TOPIC

INGUINAL BUBO AND GENITAL ULCER:

SYNDROMIC APPROACH
Dr. Rohit Kumar Singh
Resident, MD Dermatology
Base Hospital
URETHRAL DISCHARGE
PERSISTANT UETHRAL DISCHARGE
SCROTAL SWELLING
VAGINAL DISCHARGE
VAGINAL DISCHARGE (SPECULUM AND BlMANUAL)
VAGINAL DISCHARGE (SPECULUM AND MICROSCOPE)
LOWER ABDOMINAL PAIN
 LOWER ABDOMINAL PAIN
Recommended syndromic treatment
1. ceftriaxone, 250mg by intramuscular injection, once daily

PLUS
• doxycycline, 100mg orally or by intravenous injection, twice daily, or tetracycline, 500mg orally 4 times daily
PLUS
• metronidazole, 400-500mg orally or by intravenous injection, twice daily, or chloramphenicol, 500mg orally
or by intravenous injection, 4 times daily.
2. clindamycin, 900mg by intravenous injection, every 8 hours

PLUS
• gentamicin, 1.5 mg/kg by intravenous injection every 8 hours.
3. ciprofloxacin, 500mg orally, twice daily, or spectinomycin 1g by intramuscular injection, 4 times daily

PLUS
• doxycycline, 100mg orally or by intravenous injection, twice daily, or tetracycline, 500mg orally, 4 times daily
PLUS
• metronidazole 400-500mg orally or by intravenous injection, twice daily, or chloramphenicol, 500mg orally or by
intravenous injection, 4 times daily.
Note
• For all three regimens, therapy should be continued until at least 2 days after the patient has improved and should then
be followed by either doxycycline, 100mg orally, twice daily for 14 days, or tetracycline, 500mg orally, 4 times daily, for 14 days.
Patients taking metronidazole should be cautioned to avoid alcohol. Tetracyclines are contraindicated in pregnancy.
NEONATAL CONJUNCTIVITIS
 NEONATAL CONJUNCTIVITIS
Neonatal conjunctivitis (ophthalmia neonatorum) can lead to blindness when caused by N. gonorrhoeae.
The most important sexually transmitted pathogens which cause ophthalmia neonatorum are
N. gonorrhoeae and C. trachomatis. In developing countries, N. gonorrhoeae accounts for 20-75% and
C. trachomatis for 15-35% of cases brought to medical attention.
Other common causes are Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus spp. and
Pseudomonas spp. Newborn babies are generally presented because of redness and
swelling of the eyelids or "sticky eyes", or because of discharge from the eye(s).
As the clinical manifestations and possible complications of gonococcal and chlamydial infections are similar,
In settings where it is impossible to differentiate the two infections, treatment should be provided to cover
both infections.
This would include single dose therapy for gonorrhoea and multiple dose therapy for chlamydia.

Drug options Drug options

for for chlamydia
gonorrhoea
Ceftriaxone Erythromycin
Alternatives Alternatives
Kanamycin Trimethoprim/
Sulfamethoxaz
ole
 INTRODUCTION
• The term sexually transmitted diseases (STDs) is
used to refer to a variety of clinical syndromes
caused by pathogens that can be acquired and
transmitted through sexual activity

• Sexually transmitted infections (STIs) are among

the most common causes of illness in the world
and have far-reaching health, social and
economic consequences for many countries.
 STI vs STD
• STI – Infections acquired through sexual
intercourse (may be symptomatic or
asymptomatic)
• STD – Symptomatic disease acquired through
sexual intercourse
• STI is most commonly used because it applies
to both symptomatic and asymptomatic
infections

14
How Symptomatic are STIs?

Source: WHO HIV/AIDS/STI Initiative

15
 IMPACT OF STIs
• Considerable morbidity
• High rate of complications
• Facilitate HIV transmission and acquisition
• May cause infertility
• Treatment can be a high financial burden
• May cause problems in relationships—divorce,
abandonment, beatings.

16
 INTERACTION BETWEEN HIV AND STIs

• Significant interaction exists b/w HIV and STIs

– Affect similar populations
– Have a similar route of transmission
• The interaction is bidirectional
– HIV influences conventional STIs
– STIs influence HIV

17
 INFLUENCE OF HIV INFECTION ON STIs

• HIV alters the clinical features of STIs

– Syphilis: Neurosyphilis develops more frequently
and rapidly
– HSV: Ulcers are more severe, chronic, and possibly
disseminate throughout body
• Response to treatment may be reduced
– High rates of treatment failure for neurosyphilis
• Complications may increase and occur more
quickly
18
HOW DO STIs INCREASE HIV TRANSMISSION?

• Reducing physical/mechanical barriers

(disruption of epithelium)
• Increasing HIV in genital lesions, semen or
both
• Evoking a more infectious HIV variant
• Increasing the number of receptor cells or
the density of receptors per cell
 THREE APPROACHES TO
DIAGNOSIS OF RTI / STI

• Clinical approach
• Etiological approach
• Syndromic approach
 SYNDROMIC APPROACH
• Syndromic management is based on the identification
of consistent groups of symptoms and easily
recognized signs (syndromes), and the provision of
treatment that will deal with the majority or most
serious organisms responsible for producing a
syndrome.
WHO developed a simplified tool (a flowchart or algorithm) to guide
health workers in the implementation of syndromic management.
 COMPONENTS OF SYNDROMIC
APPROACH
Classification by Syndrome:
Classifying the main causal pathogens by the syndromes they
produce

Use of Algorithms:
Using flowcharts to guide the management of a given syndrome

Treatment and Counseling:

Using often more than one treatment that addresses all the
pathogens with potential to cause a given syndrome

Treatment of Partners:
Promoting treatment of sex partners
 MAIN SYNDROMES
• Urethral discharge
• Genital ulcer
• Scrotal swelling
• Vaginal discharge
• Lower abdominal pain
• Neonatal conjunctivitis
• Inguinal bubo
SYNDROMIC CASE MANAGEMENT
ADVANTAGES:

• Identifies and treats by signs & symptoms

• Syndromes easily recognised clinically
• Small number of clinical syndromes
• Treatment given for majority of organisms
• Simple and cost-effective
• Valid, feasible, immediate treatment

24
 SYNDROMIC CASE MANAGEMENT
DISADVANTAGES:

• Tendency to overtreat – justifiable in high prevalence settings

(>20%)

• Decreased specificity

• Overuse of expensive drugs

• Asymptomatic cases not fully addressed even with risk assessment

• Management of cervical infections problematic

• Vaginal discharge algorithm performs poorly in low prevalence

25
settings e.g., ANC, FP
Patient complaining of
inguinal swelling
INGUINAL BUBO
Take history SYNDROME
and examine

•Educate
Inguinal/femoral No No •Counsel
Any other STI present •Offer VCT
bubo present?
•Promote and provide condoms
Yes

Use appropriate flow chart

Ulcers Yes
present Use genital ulcer flow chart

No
Treat for LGV AND CHANCROID
• Aspirate if fluctuant
• Educate on treatment compliance
• Counsel on risk reduction
• Promote and provide condoms
• Partner management
• Offer VCT if available
• Advise to return in 07 days
• Refer if no improvement
26
INGUINAL BUBO SYNDROME
 INGUINAL BUBO
• Swelling of inguinal lymph nodes as a result of
STIs (or other causes)
• Common causes:
– Treponema pallidum (syphilis)
– Chlamydia trachomatis L1, L2,L3 (LGV)
– Hemophilus ducreyi (chancroid)
– Calymmatobacterium granulomatis
(granuloma inguinale)

28
 LYMPHOGRANULOMA VENEREUM

• Tropical or Climatic bubo

•
• Durand-Nicholas-Favre disease

• Lymphogranuloma inguinale

• Poradenitis inguinalis

• Strumous bubo
 EPIDEMIOLOGY

• 6% Prevalence Rate in Clinics

• Endemic to India

• 20 - 40 yrs.

• Male : female = 5 :1

• Urban, sexual promiscuity, low socio- economic

status.
 AETIOLOGY

• Chlamydia Serovar L1/L2/L3

• Obligate intracellular, Gram negative bacillus with

humans as Natural Hosts by Sexual Transmission /
Perinatal infection

• Intracytoplasmic inclusion bodies

• Controls the organelles of host cells for own growth

and protein synthesis

• Cell cycle – 48 to 72 hrs

 PATHOGENESIS

• Entry into cell as Metabolically inactive

elementary body (Eb) by receptor mediated
endocytosis.
• Conversion to Active Reticulate Bodies which
multiply , condense and form Eb  burst out of
host cells
• Lymphangitis, perilymphangitis, necrosis of lymph
nodes
• PMN stellate abscess- bubo
• Healing by fibrosis - esthiomene, adhesions
• Dissemination rare
 CLINICAL FEATURES
Primary stage
Incubation period : 5 – 21 days.
Single, painless, evanescent, inconspicuous
Papule / vesicle / Erosion / Ulcer
Male – coronal sulcus, prepuce, glans, urethra
Female - endocervix, post vaginal wall
Oral / Rectal localization
NSU
BUBONULUS – Lymphangitic nodules over
dorsal penis  Chord-like swelling
Constitutional symptoms
 SECONDARY ‘INGUINAL’ STAGE
• 10 – 30 days after primary lesion

• Inflammatory swelling of Inguinal nodes in males

perirectal and iliac nodes in females  ‘BUBOES’ 
Fluctuant if untreated  Multilocular Suppuration
(70%)

• Unilateral 2/3rd cases

• Constitutional symptoms with bubo

• Blue ball sign / Livid colour of overlying skin over

Bubo predicts rupture

• Groove sign of Greenblat (20%)

 SECONDARY STAGE

Dissemination (Rare, hematogenous)

• Arthritis
• Ocular inflammatory disease
• Pneumonitis
• Hepatitis
• EN / EM / EAC
 TERTIARY STAGE
• Develops in 25% of untreated
• GENITO-ANO-RECTAL syndrome, more
common in women / MSM

Clinical features
•Hyperplastic Ulcerative lesions
• Proctocolitis
• Bloody purulent discharge
• Pruritis Ani
• Tenessemus
 TERTIARY STAGE
• Lymphatic tissue hyperplasia
(LYMPHORROIDS / PERI-ANAL CONDYLOMAS)
• Chronic Ulceration / Scarring
• Fistulae / Strictures (Urethral syndrome)
• Saxophone penis
• Esthiomene

Mechanisms
Anal Intercourse
Posterior Urethral spread
Direct Spread from Vaginal Secretions
Lymphatic Dissemination by Cx
 COMPLICATIONS

• Ca rectum (2-5%)
• Epididymo-orchitis
• Prostatitis
• Seminal vesiculitis
• Malignant change in esthiomene
 EXTRAGENITAL MANIFESTATIONS

Ocular manifestations
• Can occur at any stage
• Common with L2
• Conjunctivitis, Episcleritis, Keratitis, Iritis
• Submaxillary, post auricular LN

Cutaneous manifestations
• Id eruptions (photodermatitis)
• Ilio-Psoas Abscess
 INVESTIGATIONS

• Microscopy / Identification
Gram stain, Giemsa stain, Warthin Starry,
Machiavello
• Isolation
Culture on McCoy / HeLa Cell Line (Brown Inclusion
bodies)
• Histopathology – Stellate Abscesses / PMNs
granulomatous reaction
• Serological tests: CFT, PCR, NAAT,
immunofluorescence
• CT / MRI, Lymphography
• Skin (Frei) test
 TREATMENT OF LGV

Recommended syndromic treatment

■ Doxycycline, 100 mg orally, twice daily for 21
days
OR
■ Erythromycin, 500 mg orally, four times daily
for 21 days
 GENITAL ULCER SYNDROME
Patient complains of genital ulcer

Take history & examine

Vesicles or recurrence
Yes OR PAINFL OR PAINLESS LN +/-
No No •Educate
Treat for HSV,
Ulcers and sores •Promote and
Treat for syphilis if indicated
provide
Yes condoms
•Offer VCT
•Educate and counsel
•Promote and provide condoms Treat for syphilis,
•Offer VCT chancroid and HSV
•Ask the patient to return in 7 days DO VDRL OR RPR
No
No
Ulcers healed Ulcers improving Refer
Yes
Educate and counsel Yes
Promote and provide condoms
Offer VCT
Continue treatment for further 07 days
Partner management
42
GENITAL ULCER SYNDROME
 CHANCROID

• SOFT CHANCRE
• Haemophilus ducreyi
• Small coccobacillus
• Gram – negative
• IP – 3 – 5 days
 CHANCROID PRESENTATION
• Genital ulcers
– Often Multiple, saucer shaped ulcers with erythematous halo
– With Sharply Defined, undermined edges
– Painful
– Non - indurated
– Exudative Base
– Bleed When traumatized
(grey membrane)
• Inguinal lymph nodes
– Tender
– Unilateral (> ⅔ )
– Unilocular abscess
( BUBO)
– Suppurative
– Drain spontaneously
 CLINICAL VARIANTS

1. Giant
2. Dwarf
3. Large serpiginous ulcer(ulcus molle serpiginous)
4. Pagedaemic ( ulcus molle gangrenosum)
5. Transient ( ulcus molle volant)
6. Follicular
7. Pseudo grranuloma inguinale
8. Mixed
9. Chancroidal chancroid
 COMPLICATIONS

• Painful adenitis
• Abscess and fistula – inguinal
• Kissing ulcer – extragenital spread
• Esophageal lesion in HIV pt
• Acute conjunctivitis
• Bacterial superinfection
• Scarring leads to phimosis
• Erythema nodosum / EM
• Enhance HIV transmission ( 3- 10 fold increase)
 CHANCROID DIAGNOSIS

• Smear examination
– Gram, Giemsa and Wright’s stains
– Rail – track appearance
• Culture
– Own clotted blood, fetal calves
– Shoals of fish
• Serology
– CFT
• Skin test ( Ito-Reenstierna reaction)
• Biopsy is seldom helpful
 CHANCROID TREATMENT

Recommended regimen
■ Ciprofloxacin, 500 mg orally, twice daily for 3 days
OR
■ Erythromycin base, 500 mg orally, 4 times daily for 7 days
OR
■ Azithromycin, 1 g orally, as a single dose

Alternative regimen
■ Ceftriaxone, 250 mg by intramuscular injection, as a
single dose
 GRANULOMA INGUINALE

• DONOVANOSIS
• 1st described by McLeod(1882) in Madras,
India.
• Etiology
– Klebsiella granulomatis
– Pleomorphic, Gram negative rod
– Safety pin appearance
– 99% phylogenetic homology with K. pneumoniae
– Difficult to grow in culture
 GRANULOMA INGUINALE(Donovanosis)

• IP – 1 to 12 wks
• Early lesion – vesicle or button like
papule
• Ulcer characteristics
– Sharply defined edges
– Serpiginous border
– Beefy red granulation
tissues
- Firm base
– Bleeds on touch
– Painless
– Pseudo bubo(subcut. granulomas
)
 GRANULOMA INGUINALE

• Complications
– Phagedemic ulcerations
– Keloid scarring
– Elephantoid enlargement of penis and scrotum
– Stenosis of urethral, vaginal and anal orifices
– Metastatic spread to bones (vertebrae)
 GRANULOMA INGUINALE: DIAGNOSIS
• Tissue smears
– Most effective
– From edge of lesions
– Giemsa, Wright, Leishman or
Gram stain
– CELLS OF GREEBLATS
– Silver stains
• Culture
– Tissue and egg culture
• Serum tests
– CFT
• Biopsy
– Pseudo-epithelial hyperplasia
of marginal epithelium
– Plasma cell infiltration of
corium
 GRANULOMA INGUINALE(DONOVANOSIS): TREATMENT

Recommended Regimen

• Doxycycline 100 mg orally twice a day for at least 3 weeks and until
all lesions have completely healed

Alternative Regimens

Azithromycin 1 g orally once per week for at least 3 weeks and until all lesions have completely healed
OR
Ciprofloxacin 750 mg orally twice a day for at least 3 weeks and until all lesions have completely healed
OR
Erythromycin base 500 mg orally four times a day for at least 3 weeks and until all lesions have completely healed
OR
Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally twice a day for at least 3 weeks
and until all lesions have completely healed
 HERPES GENITALIS

• DNA double stranded virus, linear

• 125-250 Kb long, relatively big
• Enveloped
• Virion size 200 nm, relatively big
• 9 HSVs, Ex. Varicella, EBV, CMV
• Diseases: Chickenbox, Mononucleosis,
Hepatitis, Encephalitis
• Recurrent eye, mouth
and genital lesions
 Clinical Manifestations

FIRST EPISODE PRIMARY INFECTION

• Characterized by multiple lesions that are more severe,

last longer, and have higher titers of virus than
recurrent infections
• Typical lesion progression:
papules vesicles pustules ulcers crusts healed
• Often associated with systemic symptoms including
fever, headache, malaise, and myalgia
• Illness lasts 2-4 weeks
HERPES GENITALIS

Multiple grouped
vesicles

Erythematous
sharp margin

Painful

Firm tender B/L

lymph node
 Clinical Manifestations
FIRST EPISODE PRIMARY INFECTION:
WITHOUT TREATMENT
• Numerous, bilateral painful genital lesions; last an
average of 11-12 days
• Local symptoms include pain, itching, dysuria, vaginal
or urethral discharge, and tender inguinal adenopathy
• Median duration of viral shedding detected by culture
(from the onset of lesions to the last positive culture)
is ~12 days
• HSV cervicitis occurs in most primary HSV-2 (70-90%)
and primary HSV-1 (~70%) infections
 Clinical Manifestations

RECURRENT INFECTION

• Prodromal symptoms are common (localized tingling,

irritation) - begin 12-24 hours before lesions
• Illness lasts 5-10 days
• Symptoms tend to be less severe than in primary
infection
• Generally no lymphadenopathy
• Usually no systemic symptoms
• HSV-2 primary infection more prone to recur than
HSV-1
 Diagnosis

VIROLOGIC TESTS
• Viral culture (gold standard)
• Preferred test if genital ulcers or other mucocutaneous
lesions are present
• Highly specific (>99%)
• Sensitivity depends on stage of lesion; declines rapidly as
lesions begin to heal
• Positive more often in primary infection (80%–90%) than
with recurrences (30%)
• Cultures should be typed
• Polymerase Chain Reaction (PCR)
• More sensitive than viral culture
• Preferred test for detecting HSV in spinal fluid
 Diagnosis

VIROLOGIC TESTS

• Antigen detection (DFA or EIA)

• Fairly sensitive (>85%) in symptomatic shedders
• Rapid (2-12 hours)
• May be better than culture for detecting HSV in
healing lesions
• Cytology (Tzanck smear)
• Insensitive and nonspecific and should not be
relied on for HSV diagnosis
 Diagnosis

TYPE-SPECIFIC SEROLOGIC TESTS

Type-specific and nonspecific antibodies to HSV

• IgM – acute infection
• Ig G – chronic infection, persists for life long
• HSV-2 antibody indicates anogenital infection
• HSV-1 does not distinguish anogenital from orolabial
infection
 HERPES GENITALIS : TREATMENT

Recommended regimen for first clinical episode

■ Acyclovir, 200 mg orally, 5 times daily for 7 days
OR
■ Acyclovir, 400 mg orally, 3 times daily for 7 days
OR
■ Valaciclovir, 1 g orally, twice daily for 7 days
OR
■ Famciclovir, 250 mg orally, 3 times daily for 7 days
 HERPES GENITALIS : TREATMENT
Recommended regimen for recurrent infection
■ Acyclovir, 200 mg orally, 5 times daily for 5 days
OR
■ Acyclovir, 400 mg orally, 3 times daily for 5 days
OR
■ Acyclovir, 800 mg orally, twice daily for 5 days
OR
■ Valaciclovir, 500 mg orally, twice daily for 5 days
OR
■ Valaciclovir, 1000 mg orally, once daily for 5 days
OR
■ Famciclovir, 125 mg orally, twice daily for 5 days
 HERPES GENITALIS : TREATMENT

Recommended regimen for suppressive therapy

■ Acyclovir, 400 mg orally, twice daily, continuously
OR
■ Valaciclovir, 500 mg orally, once daily
OR
■ Valaciclovir, 1000 mg orally, once daily
OR
■ Famciclovir, 250 mg orally, twice daily
 HERPES GENITALIS : TREATMENT

Recommended regimen for severe disease

■ Acyclovir, 5–10 mg/kg IV, every 8 hours for 5–7 days or until
clinical resolution is attained

Recommended regimen in severe herpes simplex lesions with

coinfection with HIV
■ Acyclovir, 400 mg orally, 3–5 times daily until clinical resolution
is attained

Recommended regimen for neonates

■ Acyclovir, 10 mg/kg intravenously, 3 times a day for 10–21 days
 PRIMARY SYPHILIS
(The Chancre)
• IP- 9-90 days, usually ~21 days.
• Develops at site of contact/inoculation.
• Ulcer ( HARD CHANCRE/HUNTARIAN
CHANCRE/EROSIVE CHANCRE)
– single, painless, clean-based, indurated ulcer, with firm, raised
borders. Atypical presentations may occur.
• Site:
– Mostly anogenital, but may occur at any site (tongue, pharynx,
lips, fingers, nipples.
• Non-tender regional adenopathy
• Very infectious.
• May be darkfield positive but serologically negative.
• Untreated, heals in several weeks, leaving a faint scar.
PRIMARY SYPHILITIC CHANCRE

Sharply
demarcated

Elevated

Round/oval

Smooth clean
looking floor

Indurated base

Painless

Firm discrete
B/L LN
 DIAGNOSIS OF SYPHILIS

• Evaluation based on three factors:

– Clinical findings.
– Demonstration of spirochetes in clinical specimen.
– Present of antibodies in blood or cerebrospinal
fluid.
• More than one test should be performed.
• No serological test can distinguish between other
Treponemal infections.

70
 LABORATORY TESTING

• Direct examination of clinical specimen by dark-field

microscopy or fluorescent antibody testing of
sample.

• Non-specific or non-treponemal serological test to

detect reagin, utilized as screening test only.

• Specific Treponemal antibody tests are used as a

confirmatory test for a positive reagin test.
 SERUM TEST FOR SYPHILIS
ANTIBODY ANTIGEN PRINCIPLE TESTS

Non – specific Cardiolipin Complement fixation CWR

( anti- lipoidal)
Cardiolipin coated flocculation VDRL
particles RPR
ART

Group – specific Extract of Complement fixation Reiter protein CFT

( all treponemes) non – pathogenic
trep.
Specific (pathogenic Live trep. Immobilization TPI
treponemes)
Dead trep. Immunofluorescence FTA-Abs

Disrupted trep. Enzyme linked assays ELISA

Disrupted trep. Haemagglutination TPHA

Coated RBCs
 SYPHILIS : TREATMENT

Recommended regimen
■ Benzathine benzylpenicillin,2.4 million IU by
intramuscular injection, at a single session. Because
of the volume involved, this dose is usually given as
two injections at separate sites

Alternative regimen
■ Procaine benzylpenicillin,1.2 million IU by
intramuscular injection, daily for 10 consecutive days
 SYPHILIS : TREATMENT

Alternative regimen for penicillin-allergic non-

pregnant patients
■ Doxycycline, 100 mg orally, twice daily for 14 days
OR
■ Tetracycline, 500 mg orally, 4 times daily for 14 days
Alternative regimen for penicillin-allergic pregnant
patients
■ Erythromycin, 500 mg orally, 4 times daily for 14 days
 Syphilitic Herpes Chancroid LGV Donovanosis
chancre genitalis
IP 9 – 90 days 2-7 days 1-5 days 3 d- 6 wks 1-4 wks
Initial lesion Papule Vesicle Papule/ Papule , pustle/ Papule
pustule Vesicle Subcutaneou
s nodule
Number One Multiple Multiple One Variable
Size (mm) 5-15 1-2 2-20 2-10 Variable
Edge/ Sharply Erythematous Undermined Elevated Elevated
margin Demarcated, Sharp Ragged Round Irregular
Round/oval Irregular Oval
Depth Superficial/ Superficial Excavated and Superficial Elevated
Deep Deep Irregular
Floor Smooth, Serous Purulent Variable Beefy red
Clean looking Erythematous Necrotic granulation
Base Indurated None Soft Firm Firm
Tenderness Painless Common Very tender Variable Uncommon
LNpathy Firm , Firm tender Tender, Tender , Pseudobubo
discrete Bilateral unilocular Multiloculated Unilateral
Shotty, U/L, single rupture from
Bilateral sinus multiple sinuses
 CHILDREN, ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS

• Sexual abuse of children and adolescents has come to be recognized

as a serious social problem.

• Infection may be asymptomatic.

• If remains undiagnosed and untreated may result in an unanticipated

complication at a later stage and may be transmitted to others.
• The identification of a sexually transmissible agent in a child beyond
the neonatal period, in the vast majority of cases, is suggestive of
sexual abuse
• Most cases of sexual abuse involve relatives, friends and other adults
in close and legitimate contact with the child or adolescent.
THANK YOU
 SYNDROMIC
APPROACH OF
URETHRAL
DISCHARGE IN
MALES

Dr AMRITA KUMARI
RESIDENT,DERMATOLOGY
BASE HOSPITAL,LKO
 Objectives
• To review the facts: STIs enhances the
acquisition and transmission of HIV

• To review the syndromic approach to

management

• To demonstrate the use of the algorithms

79
 How do STIs increase HIV transmission?

• Reducing physical/mechanical barriers

(disruption of epithelium)
• Increasing HIV in genital lesions, semen or
both ( even if VL is undetectable)
• Evoking a more infectious HIV variant
• Increasing the number of receptor cells or
the density of receptors per cell

80
STI – Syndromic Case Management
REQUIREMENTS:

• Adequate medical history

• Good sexual history
• Complete STI clinical examination
• Management guidelines
• Good supply of effective drugs

84
Essential Steps In STI Care Management*

Syndrome
Assessment Contact tracing
(diagnostic tools)
Compliance

Diagnosis Treatment 5Cs Confidentiality

Condom use
(screening tests)
Counseling
Risk
Assessment

* Adapted from Holmes & Ryan

85
 Risk Assessment Include:
• Sexual behaviour
• Specific exposures
• Socio demographics/other high risk markers:
– young age
– marital status: not living with steady partner
– partner problems
• History of reproductive health
• History of past STI

86
 STI Control Program

• Basic activities of STI prevention activities

(for primary and secondary prevention

strategies)

– Primary infection: prevent new infection

– Secondary prevention: prevent complication

87
WHO recommendation for STI control Program

Primary prevention
measures
1. Health education and promotion of
safer sex and risk reduction

2. Promotion of condoms
(Wide spread availability and affordability of
Condom)

3. Information campaigns on the

association between HIV and STI
88
 Secondary prevention
1. Promotion of early health care seeking behavior
2. Accessible, effective and acceptable care -Integration of STD
care into all basic health care facilities

3. Promotion of early use of health care services

( STD patients and their partners)
4.Early detection and treatment of asymptomatic infections
through case finding
Screening for asymptomatic patients
eg, SY serology in pregnant women, CT tests in CSWs

89
 Basic model for the reproductive rate of new
infection in a population

R0 = Dc
• Basic reproductive rate (Ro):
• Average of likelihood of transmission of the
disease pathogen ()
• Average rate of exposure of susceptible to
infectious people in the population (C)
• Average duration of infectiousness (D)

90
Intervention points according to the determinants of STI
transmission

Exposure of a susceptible
person

C 
Intervention point

Acquisition of
Persistence infection
and infectivity
of infection
D

91
 Intervention that reduce exposure to STI (C)

• Target on determinants of Sexual behavior

• Potential activities:
– Promotion of delayed initiation of sex among youth adolescents, abstinence,
monogamy, reduce rates of sex partner change, avoidance of concurrent
sexual partnerships

– Clinic level Health education for risk reduction

– Community-level interventions to modify community norms toward less

acceptance of specific, high-risk behaviors.

– School Health education program

92
Intervention that could shorten duration of infectivity
(D)

• Active case finding through widespread access to acceptable and

good quality clinical care, screening, and contact tracing

• Prompt and effective diagnosis and treatment for symptomatic

persons
• Clinical practice guideline (emphasis on syndromic or rapid test)

• Screening practices for asymptomatic infection

• Promoting awareness among potentially infected persons (having
symptom of STI)
• “Epidemiologic treatment” selective mass treatment
• Outbreak investigation (rare disease)

93
Intervention that reduce efficacy of STI transmission
during sexual exposure ()

• Increase consistence and correct use of barrier contraceptive

methods
– (eg, condom, spermicides)

• Decrease specific risky sexual practices

– (eg, penetrative sex)

• Vaccine
– Hepatitis B
– HPV

94
 Vertical program and horizontal program

Advantage
Vertical (STI Clinic) Horizontal (general care)

-Well equipped clinic -More accessible

-Well train staff -Used more by women
-Good diagnostic services -Less stigmatizing

95
 Disadvantage
Vertical Horizontal

- Access often restricted for - Quality of patient care can be variable

much of population - Overwork and poorly trained staff
- Stigmatizing - Poor diagnostic services
- Expensive - Limited drugs

96
Good quality care and management
- appropriated drug (efficacy, low cost)
- education
- counseling
- treatment of sexual partners

Treatment: rely on
- efficacy
- acceptability
- low cost
- antibiotic resistance considerations

97
Partner notification

Partner management
- epidemiology treatment
- Laboratory diagnosis
(if available)
- education and counseling

98
 Targeted interventions

• Sex workers, MSM and injecting drug users.

• STI services for these and other high-risk population groups need to
be scaled up universally, making them a regular component of
primary and sexual and reproductive health care.

99
Intervention in
Commercial Sex
workers

100
 STI services for CSW

• Periodic health checkup

– Clinic (government, private)
– Mobile Clinic

• Effective treatment ( MININUM OR FREE OF CHARGE)

– Individual
– Mass treatment

101
 URETHRAL DISCHARGE
URETHRAL DISCHARGE OR DYSURIA

HISTORY,EXAMINATION
EDUCATE AND COUNSEL
MILK URETHRA IF REQUIRED
PROMOTE & PROVIDE
CONDOMS
NO NO OFFER HIV COUNSELING
DISCHARGE ANY OTHER
AND TESTING IF BOTH
GENITALDISEASE
FACILITIES ARE AVAILABLE
YES YES REVIEW IF SYMPTOMS
TREAT FOR GONORRHOEA & CHLAMYDIA USE PERSIST
APPROPIRATE
EDUCATE AND COUNSEL FLOW CHART
PROMOTE AND PROVIDE CONDOMS
OFFER HIV COUNSELLING & TESTING IF
BOTH FACILITIES ARE AVAILABLE
PARTNER MANAGEMENT
ADVISE TO RETURN IN SEVEN DAYS IF
SYMPTOMS PERSIST
 PERSISTENT OR RECURRENT URETHRAL DISCHARGE
PERSISTENT OR
RECURRENT URETHRAL EDUCATE AND COUNSEL
DISCHARGE OR DYSURIA PROMOTE & PROVIDE
HISTORY,EXAMINATION CONDOMS
MILK URETHRA IF REQUIRED NO OFFER HIV COUNSELING
ANY OTHER AND TESTING IF BOTH
DISCHARGE CONFIRMED NO GENITALDISEASE ARE AVAILABLE
DOSE Hx CONFIRM RE-INFECTION YES
REPEAT USE
TREAT FOR TRICHOMONAS VAGINALIS
EDUCATE AND COUNSEL URETHRAL APPROPIRATE
PROMOTE AND PROVIDE CONDOMS DISCHARGE FLOW
MANAGE AND TREAT PARTNER TREATMENT CHART
ADVISE TO RETURN IN SEVEN DAYS IF SYMPTOMS
PERSIST
YES
IMPROVED EDUCATE AND COUNSEL
PROMOTE & PROVIDE CONDOMS
NO
OFFER HIV COUNSELING AND TESTING IF BOTH ARE AVAILABLE
REFER
 Urethritis

SYMPTOMS • Urethral discharge

• Dysuria
• Itching at end of urethra

• Urethral discharge
SIGNS
• Increased number of PMNL on Gram stain
LABORATORY of a urethral smear or in the sediment of
the first-voided urine
 Epidemiology of urethritis

• Common STI syndrome among men – 60% among STI clinic.

• NGU cases exceed gonococcal urethritis

• For both GU and NGU, peak age range is 20-24 years, followed by 15-1
and then 25-29
 Aetiology of urethritis

Gonococcal • Neisseria gonorrhoeae

• Chlamydia trachomatis (15-40%)

Non-gonococcal
• Mycoplasma genitalium (15-25%)
• Trichomonas vaginalis (5-15%)
• Ureaplasm urealyticum (<15%)
• Herpes simplex (2-3%)
• Adenovirus (2-4%)
• Haemophilus spp. (rare)
• Unknown
 Male Genital Infections
ETIOLOGY OF NGU

INITIAL, NON-RECURRENT, DOCUMENTED URETHRITIS

– Chlamydia trachomatis 20-40%
– Mycoplasma genitalium 10-20%
– Other and unknown 30-50%
– Ureaplasma urealyticum? 10-30%?
– Normal flora (oral, vaginal)? 10-20%?
– U. parvum 0
– Trichomonas vaginalis 0-5%
– Adenovirus 0-5%
– Herpes simplex virus 0-5%
See Bradshaw et al, JID 2006;193:336-45
 Neisseria gonorrhoeae
• Gram negative diplococcus

• Asymptomatic and minimally

symptomatic infections occur in the
community – may be associated with
AHU auxotrophs (US studies)

• Increasing antimicrobial resistance

• Concurrent C. trachomatis infection

common
 Chlamydia trachomatis
• Gram negative obligate intracellular
bacterium

• Common cause of post-gonococcal

urethritis

• Less common among MSM

• Isolated from urethras of:

- 25-60% (usually 30-40%) NGU cases
- 4-35% (usually 15-25%) GC cases
- 0-7% of men without urethritis
 Mycoplasma genitalium

• Intracellular bacterium without a cell wall

• Pooled data from 19 studies:

NGU (21.1%) vs. normal men (6.7%);
OR 3.8 (95% CI: 3.0 - 4.9)

CT negative NGU (21.7%) vs. normal men (6.0%); OR 5.15 (95% CI:
3.6 – 7.4)

• Genotyping analyses of concurrently infected couples

supports sexual transmission
 Trichomonas vaginalis
• Flagellated protozoon

• Initial studies using microscopy +/- culture showed an association

of T. vaginalis with NGU
• Organism frequently found in urethra of both symptomatic and
asymptomatic men by NAAT – association of T. vaginalis with NGU
vs. colonisation less clear
• T. vaginalis more important as a cause of NGU among African men
as high prevalence of trichomoniasis
 Ureaplasma species
• Higher isolation rates from men with C. trachomatis negative NGU
than among C. trachomatis positive NGU/no urethritis cases

• Isolated more often from men with first episode NGU than those
with a history of previous NGU episodes or men without urethritis

• Intraurethral inoculation of Ureaplasma sp. into non-human

primates associated with increased numbers of PMNL in
endourethral smears (some animals)

• Limited studies suggest U. urealyticum, rather than U. parvum, is

associated with NGU
 Other bacterial causes of NGU

• Most studies have not revealed differences in aerobic and anaerobic

urethral flora between CT+/CT- NGU cases

• Haemophilus influenzae and Haemophilus parainfluenzae are rare

causes of NGU

• Neisseria meningitidis may cause NGU – transmission by orogenital sex

supported by PFGE in one case study

• Association between NGU in males and BV in females – further

research required to identify responsible bacteria
 Viral causes of NGU
• Urethritis occurs in 30% of men with primary HSV (less common in
recurrent HSV)

• Recent PCR-based studies suggest HSV detected in 2-3% of cases

• In Australia, Bradshaw et al. (2006) demonstrated:

- significantly more HSV detected in 329 NGU cases compared to 307 controls
- HSV-1 was more commonly detected than HSV-2
- unprotected oral sex was a risk factor

• Adenoviruses reported among men with urethritis in Australia and

USA – seasonal, associated with receptive oral sex, may see co-existent
conjunctivitis
 Non-STI causes of NGU
• Urinary tract infection
• Bacterial prostatitis
• Urethral stricture (catheterisation/instrumentation)
• Phimosis
• Congenital abnormalities
• Chemical irritation
• Tumours
• Stevens Johnson syndrome
• Role of masturbation, “milking” urethra, frequency of sexual
activity, coffee, alcohol, foods unclear
 Asymptomatic STIs - The hidden epidemic
1600

Cases per 10,000 m en

1400

1200

1000

800 as y m ptom atic

s y m ptom atic
600

400

200

0
GC CT TV MG
Infe ction

INFECTION SYMPTOMATIC ASYMPTOMATIC OVERALL

FOR STIs (n = 27) FOR STIs (n = 274) (n = 301)
No. % No. % No. %
Neisseria gonorrhoeae infection 6 22.2% 13 4.7% 19 6.3%
Chlamydia trachomatis infection 1 3.7% 25 9.1% 26 8.6%
Trichomonas vaginalis infection 6 22.2% 37 13.5% 43 14.3%
Mycoplasma genitalium infection 2 7.4% 18 6.6% 20 6.6%

Only 9% of men were symptomatic for STIs

 Clinical presentation
Characteristic Gonorrhoea NGU

Discharge Profuse and purulent Scant and muco-purulent,

may be absent

Dysuria +++ +
(+++ with HSV/adenovirus)

Incubation period 2-6 days 1-5 weeks

Health seeking early late

behaviour

Asymptomatic +/- ++
cases
Urethral discharge
 Bacterial verus Viral NGU

CT MG Adeno HSV
Mod/severe 28% 20% 69% 78%
dysuria
Meatal erythema 33% 26% 92% 89%

Concider acyclovir in patients with proiment dysuria and

meatal inflammation?

Bradshaw C et al. JID 2006;193:336-45

 Syndromic management approach
• Syndromic management approach for all STI syndromes decreased
HIV incidence by 38%
• Works well for male urethral discharge syndrome
• Avoids lab tests but regular microbiological surveillance is part of
the syndromic approach
• Treatment must cover gonorrhoea and chlamydial infection – now
also important to consider M. genitalium and T. vaginalis infection.
 Syndromic management approach

• Educate, ensure compliance and counsel

• Promote abstinence during the course of treatment
• Promote and demonstrate condom use, provide condoms
• Stress importance of partner treatment and issue one notification slip
for each sexual partner, follow up partner treatment during review visit
• Offer HIV counselling and testing, repeat HIV test after 3 months (HIV
negative paitients)
 Diagnosis of urethritis
• Gram stain microscopy (GC, NGU) [ 5 PMNL/hpf x 5]
• Rapid tests (CT, TV – issues with current GC assays)
• Culture (GC CT, TV, Ureaplasmas, HSV, adenovirus)
• ELISA (CT)
• Monoclonal antibody tests (GC, CT)
• Nucleic acid amplification tests (GC, CT, TV, MG, HSV, Ureaplasma
urealyticum)
- PCR (Roche + others), SDA (Abbott) and TMA (GenProbe)
commercial assays
- in-house multiplex assays
 Specimen collection

Gram
staining Transport media(Amies/Stuart)
Mod.Thayre martin media
(5% co2, 350C ,24-48hr)
 Diagnosis

• Non-culture tests
– Amplified tests (NAATs)
• Polymerase chain reaction (PCR) (Roche Amplicor)
• Transcription-mediated amplification (TMA) (Gen-Probe Aptima)
• Strand displacement amplification (SDA) (Becton-Dickinson BD ProbeTec
ET)
– Non-amplified tests
• DNA probe (Gen-Probe PACE 2, Digene Hybrid Capture II)

124
 Drips

Laboratory Tests for Chlamydia

• Tissue culture has been the standard
– Specificity approaching 100%
– Sensitivity ranges from 60% to 90%

• Non-amplified tests
– Enzyme Immunoassay (EIA), e.g. Chlamydiazyme
• sensitivity and specificity of 85% and 97% respectively
• useful for high volume screening
• false positives
– Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-2
• sensitivities ranging from 75% to 100%; specificities greater than 95%
• detects chlamydial ribosomal RNA
• able to detect gonorrhea and chlamydia from one swab
• need for large amounts of sample DNA

125
 Drips

Laboratory Tests for Chlamydia (continued)

• DNA amplification assays
– polymerase chain reaction (PCR)
– ligase chain reaction (LCR)
• Sensitivities with PCR and LCR 95% and 85-98%
respectively; specificity approaches 100%
• LCR ability to detect chlamydia in first void urine

126
 Treatment of Uncomplicated Gonorrhea

RECOMMENDED
• Ceftriaxone 125-250 mg IM
• Cefixime 400 mg PO
• Cefpodoxime 400 mg PO
• Ciprofloxacin 500 mg PO
• Ofloxacin 400 mg PO No longer recommended
• Levofloxacin 250 mg PO
PLUS
• Azithromycin
or Include as syndromic
• Doxycycline management of urethritis
 Gonococcal Isolate Surveillance Project (GISP) — Percent of
Neisseria gonorrhoeae isolates with resistance or intermediate
resistance to ciprofloxacin, 1990–2003

Percent
7.5
Resistance
6.0 Intermediate resistance

4.5

3.0

1.5

0.0
1990 91 92 93 94 95 96 97 98 99 2000 01 02 03
Note: Resistant isolates have ciprofloxacin MICs ≥ µg/ml. Isolates with intermediate
resistance have ciprofloxacin MICs of 0.125 - 0.5 µg/ml. Susceptibility to ciprofloxacin
was first measured in GISP in 1990.
 Management

Co-treatment for
Chlamydia trachomatis
If chlamydial infection is not ruled out:

Azithromycin 1g Orally Once or

Twice a day for

Doxycycline 100 mg Orally
7 days

129
 Treatment of NGU

• Azithromycin 1.0 g, single dose

– Chlamydia efficacy 90-95%
– Clinical efficacy ~90%
– M. genitalium: Usually effective but apparent risk of inducible
resistance
• Doxycycline 100 mg po BID x 7 days
– Chlamydia efficacy >98%
– Clinical efficacy ~90%
– M. genitalium Not effective
• Alternatives: Other tetracyclines, erythromycin,
fluoroquinolones
 Management of Sex Partners of Men with
NGU
• Goals
– Treat/prevent chlamydia
– Prevent reinfection
• Treat with same regimen as index case
• Examine for other STDs, if practical
• Partner treatment of unknown benefit in
recurrent or persistent NGU
 Recurrent and Persistent NGU
• Symptoms may take 10-14 days to completely
resolve
• Symptoms persist or recur within 4-6 weeks in 10-
15%
• Evaluation
– Document urethritis
– Otherwise, no treatment
• Treatment
– Retreat with opposite drug (AZM or doxy)
– Metronidazole or tinidazole
Complications of Male Urethritis
Management of epididymo-orchitis
STI-related:
• Ceftriaxone 250mg imi stat
• Doxycycline 100mg po 12 hourly x 14 days

UTI-related:
• Ciprofloxacin 500mg po 12 hourly x 10 days
or
• Ofloxacin 400mg po 12 hourly x 10 days
Consider IV antibiotics if systemic illness

No improvement or clinical progression:

• Review lab tests and susceptibility data
• Assess for complications (ultrasound &/or surgery)
• Consider alternative diagnosis, e.g. TB

Scrotal support enhances lymphatic and venous drainage

 Management

Special Considerations:
Pregnancy
• Pregnant women should NOT be treated with
quinolones or tetracyclines
• Treat with alternate cephalosporin
• If cephalosporin is not tolerated, treat with
spectinomycin 2 g IM once

135
 Management

Alternative Regimens
• Spectinomycin 2 g in a single IM dose

• Single-dose cephalosporin regimens

– Ceftizoxime 500 mg IM
– Cefoxitin 2 g IM with Probenecid 1 g orally

136
 Management

Follow-Up

• A test of cure is not recommended if a

recommended regimen is administered.
• If symptoms persist, perform culture for N.
gonorrhoeae.
– Any gonococci isolated should be tested for
antimicrobial susceptibility.

137
 Prevention

Screening
• Pregnancy
– A test for N. gonorrhoeae should be performed
at the first prenatal visit for women at risk or
those living in an area in which the prevalence of
N. gonorrhoeae is high.
– Repeat test during the 3rd trimester for those at
continued risk.
• Other populations can be screened based on
local disease prevalence and patient’s risk
behaviors. 138
 Prevention

Partner Management
• Evaluate and treat all sex partners for N. gonorrhoeae
and C. trachomatis infections if contact was within 60
days of symptoms or diagnosis.
• If a patient’s last sexual intercourse was >60 days before
onset of symptoms or diagnosis, the patient’s most
recent sex partner should be treated.
• Avoid sexual intercourse until therapy is completed and
both partners no longer have symptoms.

139
 Prevention

Reporting
• Laws and regulations in all states require that
persons diagnosed with gonorrhea are
reported to public health authorities by
clinicians, labs, or both.

140
 Prevention

Patient Counseling/Education
• Nature of disease
– Usually symptomatic in males and asymptomatic in females
– Untreated infections can result in PID, infertility, and ectopic
pregnancy in women and epididymitis in men
• Transmission issues
– Efficiently transmitted
• Risk reduction
– Utilize prevention strategies

141
CONCLUSION
THANK

YOU