dyspareunia
•Dysuria urethral infectious causes multiple, painful, lymphadenitis. (“soft sore”) that heals within a vaginal discharge, •Urethral discharge •Dysuria
discharge •It may be purulent and •With a necrotic week (may go which can be and/or dysuria •Vaginal discharge –
In females: •Dysuria symptomatic or extragenital •In first base and undetected) white/yellow. - ~ •Urethral irritation thick, curdy, white,
•Asymptomatic asymptomatic (oral) episodes, purulent exudate 50% are •Urinary frequency although discharge
•Nonspecific In females: •Urethral *may go lesions and •Bordered by 2.Secondary asymptomatic. Exam findings: can appear normal
vaginal discharge •Majority discharge, may be unnoticed lymphadenitis ragged stage: Usually, no redness •No abnormalities, even or absent
(purulent or asymptomatic muco-purulent or are usually undermined •Inguinal stage or inflammation in the presence of sx, Signs
mucopurulent •Mucopurulent mucoid and may bilateral. edges happens 2-6 unless due to suggesting urethritis • PSE->
cervical discharge vaginal only be present on •In recurrent •Bleeds easily on weeks after onset another co-existing •Urethral discharge in erythematous
on cervical exam) discharge urethral milking disease, lesions contact of primary lesion condition. 20-60% of cases vaginal wall, and an
•Dysuria •Dysuria •Dysuria are usually •Autoinoculation •Painful inguino- adherent discharge
•Intermenstrual •Intermenstrual •Urethral itching unilateral for from primary femoral Diagnosis In female: may be seen, either
or post-coital or post-coital •Penile irritation each episode lesions on lymphadenopathy. 1.Amsel’s criteria 10-50% : NO sx. curd-like or white.
bleeding bleeding •Urinary frequency and limited to opposing skin •Typically -At least 3 out of 4 Common Sx:
•Dyspareunia •Cervicitis •Other clinical signs the infected may result in so- presents with criteria for •Vaginal discharge
include dermatome. called “kissing unilateral diagnosis: •Vulval itching
balanoposthitis, ulcers” enlargement, 1.Thin, white, •Dysuria
epididymo-orchitis inflammation, homogeneous •Offensive odour
and SARA (Sexually Painful unilateral suppuration, and discharge Exam findings:
acquired reactive inguinal adenitis abscess known as 2.Clue cells on •NAD in 5-15% of
arthritis) is a characteristic “buboes”, microscopy of wet women
feature (50%), rupturing in a mount •Vaginal discharge in up
leading to the third of cases. 3.vaginal fluid pH to 70% (classical frothy
formation of >4.5 yellow discharge)
buboes 3.Tertiary stage: 4. Fishy odour on •Varying in consistency
(purulent •Often called adding 10% KOH from thin and scanty to
abscess of the ‘anogenitorectal 2.Hay/Ison criteria profuse and thick
inguinal LN). syndrome’, •Strawberry cervix
Buboes are
Ref: Malaysia STI Guideline 5th Edition 2024 © Sharing Kak Amie 2024
 fluctuant & may present mostly in Only 2% are visible to
rupture, women the naked eye
releasing thick
pus & may result
in extensive
ulceration
IX 1) Gram stain of 1) Gram stain of 1) Gram stain of 1.HSV nucleic 1.Gram stain of Diagnosis is based 1.Sample: 1.Microscopy 1.Microscopy
urethral/cervical/ urethral, urethral swab → acid by NAAT scrapings from on clinical Vulvovaginal swab examination •Gram stain of
rectal discharge cervical or 5 or more PMNL - Sample: the ulcer base or suspicion, for Gram stain with •Saline wet smear vaginal discharge →
→ intracellular rectal discharge per HPF vesicular fluid pus aspirated epidemiological Hay/Ison criteria. (sensitivity 40-60%) presence of
gram-negative (not diagnostic) -To exclude gram- of exudate from the bubo information, and •In female, smear is blastopores &
diplococci (within → Increased negative from vesicles or → Gram neg the exclusion of 2.NAATs taken from posterior pseudohyphae.
PMNLs) PMNLs (average intracellular swab from coccobacilli, with other aetiologies - Should be used fornix of the cervix •10% KOH
of >5 per HPF in diplococci (GC) mucocutaneous characteristic of genital or rectal among symptomatic •Detection of motile preparation →
2) NAAT a urethral 2) Urethral swab genital lesions appearance ulcers, inguinal women only trichomonads by light- identify yeast or
- VV/anorectal/ smear & >20 wet mount (“school of fish”) lymphadenopathy, field microscopy hyphae
pharyngeal swabs per HPF in microscopy for 2.Viral culture or proctocolitis. •Microscopy should be
endocervical Trichomonas 2.Culture Special attention performed ASAP after 2.Culture
3) Culture smear) vaginalis specimens should be given to specimens collection as •Should be done for
gonorrhea *gold • To exclude 3) Multiplex PCR should be MSM’s and HIV motility diminishes with symptomatic
standard Gram-negative (for recurrent/ collected from patients. time women with
- must specifically intracellular persistent NGU) the base negative
request diplococci (GC) 4) UFEME → look 2.NAAT microscopic
’gonococcal for leukocytes 3.PCR (>95% examination
culture’, 2) Urine for 5) Urine C&S → sensitivity)
Chlamydia exclude UTI
NAAT 6) Urine for 4.Screening for
- Men: first pass Chlamydia/ other possible
urine Gonorrhoea causes of genital
- Women: (CT/GC) NAAT ulcers
endocervical
swab/ FPU
RX IM Ceftriaxone T Doxycycline 1st episode of NGU: IM Benzathine 1st episode: T Azithromycin T Doxycycline T Metronidazole spontaneous cure rate in Clotrimazole
50mg STAT 100mg BD x - T Doxycycline Penicillin 2.4MU T Acyclovir 1g STAT 100mg BD x 21 400mg BD x5days or 20-25%. pessary 500mg STAT
** If chlamydia 7days 100mg BD x 7days STAT 400mg TDS x 1 days 2g STAT,
infection has not week T Metronidazole 400mg Recurrent infection
been ruled out, Recurrent/ Surgical treatment BD x5days or 2g STAT (≥ 4episodes/yr)
all non-pregnant persistent NGU: Recurrent: •Needle T Fluconazole 150-
patients should - T Metronidazole T Acyclovir aspiration of 200mg q72h for 3
receive oral 400mg BD x5days 800mg TDS x 2 fluctuant buboes doses, then weekly
doxycycline + T Azithromycin days for 6 months
100mg BD for 7 500mg STAT, then OR OR
days. 250mg OD x4days T Acyclovir Canesten 500mg
(if treated w doxy 800mg BD x5 weekly for 6months
1st line) days
Antivirals
•Patients presenting within five days of the start of the episode, or while new lesions are still forming, should be given oral
antiviral drugs.
•Topical agents are not recommended as they are less effective than oral agents and easily generate resistance.

Supportive measures
•Saline/diluted potassium permanganate Sitz bath/dabs
•Appropriate analgesia
•Topical Lignocaine/lidocaine (gel or ointment)
Ref: Malaysia STI Guideline 5th Edition 2024 •Treatment of secondary infection © Sharing Kak Amie 2024
•In women with severe dysuria, urination with the genitals submerged in water along with spreading the labia can alleviate sx.
 Advice abstain from condomless SI for 7 days after they and their Abstain from sex •Avoid douching
sex partners have been treated & after resolution of until 1 week after •Avoid the use of
symptoms they & their shower gel and
partner(s) have antiseptic soap in a
completed bath
treatment
Contact Sexual partners within the last 60 Sexual contacts Sexual contacts Sex partner/s Routine screening Sexual partners should Contact tracing is
days must be epidemiologically of < 90 days within 10 days that have had and treatment of be treated not required
treated irrespective of the test results before diagnosis before onset of contact with the male partners are simultaneously
should be the patient’s patient within not indicated
epidemiologically symptoms the past 60 days
treated for early should be should be
syphilis, even if examined and evaluated and
serology test treated even in treated if
results are the absence of symptomatic. If
negative symptoms no symptoms
- IM Benzathine are present, they
penicillin 2.4MU should be
STAT treated for
exposure as
empirically as
follows:
−T Doxycycline
100mg BD x7
days

Ref: Malaysia STI Guideline 5th Edition 2024 © Sharing Kak Amie 2024
Components of a sexual history (The 6Ps)

i. Partners:
•Gender of sexual partner/s
•Number of partners in the last 3 months - not necessary to ask for the specific details (if > 5 partners)

ii.Practices:
•Last sexual intercourse (LSI):
- How long ago?
- Spouse, regular non-spouse, casual?
- If regular, duration of relationship?
- Type of sex and use of condoms (oral, vaginal, anal)
- In MSM, are they insertive or receptive for anal sex?
•How did you meet your partner/s?
•Any drug use (self/partner)?
•Have you or your sex partner/s ever exchanged sex for life needs? (money, housing, safety, drugs)

iii.Protection:
•Use of condoms/barrier methods – “How often would you say you use condoms? All of the time? 50% of the time?”
•If all sexual contact was protected (i.e., condoms used), when was the last unprotected vaginal/anal sex?
•If not using protection, what are the reasons?

iv.Past history:
•Known STI/symptoms (diagnosis, when and whether was treated)
•Known STI/symptoms in the partner/s (diagnosis, when and whether was treated)
•Previous sexual intercourse (PSI) with different partner (for the last 3months) – to obtain same information as LSI

v.Pregnancy planning:
•Any plans/desires to have children/more children?
•Assess timing, importance of prevention, conduct preconception education

vi.Plus (Pleasure, Problems and Pride):

•How is your sex life?
•What difficulties are you having with your sex life or during sex?
•What support do you have about your gender identity and/or sexual orientation?

Ref: Malaysia STI Guideline 5th Edition 2024 © Sharing Kak Amie 2024