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Canadian Guidelines on Sexually Transmitted Infections

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Section 4 - Management and Treatment of Specific Syndromes

Syndromic Management of Sexually Transmitted Infections

Syndromic Approach

Diagnosis of a syndrome according to standard criteria predicts the likelihood that a specific pathogen or pathogens is/are present and thus facilitates initiation of appropriate empiric treatment at the first visit rather than deferring treatment until there is microbiological confirmation. In the context of variable access to laboratory testing and variable rates of follow-up, the syndromic approach takes on greater relevance in controlling transmission and negative sequelae. See Table 1, below, for the management of sexually transmitted infection (STI) syndromes.

While the syndromic approach is an important tool in the control of STIs and their sequelae, management by syndrome alone is inadequate because infections with important pathogens such as Chlamydia trachomatis and Neisseria gonorrhoeae may be present without any symptoms or findings. Although an infection may be suspected because of disease in a partner or the presence of another STI, the infection may be diagnosed only by using a specific laboratory test. Thus, in managing STIs, diagnosis by syndrome and laboratory diagnosis by testing for specific organisms are both important and complementary. Consult the chapters of the Management and Treatment of Specific Infections section for details on the diagnosis, treatment and management of specific infections.

Table 1. Syndromic approach to the management of sexually transmitted infections
(Patients may present with more than one STI; this table provides an outline of investigations and relevant chapters where more in-depth information can be found. In many cases, screening for other STIs should be carried out.)
Syndrome Signs and symptoms Etiology Specimens and testing Microscopy results and clinical findings Next steps/
special
considerations
ASCUS
atypical squamous cells of undetermined significance
bHCG
beta human chorionic gonadotropin
DFA
direct fluorescent antibody
EIA
enzyme immunoassay
FTA-ABS
fluorescent treponemal antibody absorbed
HPF
high-power field
HSV
herpes simplex virus
IDU
injection drug use
LGV
lymphogranuloma venereum
LSIL
low-grade squamous intraepithelial lesion
MHA-TP
microhemagglutination-Treponema pallidum
MSM
men who have sex with men
NAAT
nucleic acid amplification test
PMN
polymorphonuclear leukocytes
STI
sexually transmitted infection
VDRL
Venereal Disease Research Laboratory

Asymptomatic and at Risk for STIs

(see Primary Care and Sexually Transmitted Infections chapter)

None

Neisseria gonorrhoeae

Chlamydia trachomatis

Treponema pallidum

Herpes simplex virus type 1 or 2

Human

papillomavirus

HIV

Viral hepatitis

First-catch urine

Urethral swab

Cervical swab

for:

C. trachomatis

N. gonorrhoeae

Serology for:

Syphilis

HIV

Hepatitis A (particularly with oral-anal contact)

Hepatitis B (if no history of vaccine)

Hepatitis C (particularly in IDU)

Pap testing if indicated (as per local or provincial/territorial recommendations)

An abnormal Pap test result (e.g., ASCUS, LSIL) is not diagnostic of HPV

If testing is done by methods other than NAAT and sexual contact occurred < 48 hours prior to testing, tests may be falsely negative

Window period for detection of early syphilis is 2-6 weeks depending on the screening test used

Typical window period for HIV is 3 months

If non-immune for hepatitis A and B, consider immunization

For chronic viral hepatitis, consult a colleague experienced in this area

Follow up as per recommendations of province/territory

Urethritis

Urethral discharge

Burning on urination

Irritation in the distal urethra or meatus

Meatal erythema

Possible causes:

N. gonorrhoeae

C. trachomatis

Trichomonas vaginalis

Herpes simplex virus

Mycoplasma genitalium

Ureaplasma urealyticum

Urethral swab for Gram stain and culture for gonorrhea (NAAT may also be used where available)

AND

First-catch urine for C. trachomatis (NAAT)

Presence of ≥5 PMNs per HPF and absence of Gram-negative diplococci (likely Non-Gonococcal Urethritis)

Presence of ≥5 PMNs per HPF AND Gram-negative intracellular or extracellular diplococci OR Gram-negative intracellular diplococci alone.

Presence of Gram-negative extracellular diplococci alone requires further testing.

Where microscopy results are not immediately available

See urethritis treatment flow chart in Urethritis chapter for treatment and management recommendations

See Gonococcal Infections chapter for treatment recommendations

See Table 5 in Gonococcal Infections chapter

Treat for N. gonorrhoeae and C. trachomatis if partner is infected with gonorrhea or if follow-up is not assured.

OR

Treat for C. trachomatis and consider treating for N. gonorrhoeae if local prevalence is high or sexual contact occurred in a region with high prevalence.

If patient treated for gonorrhea and chlamydia and symptoms persist consider other causes or resistance in the case of gonorrhea (see Gonococcal Infections chapter)

Cervicitis
(females)

Mucopurulent cervical discharge

Cervical friability

Vaginal discharge

Strawberry cervix

Possible causes:

N. gonorrhoeae

C. trachomatis

Trichomonas vaginalis

HSV

Cervical swab for Gram-stain, N. gonorrhoeae culture and

C. trachomatis

(NAAT or culture)

Swab of cervical lesions for HSV

Vaginal swab for wet mount

On Gram-stain presence of ≥20 PMNs per HPF with mucopurulent discharge and/or cervical friability

Trichomonads

Where microscopy results are not immediately available

See Chlamydial Infections chapter for treatment recommendations unless gonorrhea is suspected; then, see Gonococcal Infections chapter

Note: Although not a sensitive test, Gram stain may be helpful in diagnosing mucopurulent cervicitis and gonorrhea in symptomatic females

If HSV is suspected or detected see Genital Herpes simplex Virus Infections chapter for treatment recommendations.

See Vaginal Discharge chapter for treatment recommendations

Treat for N. gonorrhoeae and C. trachomatis if partner is infected with gonorrhea or if follow-up is not assured

OR

Treat for C. trachomatis and consider treating for N. gonorrhoeae if local prevalence is high or sexual contact occurred in a region with high prevalence

Genital Ulcer Disease

Ulcers (erosive or pustular)

Vesicles

Papules

Inguinal lymphadeno-

pathy

Most common:

Herpes simplex virus 1 or 2

T. pallidum

C. trachomatis (LGV serovars L1, L2 or L3)

Haemophilus ducreyi

Klebsiella granulomatis

Routine:

Swab of lesion for culture (herpes)

Swab of serous fluid from lesion for dark-field microscopy or DFA for syphilis. Check with laboratory re: availability

and

Syphilis serology should include a non-treponemal test (e.g., [RPR], [VDRL]) or treponemal-specific enzyme immunoassay (EIA)

Non-routine:

If indicated through patient history (MSM, travel)

Swab of lesion for C. trachomatis for culture or NAAT or consider serology for C. trachomatis. (not specific to LGV serovars)

Consider testing for chancroid and granuloma inguinale (link to travel); consult laboratory for availability

Herpes

Painful lesions

Grouped vesicles

Erythematous base

Fever and malaise

Syphilis

Non-painful lesions

Indurated with serous exudate

Single lesion in over 70% of cases

If initial C. trachomatis testing is positive, serovar-specific testing is required to confirm a diagnosis of LGV. See Lymphogranuloma Venereum chapter

Consider genital herpes

and empiric treatment for either primary or suspected recurrent infection (see Genital Herpes Simplex Virus Infections chapter for treatment recommendations)

Consider primary syphilis

If the initial serologic testing is negative and syphilis is suspected, serological testing should be repeated in 2-4 weeks

Empiric treatment should be considered if follow-up is uncertain)

If LGV is suspected, treat empirically according to the recommendations in Lymphogranuloma Venereum chapter

See Genital Ulcer Disease chapter for treatment recommendations

Epididymitis

Unilateral testicular pain/swelling

May have erythema and edema of the overlying skin

With or without urethral discharge

Fever

Most common (varies with age):

C. trachomatis

N. gonorrhoeae

Coliforms

Pseudomonads

First-catch urine for NAAT

(C. trachomatis); may be used for gonorrhea where available

Urethral swab for Gram stain and gonorrhea culture

and

Midstream urine for culture and sensitivity (enteric organisms, coliforms)

Doppler ultrasound if testicular torsion is suspected

Palpable swelling of the epididymis

Gram stain:

Presence of ≥5 PMNs per HPF

and/or

Gram-negative intracellular diplococci

Gram stain:

Absence of PMNs and Gram-negative intracellular diplococci

For empiric treatment recommendations, see Epididymitis chapter

See Epididymitis chapter for treatment recommendations for epididymitis likely caused by chlamydial or gonococcal infections

See Epididymitis chapter for treatment of organisms other than chlamydia or gonorrhea

See Epididymitis chapter for treatment of organisms other than chlamydia or gonorrhea

If symptoms are of rapid onset, testicular torsion needs to be considered, as this is a surgical emergency

Pelvic Inflammatory Disease

Lower abdominal pain

Deep dyspareunia

Abnormal bleeding

Fever

C. trachomatis

N. gonorrhoeae

Genital-tract mycoplasms

Other aerobic or anaerobic bacterial species

Cervical swab for Gram stain and gonorrhea culture

Cervical swab for C. trachomatis (NAAT or culture)

Vaginal swab for culture, Gram stain, PH test, whiff test and wet mount

Urine ± serum bHCG to rule out ectopic pregnancy

Other serological tests:

ESR

C-reactive protein

On bimanual exam:

Cervical motion tenderness

Adenexal tenderness

Adenexal masses

Other findings:

RUQ pain

Cervicitis

Fever

For empiric treatment recommendations and definitive diagnostic criteria, see Pelvic Inflammatory Disease chapter

Ensure treatment is appropriate to results of clinical findings and Gram stain, wet mount, PH test and whiff test, see Pelvic Inflammatory Disease chapter

Vaginal Discharge

and Low Risk for STIs (for risk factors) see Primary Care and Sexually Transmitted Infections chapter)

Vaginal discharge

Vaginal odour

Vaginal/vulvar pruritus

Vaginal/vulvar erythema

Dysuria

Most common:

Bacterial vaginosis

Vulvovaginal candidiasis

Trichomoniasis

Vaginal swab for pH test and Gram stain

Vaginal swab for wet mount/amine odour

On examination:

Watery white/grey copious discharge

On microscopy:

Predominance of Gram- negative curved bacilli and coccobacilli and presence of clue cells, vaginal pH ›4.5, whiff test positive

On examination:

Clumpy white, curdy discharge

On microscopy:

Budding yeast, pseudohyphea and, if able to test, vaginal pH <4.5,whiff test negative

On examination:

Frothy white or yellow discharge

On microscopy:

Motile flagellated protozoa

(trichomonads) and, if able to test, vaginal pH >4.5, whiff test negative

Treat for bacterial vaginosis.

See Vaginal Discharge chapter for recommendations

Treat for candidiasis.

See Vaginal Discharge chapter for recommendations

Treat for trichomoniasis.

See Vaginal Discharge chapter for recommendations.

Treat sexual partner(s)

For low-risk individuals where no testing/ microscopy is available or follow-up is not assured, treat according to clinical picture

Vaginal Discharge

and High Risk for STIs (for risk factors see Primary Care and Sexually Transmitted Infections chapter)

Vaginal discharge

Vaginal odour

Vaginal/vulvar pruritus

Vaginal/vulvar erythema

Dysuria

Most common:

Bacterial vaginosis

Vulvovaginal candidiasis

Trichomoniasis

As above, plus

cervical swab for gonorrhea culture

Cervical swab for C. trachomatis (NAAT or culture)

For women without a cervix, see Gonococcal Infections and Chlamydial Infections chapters for specimen-collection recommendations

As above

As above

For high-risk individuals where no testing/microscopy is available or follow-up is not assured, treat for bacterial vaginosis, Vulvovaginal candidiasis, trichomonas, chlamydia and consider treating for N. gonorrhoeae if local prevalence is high or sexual contact occurred in a region with high prevalence.

Intestinal and Enteric Syndromes:

Proctitis

Proctocolitis

Enteritis

Varies according to specific syndrome:

Mucopurulent rectal discharge

Anorectal pain

Constipation

Bloody stools

Diarrhea

Nausea

Abdominal pain/cramps

Bloating

Fever

Varies according to specific syndrome:

N. gonorrhoeae

C. trachomatis (LGV and non-LGV serovars)

T. pallidum

Herpes simplex virus

Entamoeba histolytica

Campylobacter spp.

Salmonella spp.

Shigella spp.

Giardia lamblia

Specimen collection should be adapted to clinical presentation and patient history

By anoscopic exam routinely obtain:

Rectal swab for gonorrhea culture and chlamydia culture or NAAT (NAAT is not approved for rectal specimens at this time)

If lesions are present:

Syphilis serology

Swab for herpes culture

Stool for culture and ova and parasites

On examination:

Mucopurulent and/or bloody rectal discharge

If the initial test for chlamydia is positive:

send for LGV serovar testing; see Lymphogranuloma Venereum chapter

On examination:

Anal lesion

History and symptoms suggestive of enteric pathogens

Treat for gonorrhea and chlamydia as per the recommendations in the Sexually Transmitted Intestinal and Enteric Infections chapter

If LGV is suspected, treat empirically as per the Lymphogranuloma Venereum chapter

If syphilis is suspected and follow-up is not assured, treat empirically as per the recommendations in the Syphilis chapter

If HSV is suspected, see Genital Herpes Simplex Virus Infections chapter to determine whether treatment is warranted

See Sexually Transmitted Intestinal and Enteric Infections chapter for treatment recommendations for the possible causative organisms

Papular Anal/Genital Lesions

Growths in anal/genital region or on mucous membranes

Multiple and or polymorphic

Asymmetrical

Non-inflammatory

May be accompanied by:

Pruritus

Bleeding/

obstruction, depending on location (i.e., urethra or vagina)

Human papillomavirus

Molluscum contagiosum

Skin tags

Carcinoma

Normal variations

Visual examination and anal and/or vaginal exam as required by history/findings

Pap testing if indicated as per local or provincial/territorial recommendations

Multiple or single cauliflower-like lesions (condyloma accuminata)

External lesions

Internal lesions:
anal/vaginal or cervical

Flat asymmetric lesions (condyloma lata)

Round, flat, umbilicated papule (Molluscum contagiosum)

Symmetrical papular genital lesions

Coronal sulcus (pearly penile papules)

Vestibular papillae

(micropapillomatis labialis)

Chronic lesion, ulceration or irregular pigmentation (may be indicative of cancerous lesion)

Treat as per the recommendations in the Genital Human Papillomavirus Infections chapter

Refer to a specialist for consultation and treatment

Sign of secondary syphilis; see Syphilis chapter for treatment recommendations

May heal spontaneously with or without treatment. Can be treated with liquid nitrogen

Normal findings; no need for treatment

Refer to a specialist for consultation and treatment

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