**3. Syndromic management**

The diagnosis and management of STIs in the tropics has a dual nature. Sophisticated testing equipment and facilities comparable to those available in developed nations can often be found in large urban centers and popular resort destinations in developing countries. However, in many parts of the developing world, the absence of etiologic diagnostic capacity due to constraints imposed by cost, lack of equipment or trained personnel, and time management has forced health care providers to rely on a syndromebased approach to STI management. This approach employs clinical algorithms based on an STI syndrome to determine antimicrobial therapy. The following sections discuss management of the most common clinical syndromes encountered in STIs. Sexual partners of the index patient should also be examined for STIs and promptly treated for the same condition as treatment failures are common when partners are not treated. Often, treatment regimens to cover multiple infectious agents are recommended due to the difficulty in distinguishing between the overlapping clinical presentations of different STIs, the high prevalence of mixed infections in many areas, and to ensure adequate therapy in the case of loss to follow-up. Syndromic management enables many STIs to be treated and resolved at local clinics which may lack all but the most rudimentary laboratory capabilities. However, patients that do not respond to therapy or those that show systemic signs indicative of other disease conditions warrant referral to a clinic with more comprehensive facilities.

#### **3.1 Urethral discharge in men**

*Neisseria gonorrhoeae* and *Chlamydia trachomatis* are the major STI pathogens causing urethral discharge. In the syndromic management scheme, treatment of men with urethral discharge should cover both of these organisms. Treatment regimens may be found in the specific sections describing these STIs. Single-dose therapies are preferred. Whenever possible microscopic examination of the urethral smear should be performed; the appearance of more than 5 polymorphonuclear leukocytes per high power field (x1000) is indicative of urethritis. A Gram stain could also demonstrate the presence of gonococci and permit specific treatment. Patients should return in 7 days if symptoms persist. Treatment failure may be due to drug resistance necessitating use of one of the alternative drugs for these STI agents. Patients indicating poor compliance with therapy or the possibility of re-infection can be re-treated with the same drug regimen. *Trichomonas vaginalis* can also be a cause of urethritis in men. In areas of high local *T. vaginalis* prevalence, treatment for this organism should also be given at this time. If symptoms still persist, the patient should be referred to a facility possessing the resources for a more extensive workup.

Sexually Transmitted Infections in the Tropics 461

Inguinal buboes are frequently associated with LGV and chancroid. If genital ulcers accompany the buboes, patients should be managed using the genital ulcer syndromic management approach. Inguinal buboes not accompanied by genital ulcer presentation should be treated with a regimen effective against LGV and chancroid. The recommended syndromic treatment is ciprofloxacin, 500 mg orally twice daily for 3 days plus doxycycline, 100 mg orally twice daily for 14 days, or erythromycin, 500 mg orally four times daily for 14 days. Some cases may require longer treatment than 14 days if the buboes are not resolved. Fluctuant lymph nodes can be aspirated through healthy skin. Incision and drainage or

There are multiple infectious causes for epididymitis as well as non-infectious causes such as trauma, testicular torsion, and tumor. Patients with testis that are rotated or elevated or with a history of trauma should be referred for surgical option. An STI is more likely the cause for men under 35 years of age than for older men. An epididymitis which is accompanied by urethral discharge should be treated with drugs for both gonococcal and

An abnormal vaginal discharge in terms of quantity, color, or odor most commonly results from vaginal infection. *Trichomonas vaginalis* is the most common STI cause of vaginal infection, though bacterial vaginosis (BV) and yeast infections also produce vaginal discharge. All women presenting with vaginal discharge should be treated for trichomoniasis and BV, in the absence of specific diagnosis, with metronidazole, 400-500 mg orally twice daily for 7 days. Metronidazole is not recommended in the first trimester of pregnancy. Pregnant women should be treated with metronidazole, 200-250 mg orally 3 times daily for 7 days. In rare cases, vaginal discharge may result from a mucopurulent cervicitis due to infection with *N*. *gonorrhoeae* or *C*. *trachomatis*. Treatment for cervical infection in women presenting with vaginal discharge is dependent on the local prevalence of these STIs. Women in high risk areas for *N*. *gonorrhoeae* or *C*. *trachomatis* with vaginal discharge and evidence of cervicitis should be offered treatment for these STIs in addition to

There are multiple causes of lower abdominal pain in sexually active women in addition to pelvic inflammatory disease (PID) caused by STIs. Women presenting with lower abdominal pain and a missed or overdue period, pregnant, recent delivery, abortion, or miscarriage, abdominal guarding and/or tenderness, abnormal vaginal bleeding, or abdominal mass, should be referred for surgical or gynecological assessment. In the absence of these signs women with lower abdominal pain accompanied by cervical excitation tenderness or lower abdominal tenderness and vaginal discharge should be managed for PID. The etiologic agents for PID include *N*. *gonorrhoeae*, *C*. *trachomatis*, *T. vaginalis*, anaerobic and facultative bacteria, and perhaps *Mycoplasma*. When diagnostic capacity to distinguish these agents is absent the treatment regimen must be effective against all these

**3.3 Inguinal bubo** 

**3.4 Scrotal swelling** 

chlamydial infection.

**3.5 Vaginal discharge** 

excision of nodes may delay healing.

treatment for BV and trichomoniasis.

**3.6 Lower abdominal pain** 

#### **3.2 Genital ulcers**

Five STIs typically produce genital ulcers; herpes, syphilis, chancroid, lymphogranuloma venereum (LGV), and granuloma inguinale or donovanosis (Table 2). Physical examination should focus on the characteristics of the lesion(s): single or multiple, painless or painful, indurated or soft, irregular or regular borders, and how they began, as a papule or a vesicle. The examination should also determine the time since exposure, the presence or absence of lymphadenopathy, and the presence of systemic symptoms which may indicate another etiology. Syphilis ulcers are painless, indurated, sharply demarcated with a red, smooth base. When present, inguinal adenopathy is firm, rubbery, nontender and usually bilateral. Herpes ulcers begin as multiple grouped vesicles on a red base which forms shallow ulcers that may coalesce. Herpes inguinal adenopathy is bilateral, firm, and tender when present. Chancroid ulcers are shallow and often multiple with irregular shape, sharply demarcated borders, and undermined edges. Chancroid inguinal adenopathy is typically unilateral, fixed, and tender, with overlying erythema and may supperate. Granuloma inguinale ulcers are shallow sharply demarcated lesions with a beefy red friable base and usually without inguinal adenopathy. LGV ulcers are usually a single lesion, transient, and frequently not noticed. Inguinal adenopathy in LGV is usually unilateral, firm, tender, fixed, and may supperate or form fistulas. When genital ulcers present as vesicles only, syndromic management recommends treatment for both herpes infection and for syphilis if the patient has a positive RPR syphilis test, or has not received recent syphilis treatment. Patients with ulcers and no vesicles should be treated for syphilis plus either chancroid, granuloma inguinale, or lymphogranuloma venereum dependent on clinical presentation and local prevalence of these agents. In areas where herpes prevalence exceeds 30%, patients with ulcers should also be treated for herpes. Patients whose ulcers do not respond to both initial treatment and follow-up therapy should be referred for more extensive diagnostic testing.


Table 2. Characteristics of Genital Ulcers

#### **3.3 Inguinal bubo**

460 Current Topics in Tropical Medicine

Five STIs typically produce genital ulcers; herpes, syphilis, chancroid, lymphogranuloma venereum (LGV), and granuloma inguinale or donovanosis (Table 2). Physical examination should focus on the characteristics of the lesion(s): single or multiple, painless or painful, indurated or soft, irregular or regular borders, and how they began, as a papule or a vesicle. The examination should also determine the time since exposure, the presence or absence of lymphadenopathy, and the presence of systemic symptoms which may indicate another etiology. Syphilis ulcers are painless, indurated, sharply demarcated with a red, smooth base. When present, inguinal adenopathy is firm, rubbery, nontender and usually bilateral. Herpes ulcers begin as multiple grouped vesicles on a red base which forms shallow ulcers that may coalesce. Herpes inguinal adenopathy is bilateral, firm, and tender when present. Chancroid ulcers are shallow and often multiple with irregular shape, sharply demarcated borders, and undermined edges. Chancroid inguinal adenopathy is typically unilateral, fixed, and tender, with overlying erythema and may supperate. Granuloma inguinale ulcers are shallow sharply demarcated lesions with a beefy red friable base and usually without inguinal adenopathy. LGV ulcers are usually a single lesion, transient, and frequently not noticed. Inguinal adenopathy in LGV is usually unilateral, firm, tender, fixed, and may supperate or form fistulas. When genital ulcers present as vesicles only, syndromic management recommends treatment for both herpes infection and for syphilis if the patient has a positive RPR syphilis test, or has not received recent syphilis treatment. Patients with ulcers and no vesicles should be treated for syphilis plus either chancroid, granuloma inguinale, or lymphogranuloma venereum dependent on clinical presentation and local prevalence of these agents. In areas where herpes prevalence exceeds 30%, patients with ulcers should also be treated for herpes. Patients whose ulcers do not respond to both initial treatment and follow-up therapy

should be referred for more extensive diagnostic testing.

Table 2. Characteristics of Genital Ulcers

**3.2 Genital ulcers** 

Inguinal buboes are frequently associated with LGV and chancroid. If genital ulcers accompany the buboes, patients should be managed using the genital ulcer syndromic management approach. Inguinal buboes not accompanied by genital ulcer presentation should be treated with a regimen effective against LGV and chancroid. The recommended syndromic treatment is ciprofloxacin, 500 mg orally twice daily for 3 days plus doxycycline, 100 mg orally twice daily for 14 days, or erythromycin, 500 mg orally four times daily for 14 days. Some cases may require longer treatment than 14 days if the buboes are not resolved. Fluctuant lymph nodes can be aspirated through healthy skin. Incision and drainage or excision of nodes may delay healing.

#### **3.4 Scrotal swelling**

There are multiple infectious causes for epididymitis as well as non-infectious causes such as trauma, testicular torsion, and tumor. Patients with testis that are rotated or elevated or with a history of trauma should be referred for surgical option. An STI is more likely the cause for men under 35 years of age than for older men. An epididymitis which is accompanied by urethral discharge should be treated with drugs for both gonococcal and chlamydial infection.

#### **3.5 Vaginal discharge**

An abnormal vaginal discharge in terms of quantity, color, or odor most commonly results from vaginal infection. *Trichomonas vaginalis* is the most common STI cause of vaginal infection, though bacterial vaginosis (BV) and yeast infections also produce vaginal discharge. All women presenting with vaginal discharge should be treated for trichomoniasis and BV, in the absence of specific diagnosis, with metronidazole, 400-500 mg orally twice daily for 7 days. Metronidazole is not recommended in the first trimester of pregnancy. Pregnant women should be treated with metronidazole, 200-250 mg orally 3 times daily for 7 days. In rare cases, vaginal discharge may result from a mucopurulent cervicitis due to infection with *N*. *gonorrhoeae* or *C*. *trachomatis*. Treatment for cervical infection in women presenting with vaginal discharge is dependent on the local prevalence of these STIs. Women in high risk areas for *N*. *gonorrhoeae* or *C*. *trachomatis* with vaginal discharge and evidence of cervicitis should be offered treatment for these STIs in addition to treatment for BV and trichomoniasis.

#### **3.6 Lower abdominal pain**

There are multiple causes of lower abdominal pain in sexually active women in addition to pelvic inflammatory disease (PID) caused by STIs. Women presenting with lower abdominal pain and a missed or overdue period, pregnant, recent delivery, abortion, or miscarriage, abdominal guarding and/or tenderness, abnormal vaginal bleeding, or abdominal mass, should be referred for surgical or gynecological assessment. In the absence of these signs women with lower abdominal pain accompanied by cervical excitation tenderness or lower abdominal tenderness and vaginal discharge should be managed for PID. The etiologic agents for PID include *N*. *gonorrhoeae*, *C*. *trachomatis*, *T. vaginalis*, anaerobic and facultative bacteria, and perhaps *Mycoplasma*. When diagnostic capacity to distinguish these agents is absent the treatment regimen must be effective against all these

Sexually Transmitted Infections in the Tropics 463

The actual number of new or existing cases of trichomoniasis is not known with complete surety because trichomoniasis is not a reportable disease and because of the significant number of asymptomatic cases. Trichomoniasis is usually asymptomatic in men, although sometimes it can cause non-gonococcal, non-chlamydial urethritis, epididymitis, and prostatitis. Clinical trichomoniasis in women ranges from asymptomatic carriers to flagrant vaginitis. Women have symptomatic disease more often than men. One third of asymptomatic woman will become symptomatic within 6 months of the onset of infection. Symptoms can include a vaginal discharge, vulvovaginal irritation and itching, painful urination or intercourse, foul odor, and lower abdominal pain. The presence or absence and severity of these symptoms determine whether the infection is classified as acute, chronic, or

Trichomoniasis is associated with a higher risk for other infectious diseases and adverse pregnancy outcomes such as preterm birth, premature rupture of placental membranes, and low birth weight infants. One study has also found an association between *T. vaginalis infection* in pregnancy and mental retardation in children. *Trichomonas vaginalis* infection is associated with pelvic inflammatory disease, especially PID leading to sterility. Trichomoniasis is significantly associated with HSV infection. *Trichomonas vaginalis* infection also increases the risk of human immunodeficiency virus (HIV) acquisition and the Centers for Disease Control and Prevention (CDC) estimates that as much as 20% of HIV transmission in the African American population in the United States may be attributable to *T. vaginalis* infection. *Trichomonas vaginalis* infection also increases the risk of cervical neoplasia and prostate cancer. Exposure to *T. vaginalis* results in a 2-fold increase in the risk of diagnosis of extraprostatic prostate cancer and a 3-fold increase in the risk of cancer that led to cancer-specific death. Thus, although trichomoniasis itself is a curable disease, *T.* 

Because of the high prevalence of trichomoniasis, any woman seeking medical care for vaginal discharge should be tested for *T. vaginalis* infection. Trichomoniasis is traditionally diagnosed microscopically (wet mount) by observing mobile protozoa in vaginal secretions, cervical samples, or from urethral or prostatic swabs. However, this method has a relatively low sensitivity and requires immediate evaluation of a wet preparation slide for optimal results. The low sensitivity of this diagnostic method leads to under-diagnosis. The current gold standard for diagnosis of trichomoniasis is culture in Diamonds media and is widely used. Rapid antigen based point-of-care tests and nucleic acid based diagnostic tools are also available. Both of these techniques have high sensitivity and specificity. Papanicolaou (Pap) smear allows for direct visualization in saline prep and can be performed within 10-20 minutes of sample collection but is not widely used. The Whiff test can be performed by mixing vaginal secretions with 10% potassium hydroxide (KOH) to yield a strong fishy odor. This test has a poor specificity due to the fact that bacterial vaginosis can yield a similar result. All of the above mentioned diagnostic methods are applicable for diagnosis in women. In men, culture testing of urethral swabs, urine, or semen and the nucleic acid

*vaginalis* infection may indirectly be a life threatening disease.

amplification tests are more sensitive diagnostic tools.

**4.2 Clinical manifestations** 

asymptomatic.

**4.4 Diagnosis** 

**4.3 Health sequelae** 

pathogens. The recommended syndromic treatment is a single dose therapy for gonorrhea, plus doxycyline, 100 mg orally twice daily, or tetracycline, 500 mg orally 4 times daily for 14 days, plus metronidazole, 400-500 mg orally twice daily for 14 days. Patients who do not respond to therapy within three days should be referred for a more complete diagnostic evaluation.
