Sexually transmitted infection syndromes

Acute proctitis

Organism

There are many causes of anal and rectal inflammation. This section is limited to sexually transmitted causes, but surgical conditions (e.g. fistulae or haemorrhoids) and inflammatory conditions (e.g. Crohn's disease) should always be considered.

Proctitis caused by sexually transmitted organisms is associated with anal sex and is usually caused by Neisseria gonorrhoeae orHerpes simplex virus (HSV). In men who have sex with men (MSM), Shigella and Campylobacter jejuni infections and sometimes parasitic gastro-intestinal infections may be acquired from sexual activities, and proctitis may occur as part of an infective enteritis caused by these organisms. While Chlamydia trachomatis does not usually cause an acute proctitis, rates of rectal chlamydia are increasing and lymphogranuloma venereum (LGV) proctitis (usually symptomatic) has been documented as an ongoing epidemic amongst MSM.

Clinical presentation

Proctitis is suggested by anal discharge, blood and/or mucus in stools, and pain during defecation. Herpes often causes ulceration and accompanying anal pain, itch and discomfort, while gonorrhoea causes a more generalised inflammation and exudate. A primary herpes proctitis tends to be extremely painful and uncomfortable. LGV is usually symptomatic while a gonococcal proctitis is only rarely the cause of much discomfort.

Investigations

In suspected proctitis, proctoscopy should be performed unless patient discomfort makes this impossible, and the following investigations are suggested:

  • swab of purulent exudate for Gram-stained smear and culture
  • swab for chlamydia NAAT
  • swab for herpes culture and/or NAAT
  • faeces culture for enteric pathogens if history suggests infective cause
  • test for other STIs including HIV, LGV serology (if relevant)
  • If rectal NAAT for chlamydia is positive, discuss with the laboratory the possibility of further testing of the specimen for LGV serovars to enable diagnosis of LGV.

Treatment

In cases where a sexually transmitted cause is suspected, treatment should be given immediately before the results of tests are available. Treat for both gonorrhoea and chlamydia and consider the need for specific herpes therapy.

  • Ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly, as a single dose

        and

  • azithromycin 1 g orally STAT dose (preferred therapy)

        or

  • doxycycline 100 mg orally, 12-hourly for 10 days

        or

  • roxithromycin 300 mg orally, daily for 10 days
plus if herpes is clinically suspected

  • valaciclovir 500 mg orally, 12-hourly for five days

        or

  • aciclovir 200 mg orally, five times daily for five days.

Rectal LGV should be treated with doxycycline 100 mg, 12-hourly for three weeks following azithromycin 1 g orally STAT dose.

In addition, the following procedures are recommended:

  • In all cases, educate the patient about safer sex practices and promote condom use.
  • Partner(s) should be investigated and treated as appropriate.
  • Advise return visit in one week.
  • Patients should be advised not to have sex until they have been re-assessed.
Sexually transmitted infection syndromes

Syndromic testing and treatment is a public health approach in areas with high rates of STIs.

According to the World Health Organization:*

  • A syndrome is a group of symptoms that patients describe combined with the signs that providers observe during examination. Although sexually transmitted diseases (STDs) are caused by many different organisms, these organisms only cause a limited number of syndromes.

The four main STI syndromes are:

  • vaginal discharge in women
  • urethral discharge/dysuria in men
  • genital ulceration in both men and women
  • lower abdominal pain in women.

Acute proctitis is also discussed.

* World Health Organization, 1997, STD Case Management. The Syndromic Approach for Primary Health Care Settings – Participants’ Version, WHO, Manila.

Vaginal discharge

Vaginal discharge may originate from either the vagina, cervix or upper genital tract. Vaginal discharges are commonly due to bacterial vaginosis, candidiasis and trichomoniasis (although the latter is rare in urban areas).

Vaginitis

Symptoms

  • There may be an odour (as in the case of bacterial vaginosis or trichomoniasis) or itch (candidiasis) or vulval swelling or soreness (trichomoniasis or candidiasis).
  • Vaginal infections (as opposed to cervical infections) may cause increased volume of vaginal discharge usually noticed by the patient, i.e. is symptomatic.

Signs

On examination there is usually increased discharge noted at the introitus and, on inserting a speculum, a pooling of vaginal discharge in the posterior fornix or adherent to the vaginal walls. It is important to note the colour and consistency of the discharge, its odour, and whether the vaginal walls are inflamed.

Cervicitis

Cervicitis is defined as >30 white blood cells per high-powered field (WBC/HPF) microbiologically and clinically as inflammation (redness, swelling, contact bleeding, discharge).

Symptoms

  • Cervical discharge is usually more scanty and may not be noticed by the patient, i.e. asymptomatic, although the patient may notice a change in colour to yellow as the discharge becomes purulent or mucopurulent.
  • These may be due to STIs such as gonorrhoea, chlamydia or genital herpes. Alternatively, they may be due to physiological causes such as hormones or exposed columnar epithelium (ectopy) causing increased mucoid or mucopurulent discharge at the cervix.
  • Coexisting urethral infection can occur in women with sexually acquired cervicitis. A history of dysuria without urinary frequency is an important clue to the possible presence of an STI.

Signs

  • On speculum examination a purulent or mucopurulent discharge from the endocervical canal is an important sign as most cases are likely to be due to gonorrhoea or chlamydia.
  • Often this is associated with an inflamed, oedematous cervix with contact bleeding when taking swabs or smears.
  • Often a previously unnoted cervical discharge is seen on the tip of the swab.
  • Note: most cases of cervicitis are asymptomatic and may also not have any signs, i.e. the cervix can look entirely normal in cases of gonorrhoea and chlamydia.
  • Other organisms associated with cervicitis include Herpes simplex virus (HSV), Trichomonas vaginalis, and anaerobes. In some cases of clinically evident mucopurulent cervicitis, no pathogens are able to be isolated.

Investigations and specimen collection

Laboratory tests allow precise diagnosis, and should be performed. If the patient complains of or shows signs of a vaginal discharge:

  • Take a medical history and undertake a physical examination.
  • Examine the urethra and vulva for redness and discharge. If urethral discharge (pus) is present, swab for culture.
  • Pass a speculum, and visualise the vagina and cervix.
  • Collect a high vaginal swab.
  • Test vaginal pH on indicator paper (normal is pH <4.5). Note if there is a fishy odour.
  • If pus is present or the cervix is inflamed, take endocervical swabs for MC&S.
  • Collect endocervical specimens for gonorrhoea and chlamydia using a swab or cytobrush for NAAT.
  • Collect first void urine for gonorrhoea and chlamydia NAAT.
  • If the patient has urinary frequency, take a mid-stream specimen for culture and sensitivity.
  • If ulcers are also present, take a swab from the ulcers for genital herpes.
  • Perform a pelvic examination on every new patient or where there is abdominal pain.

Special considerations

  • If the patient has had anally receptive sex, take two anal swabs for gonorrhoea (culture and sensitivity) and chlamydia (NAAT). Alternatively, the patient can be instructed how to take two blind anal swabs herself. Refer to the STI self testing card (PDF 346KB)for instructions.
  • If the patient has had oral sex, take two throat swabs for gonorrhoea (culture and sensitivity) and chlamydia (NAAT).
  • Collect blood for serological tests – syphilis, HIV and hepatitis B. Also test for hepatitis C if there is a history of injecting drug use.
  • If GeneXpert point-of-care test available, see specimen collection for more information.

Immediate treatment

Without waiting for laboratory results, proceed as follows:

Vaginitis

  • If itchy, reddened vaginal walls, soreness or reddened or swollen vulva and a normal or low pH (<4.5), treat for candidiasis.
  • If vulval soreness, redness, copious greenish discharge, and reddened vaginal walls and cervix, a fishy odour and a raised pH >4.5, treat for trichomoniasis.
  • If vulva and vaginal walls are not inflamed or sore or itchy, a slight homogenous grey-white discharge with a fishy odour, and a raised pH >4.5, treat for bacterial vaginosis.
  • If the vaginal pH is >4.5, treat as for bacterial vaginosis or trichomoniasis.

Cervicitis

  • If a purulent cervicitis is seen, treat for both gonorrhoea and chlamydia.
  • If shallow painful ulcerative lesions are seen on the vulva and there is cervicitis, treat for genital herpes.
  • If abdominal pains accompany the cervicitis, treat for pelvic inflammatory disease (PID).
  • In all cases, educate the patient about safer sex practices and promote condom use.
  • Partner(s) should be investigated and treated as soon as possible, preferably within 24 hours.
  • Advise return visit for review and discussion of results.
  • Patients should be advised not to have sex for a week and until their partner has also completed treatment.
  • If GeneXpert point-of-care test available, treat the infection detected. If neither chlamydia nor gonorrhoea detected, treat as for chlamydia to cover Mycoplasma and other infections.
Urethral discharge dysuria in men
  • Symptoms and signs described in urethral discharge syndrome vary and may include urethral discharge, dysuria, and meatal inflammation without urinary frequency.
  • Urethritis is defined as >5 WBC/HPF on a smear.
  • There may be white cells or bacteria in the urethral exudate seen on a smear on a glass slide, or Chlamydia trachomatis andNeisseria gonorrhoeae may be isolated from urethral swabs or from FVU.
  • Laboratory testing is always required to confirm the diagnosis and to identify the infecting pathogen.
  • If there are symptoms of urinary frequency, then a urinary tract infection may also be possible (although it is uncommon in men under 40 years of age).
  • Other organisms associated with urethritis include Mycoplasma genitalium, Herpes simplex virus (HSV), Trichomonas vaginalis, adenoviruses, Ureaplasma urealyticum and anaerobes. However, U. urealyticum and anaerobes may also exist as normal urethral flora in many men.
  • In many cases of clinically evident and laboratory-proven urethritis, no pathogens are able to be isolated.

Investigations and specimen collection

If discharge present or recent symptoms of discharge

  • Milk discharge forward to see any discharge at the meatus, collect specimens for MC&S. Smear first onto a glass slide for microscopy then place swab in charcoal transport media tube for culture and sensitivity.
  • Collect FVU for chlamydia and gonorrhoea NAAT. Inspect the urine for presence of threads as this helps confirm diagnosis of urethritis.
  • If there is urinary frequency, collect a midstream urine specimen for culture and sensitivity.

Special considerations

  • If the patient has had anally receptive sex, take two anal swabs for gonorrhoea (culture and sensitivity) and chlamydia (NAAT). Alternatively, the patient can be instructed how to take two blind anal swabs himself. Refer to the STI self testing card (PDF 346KB)for instructions.
  • If the patient has had receptive oral sex, take two throat swabs for gonorrhoea (culture and sensitivity) and chlamydia (NAAT).
  • Collect blood for serological tests – syphilis, HIV and hepatitis B. Also test for hepatitis A if symptomatic or if there is a history of male-to-male and/or oro-anal sex and if there is an intention to vaccinate if negative (see Viral hepatitis). Test for hepatitis C if there is a history of injecting drug use.
  • If GeneXpert point-of-care test available, see information on specimen collection.

Immediate treatment

  • If discharge is present or if there is a good symptomatic history and the presence of threads in FVU, treat for both gonorrhoeaand chlamydia.
  • In all cases, educate the patient about behaviour change, i.e. safer sex practices, and promote condom use.
  • Partner(s) should be investigated and treated as soon as possible, preferably within 24 hours.
  • Advise return visit, if necessary, to check that symptoms have settled.
  • Patients should be advised not to have sex for a week and until their partner has also completed treatment.
  • If GeneXpert point-of-care test available, treat the infection detected. If neither chlamydia nor gonorrhoea detected, treat as for chlamydia to cover Mycoplasma and other infections.
Genital ulceration
  • Genital herpes (Herpes simplex virus (HSV) infection) is the most common STI causing genital ulceration in Australia. Symptomatic infection causes multiple painful, shallow irregular-edged ulcers or blisters anywhere in the anogenital region. They usually produce painful inguinal lymphadenopathy on the same side as the lesion. However, lesions may be more like linear splits or minor abrasions. Primary genital herpes (no prior exposure to the herpes virus) may present with systemic symptoms as well, e.g. fever, malaise, myalgia.
  • Primary syphilis is rare, but increasing, in urban Australia. However, it must always be excluded if a solitary, long-lasting, painless thickened indurated ulcerative lesion is present, especially if there has been recent sexual contact in remote Aboriginal communities in Australia, increasingly within the urban gay population, or in South-East Asia or Africa. Occasionally there are two kissing lesions that touch each other in a flexure. There is usually rubbery inguinal adenopathy on the same side as the lesion.
  • Donovanosis is found in northern and central Australia, and may produce beefy, smelly, painless red lesions, beginning as a nodule or nodules which then slowly erode and enlarge.
  • Chancroid produces single or multiple painful lesions with secondary infection and purulent sloughing, and may produce very large painful inguinal adenopathy leading to ulceration (a bubo). It is not endemic to Australia and should be considered in patients with sexual contact in Africa, India or South-East Asia.
  • Lymphogranuloma venereum (LGV) is rare, and seen in men who have sex with men in urban Australia or in those with sexual contacts in countries where these infections are endemic, such as South-East Asia, India and Africa. It classically produces a small, painless, transient genital ulcer, and then painful enlargement of the inguinal nodes (bubo) both above and below the inguinal ligament. However, in recent years cases in men who have sex with men have generally presented an acute proctitis. Subsequently, abscess formation and fistulae develop and finally blockage of the lymphatics and oedema occurs.
  • Diagnostic procedures for, and management of, genital ulceration, when the diagnosis is uncertain or the patient has recently returned from overseas, should be done by or in consultation with a specialised STI or sexual health service or a sexual health physician.
  • Pyogenic infections, trauma, drug eruptions, secondarily infected scabies, candidiasis, Behcet's disease, other dermatological conditions and neoplasms sometimes cause ulcerative lesions and may present diagnostic difficulties.

Investigations and specimen collection

If a patient complains of a genital sore or ulcer:

  • Take a medical history especially about travel, sex in high-risk areas, male-to-male sex and length of time the ulcer has been present.
  • Examine the ulcer, check for a rolled edge and induration or thickening of the ulcer base, or inguinal adenopathy.
  • Collect an HSV PCR (NAAT) swab from the genital lesion to exclude herpes. Note: The HSV PCR (NAAT) swab detects viral shedding from a herpes lesion. Viral shedding occurs during the early stages of a lesion. Therefore, a negative HSV PCR (NAAT) test result on an older herpes lesion does not preclude a diagnosis of herpes.
  • If the ulcer is clinically suggestive of donovanosis or syphilis:
    • Clean the ulcer with saline if required. From the inside edge of the ulcer/nodule take a dry swab. Send this swab to test for NAAT for donovanosis, syphilis and HSV by specifying the likely diagnosis or diagnoses.
    • Collect an impression smear (scrape and slide) or any other confirmatory tests for donovanosis.
    • HSV serology may be considered if the ulcer appears old or mostly healed, or if there are episodes of recurrent ulceration or known contact with infection. (Remember serology is not a substitute for the PCR swab and window periods may apply to the interpretation of results).
    • Take blood for syphilis serology, and offer HIV and hepatitis B serology.

Immediate treatment

  • Do not apply any antibiotic cream or give oral antibiotics if syphilis or donovanosis is in doubt/suspected without first having taken adequate swabs and syphilis serology.
  • If multiple painful, shallow irregular-edged ulcers or multiple recurrent vesicular lesions are evident, treat for herpes.
  • Refer all suspected cases of ulcers due to syphilis, donovanosis or chancroid to a specialist centre, or discuss management with a sexual health or infectious diseases specialist.
  • Where painless ulcers are evident, treatment for donovanosis and syphilis should be commenced in areas where laboratory diagnosis is likely to be delayed:
    • bicillin 1.8 g intramuscularly plus
    • azithromycin 1 g orally (directly observed).
  • In all cases, educate the patient about safer sex practices and promote condom use. Give out condoms.
  • Partner(s) should be investigated and treated as appropriate.
  • Stress importance of a return visit in one week.
  • Patients should be advised to avoid sex until ulcers have healed and partners have also been investigated and treated if necessary.
  • If rectal LGV is suspected, three weeks of antibiotic therapy such as doxycycline 100mg 12-hourly is recommended.
Lower abdominal pain syndrome

Women often present with lower abdominal pain. The causes range from minor but uncomfortable problems such as constipation or period pain, to life-threatening problems such as a ruptured ectopic pregnancy or appendicitis.

Some simple rules to manage lower abdominal pain include:

  • Always do a pregnancy test on women of child-bearing age.
  • Think past an obvious cause of the pain, e.g. many women have an abnormal dipstick urine test, but urinary infection may not be the cause of the pain.
  • Pelvic inflammatory disease (PID) is a common cause of lower abdominal pain in areas of high rates of gonorrhoea and chlamydia in WA. Always think about PID as a possible diagnosis and treat early to avoid complications especially if the patient is at risk of infertility (e.g. young, recent change of partner or multiple partners, recurrent STIs, past infertility, following termination of pregnancy or other instrumentation).
  • Take a risk history.

If a patient complains of lower abdominal pain, take a medical history, examine and consider:

  • urinary tract infections – dysuria (pain on passing urine) and frequency
  • appendicitis – usually central abdominal pain moving to the right lower quadrant and accompanied by nausea, vomiting and poor appetite
  • gastroenteritis or colitis – accompanied by bowel changes, diarrhoea and blood or mucus per rectum
  • endometriosis.

Consider ectopic pregnancy or other gynaecological conditions, such as an ovarian cyst or endometritis, if the patient has also:

  • missed a period or the last period is overdue
  • had a recent delivery or abortion
  • unexpected vaginal bleeding.

It is important to perform a pregnancy test and exclude an ectopic pregnancy, which needs urgent referral to a gynaecologist.

The term PID refers to infections of the female upper genital tract – uterus, fallopian tubes, ovaries or pelvic cavity. It can be caused by gonorrhoea, chlamydia or anaerobic bacteria, or a variety of bacteria commonly found in the vagina, such as the different bacteria that can cause bacterial vaginosis, especially post-instrumentation.

Symptoms include constant pain in the lower abdomen that worsens with movement such as running or going up and down stairs, or pain with intercourse (deep dyspareunia). There can be fever or raised temperature, malaise, irregular or heavy periods, or pain can start after a recent period.

Signs on pelvic examination include a cervical discharge and/or vaginal discharge, cervical excitation (pain on rocking the cervix), tenderness, heat or swelling in the fornices. Abdominal examination can show tenderness in the iliac fossae, guarding or rebound tenderness.

Clinical examination, investigations and specimen collection

If the patient has a temperature (>38 °C), rebound tenderness, guarding, pain during examination and/or vaginal discharge, consider PID in the differential diagnosis of an acute abdomen. The following investigations should be performed where PID is considered:

  • Examine the urethra and vulva for redness and discharge.
  • Pass a speculum and visualise the vagina and cervix.
  • On examination any vaginal discharge should be noted as that may indicate an ascending infection.
  • Collect a high vaginal swab using a charcoal swab – smear initially onto a glass slide for microscopy and then insert in a charcoal transport media tube for culture and sensitivity.
  • Test vaginal pH on indicator paper (normal is pH < 4.5). Note if there is a fishy odour.
  • On examination, the cervix should be observed carefully as any purulent discharge is significant.
  • Take one endocervical swab for MC&S – smear initially onto a glass slide for microscopy and then insert in a charcoal transport media tube for culture and sensitivity. This specimen is suitable for culture of gonococci, anaerobes, Mycoplasma spp. and other endogenous flora.
  • Take a second endocervical swab for chlamydia and gonorrhoea NAAT. Note that point-of-care testing for chlamydia and gonorrhoea is not indicated in patients with PID as it will not alter the treatment required.
  • Perform a pelvic examination to check the pelvic area for masses, heat, tenderness, or fullness in the adnexa. An important sign is cervical excitation.
  • Collect first void urine for gonorrhoea and chlamydia NAAT.
  • If the patient has urinary frequency, take a mid-stream specimen for culture and sensitivity.
  • Do a pregnancy test.
  • Pelvic ultrasound may be required.
  • Take a full blood picture and measure erythrocyte sedimentation rate (ESR) as well as C reactive protein.

Immediate treatment

  • Assess disease severity and consider hospitalisation.
  • If PID is considered, treat immediately.
  • Ensure the patient understands that their condition is likely to be the result of an STI and that recent partners may be asymptomatically infected.
  • Undertake contact tracing and treatment of partner(s).
  • Advise return visit in three days to ensure improvement and test of cure.
  • Patients should be advised not to have sex until they have been assessed.
  • In all cases, educate the patient about safe sexual behaviour.