Table 1





 Syphilis Treponema pallidum A. Primary Syphilis

  • Characterized by a single or less often multiple, painless, indurated ulcer (chancre) at the site of inoculation
  • Regional lymph nodes are enlarged, feel rubbery and are painless

B. Secondary Syphilis

  • Characterized by variable mucocutaneous and systemic signs e.g. symmetrical non-itchy rashes, mucous membrane lesions, patchy alopecia, generalised lymphadenopathy

C. Latent SyphilisD. Tertiary Syphilis

 Gonorrhea Neisseria gonorrhoeae
  • Common sites of infection include the urethra, the endocervix, the rectum, the pharynx and the conjunctiva
  • Profuse purulent discharge from the affected genital site
  • Often accompanied by local pain and discomfor
Chlamydia Trachomatis
Non-gonococcal Urethritis (NGU)
Chlamydia trachomatis
Ureaplasma urealyticum
Mycoplasma genitalium
  • May be asymptomatic
  • Urethral discharge, dysuria, penile irritation or none
  • May cause pelvic inflammatory disease, ectopic pregnancy and tubal infertility in women
 Bacterial Vaginosis Prevotella species, Mobiluncus species, Gardnerella vaginalis, Ureaplasma and Mycoplasma hominis
  • May be asymptomatic or
  • A fishy-smelling, thin homogenous vaginal discharge


 Genital herpes Herpes simplex virus type 1 & 2
  • Chronic, life-long viral infection
  • May be asymptomatic or have mild, unrecognised symptoms
  • Presents with multiple grouped vesicles, which rupture easily leaving painful erosions and ulcers
 Molluscum contagiosum Molluscum Contagiosum virus
  • Discrete, smooth, pearly or flesh-coloured, dome-shaped papules with a mildly erythematous base and a central punctum
  • Often confined to the genital area
 Genital warts Human Papilloma Virus
  • Cause genital, papular and flat warts
  • Condyloma acuminata – exophytic, filiform, cauliflower-shaped warts
  • Multifocal – usually 5 to 15, in areas of trauma during sex, 1-10 mm diameter
  • Oncogenic HPV – mostly give rise to subclinical lesions, intraepithelial neoplasia (IN) and anogenital cancer
 Viral Hepatitis Hepatitis A, B and C viruses
  • May be asymptomatic or have mild non-specific symptoms
  • Flu-like symptoms (malaise, myalgia, fatigue), often with right upper abdominal pain
  • Jaundice (hepatic and cholestatic) associated with anorexia, nausea, fatigue, liver enlargement and tenderness
 HIV and AIDs infection Human immunodeficiency virus type 1 & 2 1. Acute seroconversion

  • Fever, flu-like illness, lymphadenopathy, and rash

2. Asymptomatic infection

  • Few or no signs or symptoms for a few years to a decade or more



 Vaginal candidiasis Candida albicans
  • Female patients complain of vulval pruritus and discharge. Non-specific symptoms include soreness, burning, dyspareunia and external dysuria.
  • Male patients may complain of a penile rash


 Trichomoniasis Trichomonas vaginalis
  • May be asymptomatic
  • Present with a purulent foul smelling vaginal discharge that is yellow-green in colour, and vulvar pruritus or irritation
  • The vagina and cervix (strawberry cervix) are often inflamed


 Scabies Sarcoptes scabiei
  • Pruritic papules on the genitals, finger webs, wrists, axillae and buttocks
  • Nocturnal exacerbation of the itch
  • Family members and sexual partners may have similar symptoms
 Pubic lice infestation Pediculosis pubic
  • Presence of brown adult lice on the pubic hair, body hair and rarely, eyebrows and eyelashes
  • Presence of eggs (nits) which adhere to the hairs
  • Small haemorrhagic spots may also be seen on the pubic/genital skin and underwear
  • Blue macules (maculae caeruleae) may be visible at feeding sites
  • May be no symptoms or there may be itch due to hypersensitivity to the feeding lice.


Table 2

Management of Sexually Transmitted Infections

Treatment of STDs / STIs

Here we discuss the management of the most common clinical syndromes caused by sexually transmitted agents.

For all these conditions (except vaginitis) the sexual partner(s) of patients should also be examined for STI and promptly treated for the same condition(s) as the index patient.

Successful management of STI requires that staff are respectful of patients and are not judgmental. Examination is done in appropriate surroundings where privacy can be ensured and confidentiality guaranteed.

Urethral discharge

Male patients complaining of urethral discharge and/or dysuria should be examined for evidence of discharge. If none is seen, the urethra should be gently massaged from the ventral part of the penis towards the meatus.

The major pathogens causing urethral discharge are N. gonorrhoeae and Chlamydia trachomatis (C. trachomatis). In the syndromic management, treatment of a patient with urethral discharge should adequately cover these two organisms. Where reliable laboratory facilities are available, a distinction may be made between the two organisms and specific treatment instituted.

Persistent or recurrent urethral discharge

Persistent or recurrent symptoms of urethritis may be due to drug resistance, poor compliance or re-infection. In some cases there may be infection with Trichomonas vaginalis (TV).

There is new evidence suggesting high prevalence of TV in men with urethral discharge in some geographical settings. Where symptoms persist or recur after adequate treatment for gonorrhoea and chlamydia in index patient and partner(s), the patient should be treated for TV, if the local epidemiological pattern so indicates. If the symptoms still persist at follow up the patient must be referred.

Genital ulcer

The relative prevalence of causative organisms for genital ulcer disease varies considerably in different parts of the world and may change dramatically over time. Clinical differential diagnosis of genital ulcers is inaccurate, particularly in settings where several aetiologies are common. Clinical manifestations and patterns of genital ulcer disease may be further altered in the presence of HIV infection.

After examination to confirm the presence of genital ulceration, treatment appropriate to local aetiologies and antibiotic sensitivity patterns should be given. For example, in areas where both syphilis and chancroid are prevalent, patients with genital ulcers should be treated for both conditions at the time of their initial presentation to ensure adequate therapy in case of loss to follow-up. In areas where granuloma inguinale is also prevalent, treatment for this condition should be included. In areas where granuloma inguinale or lymphogranuloma venereum (LGV) is prevalent, treatment for these conditions should be included. In many parts of the world, genital herpes is the most frequent cause of genital ulcer disease. Where HIV infection is prevalent, an increasing portion of cases of genital ulcer disease is likely to harbour herpes simplex virus. Herpetic ulcers may be atypical and persist for long periods in HIV-infected patients.

Laboratory-assisted differential diagnosis is rarely helpful at the initial visit, as mixed infections are common. In addition, in areas of high syphilis prevalence, a reactive serological test may reflect a previous infection and give a misleading picture of the patient’s present condition.

Genital ulcer and HIV infection

There have been a number of anecdotal reports in the literature suggesting that the natural history of syphilis may be altered as a result of concomitant HIV infection. Some reports have indicated atypical presentations of both primary and secondary syphilis lesions. Some reports have also noted an increase in treatment failure rates among patients with early syphilis who are treated with single-dose therapies of penicillin.

In chancroid atypical lesions have been reported in HIV-infected individuals. The lesions tend to be more extensive, producing multiple lesions that may be accompanied by systemic manifestations such as fever and chills. Reports of rapidly aggressive lesions have been noted by some clinicians. This emphasizes the need for early treatment, especially in HIV-infected individuals.

There is evidence to suggest that HIV infection may increase rates of treatment failure in chancroid, especially when single-dose therapies are given. More research is needed to confirm these observations.

Herpes simplex lesions may present as persistent multiple ulcers that require medical attention, as opposed to self-limiting vesicles and ulcers which occur in immunocompetent individuals. Thus, antiviral treatment may have to be considered therapeutically or prophylactically to offer comfort to the patient. Adequate education needs to be given to the patient to explain the nature and purpose of treatment in order to avoid false expectations of cure.

Genital Ulcer Disease Management

  • Treat for syphilis, and, depending upon local epidemiology, either chancroid, granuloma inguinale or lymphogranuloma venereum
  • Aspirate any fluctuant glands (surgical incision should be avoided)
  • Educate and counsel on risk reduction
  • Offer syphilis serologic testing and HIV serologic testing where appropriate facilities and counselling are available
  • Review if lesion not fully healed

Herpes Simplex Management

  • Advise on basic care of the lesion (keep clean and dry)
  • Educate and counsel on compliance and risk reduction
  • Offer syphilis and HIV serologic testing where appropriate facilities and counselling are available
  • Promote and provide condoms
  • Advise to return in 7 days if lesion is not fully healed, and sooner if there is clinical deterioration; if so, treat for other causes of GUD as per guidelines

Vaginal discharge

A spontaneous complaint of abnormal vaginal discharge is most commonly due to a vaginal infection. Rarely, it may be the result of muco-purulent STI-related cervicitis. T. vaginalis, C. albicans and bacterial vaginosis are the commonest causes of vaginal infection and N. gonorrhoeae and C. trachomatis cause cervical infection. The clinical detection of cervical infection is difficult because a large proportion of women with gonococcal or chlamydia. cervical infection is asymptomatic. The symptom of abnormal vaginal discharge is highly indicative of vaginal infection, but poorly predictive for cervical infection. Thus, all women presenting with vaginal discharge should receive treatment for trichomoniasis and bacterial vaginosis.

Among women presenting with discharge, one can attempt to identify those with an increased likelihood of being infected with N. gonorrhoeae and/or C. trachomatis. Microscopy adds little to the diagnosis of cervical infection and is not recommended. To identify women at greater risk of cervical infection, an assessment of a woman’s risk status is useful, especially when risk factors are adapted to the local situation.

Knowledge of the prevalence of gonococcal and/or chlamydia in women presenting with vaginal discharge is important for the decision to treat for cervical infection. The higher the prevalence, the stronger the justification for treatment. Risk assessment positive women have a higher likelihood of cervical infection than those who are risk negative. Women with vaginal discharge and a positive risk assessment could therefore, be offered treatment for gonococcal and chlamydia cervicitis.

Where resources permit, one could consider the use of laboratory tests to screen women with vaginal discharge. Such screening could be applied to all women with discharge or selectively to those with discharge and a positive risk assessment.

In some countries, syndromic management algorithms have been used as a screening tool to detect cervical infection among women not presenting with a genital complaint (e.g. in family planning settings). While this may assist in detecting some women with cervical infections, it is likely that there will be substantial over-diagnosis.



Effective prevention and care of STI can be achieved using a combination of responses:

  • promotion of safer sex behaviour
  • condom programming – encompassing a full range of activities from condom promotion to the planning and management of supplies and distribution
  • promotion of health-care-seeking behaviour
  • integration of STI prevention and care into primary health care, reproductive health care facilities, private clinics and others
  • specific services for populations at risk – such as female and male sex workers, adolescents, long-distance truck drivers, military personnel, and prisoners
  • comprehensive case management of STI
  • prevention and care of congenital syphilis and neonatal conjunctivitis
  • early detection of symptomatic and asymptomatic infections.

COMPREHENSIVE CASE MANAGEMENT OF STIOne of the essential components of the public health package is comprehensive case management of STI, which comprises:

Identification of the syndrome: This can be done through syndromic diagnosis or laboratory tests.

Educating the patient: Patients should be informed about the nature of the infection, the importance of taking the full course of medication, among other things.

Antibiotic treatment for the syndrome: Whichever means is used for diagnosis – flow charts or laboratory tests – the availability and use of effective antibiotics is an absolute requirement. The drugs must be available at the first point of contact with a patient with an STI. Effective treatment must also be available and used in the private sector.

Condom supply: With people being encouraged to use condoms, health authorities should ensure that there is an adequate supply of good-quality, affordable condoms at health facilities and at various other distribution points in the community. Social marketing of condoms is another way of increasing access to condoms.

Counselling: Counselling should be made available for cases where it is needed – for example, in chronic cases of genital herpes or warts – either for individuals or for couples in a sexual relationship.

Information on partner notification and treatment: Contacting sex partners of clients with STI, persuading them to present themselves to a site offering STI services, and treating them – promptly and effectively – are essential elements of any STI control programme. These actions, however, should be carried out with sensitivity, with social and cultural factors taken into account. This will avoid ethical problems, as well as practical problems such as rejection and violence, particularly against women.

Reproduced and adapted from:
Guidelines for the Management of Sexually Transmitted Infections

World Health Organization
Original: English
Distr.: General
Copyright © World Health Organization 2001.