Syndrome

Who

Organisms and Etiology

Symptoms and Signs

NO SYMPTOMS BUT AT RISK

At risk:

• Sexually active males and females < 25 years of age

Most at risk:

• Contact to known case of STD
• Street involved and/or substance use
• Unprotected sex
  new or > 2 partners in past 6 months
• Men who have sex with men (MSM)
• Previous STD

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Herpes simplex virus (HSV)
• Human papillomavirus
• HIV
• Hepatitis A virus especially in MSM
• Hepatitis B virus
• Hepatitis C virus mostly in IDU
• Others

• None

OR

• Subtle

URETHRITIS AND CERVICITIS

At risk:

• Sexually active males and females < 25 years

Most at risk:

• Sexually active and contact to known case of STD
• Street involved substance use
• New or > 2 partners in past 6 months

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Trichomonas vaginalis
• Herpes simplex virus (HSV)
• Others

Cause urethritis but not cervicitis:

• Mycoplasma hominis
• Ureaplasma urealyticum

Males:

• Urethral discharge
• Burning on urination
• Irritation in the distal urethra or meatus
• Unexplained pyuria

Females:

• Genital discharge
• Lower abdominal pain of recent onset
• Intermenstrual bleeding
• Purulent or mucopurulent cervical discharge
• Check for abdominal tenderness

Diagnostic Features

Specimens and Testing

Treatment

Contact Management

If sexual contact occurred < 1 week previously, tests may not yet be positive.

Note: HIV Antibody window period could be as long as 3 months.

• Cervical/urethral swabs OR urine for C. trachomatis

• Cervical/urethral swabs for N. gonorrhoeae if "Most at Risk"

• Exam for ulcers/ papules

• Test for HSV if lesions

• HIV testing and counselling

Females:

• Exam for abdominal tenderness
  Pap smear if >1 year since previous one
  pregnancy test if missed period

• If known contact to STD, same treatment as index patient. Otherwise, treat on results of screening.

• Consider immunization against hepatitis B for all "At Risk" and against hepatitis A for men who have sex with men (MSM).

If tests are positive, manage accordingly.

Males:

-> = 4

• Polymorpho- nuclear (PMN) cells per oil immersion field on Gram stain of discharge

Females:

• Signs are best detected during a non-menstrual phase.

• Mucopurulent endocervical discharge in women "Most at Risk" (OR when follow-up is uncertain) may be sufficient for presumptive treatment.

Males:

Urethral swabs for:

• Gram stain, culture for N. gonorrhoeae, test for C. trachomatis.

Alternative for C. trachomatis: urine PCR.

Females:

Vaginal swab for:

• pH test, amine odour whiff test, wet mount, Gram stain.

Endocervical swab for:

• Gram stain, culture for N. gonorrhoeae, test for C. trachomatis.

Alternative for C. trachomatis: urine PCR.

Males:

>= 9 years:

• Cefixime 400 mg orally in a single dose PLUS azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally bid for 7 days.

Males under 9 years

(cervicitis does not occur in prepubertal girls):

• Cefixime 8 mg/kg orally in a single dose (max. 400 mg) PLUS azithromycin 10-15 mg/kg orally in a single dose (max. 1 g).

Treat all partners who have had sexual contact with the index case within at least 60 days prior to the onset of symptoms with:

• Cefixime 400 mg PLUS azithromycin 1 g in single doses.

• Patients and contacts should abstain from unprotected sex until 7 days after treatment of both partners is complete.