1. SYNDROMIC MANAGEMENT OF STD’s
SWETHA SARAVANAN

2. ADVANTAGES
• No need for a specialist
• Simple, Inexpensive
• No need for a specific investigation
• Effective against mixed infection
• Instant management
• Free from errors of clinical judgement

3. DISADVANTAGES
• Not a scientific procedure
• Drug wastage
• Statistical reports on specific STDs cannot be produced
• Promotes antibiotic resistance

4. CRITICISMS
• Too simple for a physician
• Does not use clinical skills / experience
• Simple lab tests should be included

5. STI ASSOCIATED SYNDROMES
Urethral discharge
Scrotal swelling
Inguinal bubo
Genital ulcer disease

6. Cont.
Vaginal discharge
Lower abdominal pain
Oral and anal STI

7. URETHRAL DISCHARGE IN
MALES
 Gonorrhoea
 C. trachomatis D to K
 Trichomonas vaginalis

8. HISTORY
Urethral discharge
 Pain / burning micturation
 Inc. in frequency of urination
 Oro-genital sex

9. EXAMINATION
Redness & swelling
– urethral meatus
 Urethral Discharge
– milk the penis

10. TREATMENT
 Treat both C & G
 Uncomplicated C + G
 T. Cefixime 400mg single dose +
 T. Azithromycin 1g single dose (supervised)
 T. Erythromycin 500mg QID 7D
(allergy to Azithromycin)

11.  If symptoms persist or recur
T. Secnidazole 2gm single dose ( for T.
vaginalis)
 Not resolving – prompt referral

12. PARTNER MANAGEMNET
Treat all recent partners
 Treat similarly for G/C
R/O pregnancy & allergy
sexual abstinence / use of condom
Follow up – in a week’s time

13. FOLLOW UP after 7 days
 Reports of HIV, syphilis & Hepatitis B
 Persisting symptoms - failure or re-infection
 For prompt referral

14. TREATMENT OF PREGNANT
PATNER
 Per speculum / per vaginal examination
 Treat for G/C
 Gonococcal – Cephalophorins – safe & effective
 T. Cefixime 400mg single dose (or)
 Inj. Ceftriaxone 125mg IM +
T. Erythromycin 500mg QID X 7D

15. CONT..
 Chlamydial – C. Amoxicillin 500mg TDS X 7D
 Quinolones & Doxcyclin - Contraindicated

16. SCROTAL SWELLING
• N. gonorrhoeae
• C. trachomatis D to K

17. HISTORY
 Scrotal swelling & pain
 Pain or burning micturation
 Malaise, fever
 Oro-genital sex

18. EXAMINATION
Scrotal swelling
Redness and edema of skin
Tenderness – epididymis & V. deferens
Discharge, ulcer, inguinal nodes
Trans-illumination test

19. DIFFERENTIAL DIGNOSIS
Scrotal swelling – Infectious causes
TB, filariasis, coliforms, pseudomonas, mumps
Non infectious causes
Trauma, hernia, hydrocoele, T. torsion/ tumour

20. Treat for G/C
 T. Cefixime 400mg single dose X 7 Days +
C. Doxycycline 100mg BD X 14 Days
 Long term parental : complicated G. infection
 Delay in treatment : scarring / sub-fertility

21. TREATMENT OF PREGNANT
PARTNER
Doxycycline &
Erythromycin esolate (hepatotoxic)
Contraindicated
 Erythromycin base
(or) erythromycin ethyl succinate
(or) amoxicillin can be used

22. INGUINAL BUBO
• Chancroid- Haemophilus ducreyi
• LGV - C. trachomatis (L1,L2,L3)

23. HISTORY
Inguinal swelling (painful)
Preceding ulcer / discharge
Malaise, fever
Oro-genital sex

24. EXAMINATION
 Enlarged inguinal nodes – tender / fluctuant
 Redness and edema of skin
Multiple sinuses
Odema – genital & lower limb
Genital ulcer / discharge

25. DIFFERENTIAL DIAGNOSIS
TB, Filariasis
Acute infection – pubic area, genitals, buttocks,
anus, lower limb
Suspected malignancy (or) TB - biopsy

26. TREATMENT
LGV C. Doxycycline 100mg BD X 21 days
+
Chancroid T. Azithromycin single dose (or)
T. Ciprofloxacin 500mg BD X 3 days

27. CONT..
 Never incise a bubo – fistula
 Surgical intervention – severe vulval edema

28. PARTNER MANAGEMENT
 Treat all recent partners
 Treat similarly for LGV & chancroid
 Sexual abstinence / Use of condom
 Follow up – in a week’s time

29. TREATMENT OF PREGNANT
PATNER
 Doxycycline, Quinolones, sulfonamides
Erythromycin esolate (hepatotoxic) Contraindicated
 Erythromycin base 500mg QID x 21D (or)
Erythromycin ethyl succinate can be used

30. GENITAL ULCERS
 Granuloma inguinale (K. granulomatis)
 Chancroid (Haemphilus ducreyi)
 Genital Herpes (Herpes simplex)
 Syphilis (Treponema pallidum)

31. HISTORY
 Genital ulcer / vesicles
 Burning sensation
 Oro-genital sex

32. EXAMINATION
• Painless ulcer + shotty lymph node – Syphilis
• Painful ulcer (single/ multiple) ± painful bubo –
Chancroid
• Painful vesicle / ulcer – Herpes simplex
• Painless ulcer, No lymph node – G.I

33. Syphilitic ulcer
Chancroid –kissing ulcer

34. Herpes – polycyclic
superficial ulcer
Herpes –
Vesicular stage

35. TREATMENT
 Herpes T. Acyclovir 400mg TDS x 7D
 Syphilis
Inj Benzathine penicillin 2.4 million IU IM in two
divided dose (or)
Doxycycline 100mg BD x 14D
+
T. Azithromycin 1g single dose (or)
T. Ciprofloxacin 500mg BD x 3D
(to cover Chancroid)

36. PARTNER MANAGEMENT
 Treat all recent partner (with in 3 months)
 Sexual abstinence / use of condom
 Testing for HIV, Hepatitis B
 Follow up – in a week’s time

37. TREATMENT OF PREGNANT
PARTNER
Contraindicated
1. Doxycycline, Quinolones
2. Erythromycin esolate (hepatotoxic)
3. Sulfonamides
RPR +ve patients - should be considered
infected
(unless adequate treatment is documented &
antibody titers have declined)

38. CONT..
 Syphilis (primary, secondary or early latent) –
Inj Benzathine penicillin 2.4million IU IM
+ 2nd dose after 1 week
 Penicillin allergy - Erythromycin 500mg QID x 15D
(Erythromycin base or erythromcin ethyl succinate)
 Neonates should be treated for syphilis after delivery

39. CONT..
 Genital herpetic lesions at the onset of labour –
caesarean section to prevent neonatal herpes
 Genital Herpes (first episode or recurrent) with no active
lesions - oral Acyclovir

40. VAGINAL DISCHARGE
• N. gonorrhoea
• C. trachomatis D to K
• T. vaginalis
• Herpes simplex
• Candida albicans
• Gardenerella vaginalis
• Mycoplasma

41. Vaginitis
Chalamydial cervicitis
Gonococcal cervicitis

42. HISTORY
 Menstrual history
 Nature & type of discharge - (amount, smell, consistency)
 Genital itching, Burning micturation, frequency
 Ulcer / swelling, Low backpain

43. EXAMINATION
Discharge in vaginitis
 Trichomoniasis – greenish frothy
 Candidiasis – curdy white
 Bacterial vaginosis – adherent discharge
 Mixed infection – atypical discharge

44.  Cervicitis
 Erosion, ulcer, mucopurulent discharge
 Bimanual pelvic examination to R/O PID
 If speculum examination is not possible
 – treat for both vaginitis and cervicitis

45. PER SPECULUM EXAMINATION
Bacterial
vaginosis
Cervicitis
Vulvovaginitis
- Candidiasis

46. INVESTIGATION
 T. vaginalis - Wet mount microscopy
 C. albicans – 10% KOH
 B. Vaginosis – gram stain – clue cells
 N. gonorrhoeae – gram stain – gonococci
 Whiff test

47. INVESTIGATION
Normal cells
Gram –ve
Intracellular
diplococci
Clue cells –
saline prep
Clue cells –
Gram stain

48.  Vaginitis (TV + BV + Candida)
T. Secnidazole 2g single dose (or)
T. Tinidazole 500mg BD 5D
T. Metoclopropramide 30mts before T. secnidazole to
prevent GI
 Candidiasis
T. Fluconazole 150mg single dose (or)
Clotrimazole 500mg pessaries once

49. Cervicitis (chlamydia + gonorrhoea)
 T. Cefixime 400mg single dose +
T. Azithromycin 1g 1 hour before lunch
 If vomiting < 1 hour – anti emetic & repeat
 Avoid douching
 Recurrent infection – consider pregnancy, diabetes & HIV
 Follow up after a week

50. MANAGEMENT IN PREGNANT
WOMAN
 Per speculum examination
R/O complications like abortion & premature rupture
 Vaginitis (TV + BV + Candida)
1st trimester
 Candidiasis - Clotrimazole pessary/cream
(Flucanozole is contraindicated)
 TV or BV – metronidazole pessary/cream

51. PARTNER MANAGEMENT
 Treat current partner if no improvement after initial
treatment
 Treat using same protocol , if partner is symptomatic
 Sexual abstinence / use of condom
 Follow up – in a week’s time

52. PELVIC INFLAMMATORY
DISEASE
Causative organisms
 N. gonorrhoeae
 C. trachomatis
 Mycoplasma, gardnerella, anaerobic bacteria
(Bacteroides sp.gram +ve cocci)

53. HISTORY
 Lower abdomen pain, Fever
 Vaginal discharge, Menstrual irregularities
 Dysmenorrhoea, Dyspareunia
 Low backache, IUD

54. EXAMINATION
 G/E – pulse, BP, Temp
 Per speculum – vaginal / cervical
discharge, congestion or ulcer
 Lower abdominal tenderness / guarding

55. INVESTIGATION
 CBC, ESR
 Urine microscopy – pus cells
 Gram stain – gonorrhoea
 Wet smear examination

56. DIFFERENTIAL DIAGNOSIS
 Ectopic pregnancy
 Twisted ovarian cyst
 Ovarian tumour
 Appendicitis
 Abdominal TB

57. MILD / MODERATE PID
 Cover C / G & anaerobes
 T. Cefixime 400mg BD x 7D +
T. Metronidazole 400mg BD x 14D +
T. Doxycycline 100mg BD x 14D
 T. Ibubrufen + T. Ranitidine
 Remove IUD under antibiotic cover
 Abstinence , use of condom

58. SEVERE PID- HOSPITALIZATION
 Uncertain diagnosis
 Surgical emergencies
– appendicitis or ectopic pregnancy
 Suspected pelvic abscess
 Intolerance to OP treatment
 Fail to respond to OP treatment

59. Partner management
 Treat recent partner (< 2 months)
 Treat urethral discharge (G/C)
 Sexual abstinence / use of condom
 Testing for HIV, Syphilis & Hep B
 Follow up

60.  Parental regimen is safe
 Doxycycline is contraindicated
 Metronidazole is not recommended during first
3 months
(Do not withhold for severely acute PID)

61. ORAL & ANAL STI
Causative Organism
 N. gonorrhoea
 C. trachomatis
 T. pallidum
 H. ducreyi
 K. granulomatis
 H. simplex

62. HISTORY
 Unprotected oral sex with pharyngitis
 Unprotected anal sex with
anal discharge/ tenesmus, diarrhoea, blood in
stool, abdominal cramping, nausea, bloating,
rectal pus

63. EXAMINATION
 Oral ulcers, pharyngitis
 Genital or anorectal ulcer
 Vesicles
 Rectal pus
 Proctoscopy

64. Oral candidiasis
Condylomata lata
- sec syphilis
Split Papules
- sec syphilis

65. INVESTIGATION
 Syphilis
– RPR / VDRL
 Gonorrhoea (gram stain)
gram –ve intracellular diplococci

66. THANK YOU