GARISPANDUAN PENYAKIT KELAMIN 2015

1. SEXUALLY TRANSMITTED
INFECTIONS
DR. NAZRILA HAIRIZAN NASIR
PAKAR PERUBATAN KELUARGA
KLINIK KESIHATAN PANDAMARAN

2. INTRODUCTION
 Sexually transmitted disease (STD),
is also known as sexually transmitted
infection (STI) or venereal disease
(VD).
 In recent years the term sexually
transmitted infection (STI) has been
preferred

3.  A person may be infected, and may
potentially infect others, without
showing signs of disease.

4.  STIs can be transmitted via human
sexual behaviour including vaginal
intercourse, oral sex and anal sex.
 It may also be transmitted via the
use of IV drug needles after its use
by an infected person, as well as
through childbirth or breastfeeding.

5.  STI incidence rates remain high in most of the
world
 In 1999, the WHO estimates that 340 million
new cases of STIs have occurred worldwide.
 The largest number of new infections occurred
in the region of
 South and Southeast Asia,
 sub-Saharan Africa
 Latin America and the Caribbean.

6.  The highest rate of new cases per 1000
population has occurred in sub Saharan Africa
 About 60% of these infections occur in young
people <25 years of age

7. CAUSATIVE ORGANISM
STD BACTERIAL
Gonorrhoea Neisseria gonorrhoea
Syphillis Treponema pallidum
Chancroid Haemophillus ducreyi
Non specific urethritis Chlamydia trachomatis
Lymphogranuloma
venerium
Chlamydia trachomatis

8. CAUSATIVE ORGANISM
STD VIRAL
AIDS HIV 1 and HIV 2
Genital Herpes Herpes simplex virus
Genital warts Human Papilloma virus
Hepatitis HBV, HCV

9. CAUSATIVE ORGANISM
STD CAUSATIVE ORGANISM
Vaginal thrush
Balanoposthitis
FUNGAL
Candida albicans
Vaginitis, urethritis
Balanoposthitis
PROTOZOAL
Trichomonas vaginalis
Genital scabies ARTHROPODS
Sarcoptes scabei

10. GONORRHOEA
 CAUSATIVE ORGANISM
 Neisseria gonorrhoea
 INCUBATION PERIOD
 2-5 Days

11.  SIGNS AND SYMPTOMS
 Urethral (>80%) / Vaginal discharge – often
purulent
 Dysuria(50% Men)+ frequency
 Aymptomatic infection is common in females
 Endocx: >50%
 Rectum >85% ( also in Men)
 Pharynx :>90% ( also in Men)

12. GONORRHOEA DISCHARGE

13.  DIAGNOSIS
 Urethral smear ( cervical/rectal exudates)– gram
negative intracellular diplococci, pus cells +++
 Urethral culture – Thayer Martin or Stuarts/Amine

14. DISCHARGE OF GC

15.  Recommended Treatment
 IM Ceftriaxone 500 mg stat
 AND
 Azithromycin 1g orally
 NB : Dose of Cefftriazone has been increased from 250mg
as development of resistance in other parts of the world
 Addition of azithromycin is for synergestic therapeutic
effect, reduce resistance and treatment of co-infection
with C. trachomatis

16.  Alternative treatment
 Cefixime (ZINECEF) 400mg stat dose orally
 IM Spectinomycin 2 gm stat or
 IM Cefotaxime 500mg stat
 NB : Penicillins, tetracyclines, quinolones no longer
recommended for Rx of Gonorrhoea: high resistant rates
 Azithromycin alone not recommended RX for gomnorrhoea

17.  Advice
 No unprotected sex, no alcohol till they n their
partners complete treatment
 Contact tracing
 Examine and investigate sex partner( within 3
preceding months) ,
 treat for gonorrhoea preferably after evaluation for
sexual acquired infection

18.  Follow up
 1 week – 2GT, urethral smear and culture to detect
PGU
 2 weeks – 2GT, urethral smear

19. POST GONOCOCCAL URETHRITIS
 Diagnosis
If 7 days or more after treatment of gonorrhea
 2GT : 1st glass threads
: 2nd glass clear ( not done anymore as
not very useful)
 Urethral smear negative, PC > 5 phf
 Treatment
 As for NSU

20. NON SPECIFIC URETHRITIS(NSU) /
CHLAMYDIA
 Causative organism
 Chlamydia sp
 Incubation period
 1-3 weeks
 Clinical presentation : in women
 Asymptomatic (60-70%)
 Mucopurulent vaginal discharge (30-40%)
 Intermenstrual/post coital bleed
 Lower abd pain
 Acute and chronic symptoms and signs of PID

21. NON SPECIFIC URETHRITIS(NSU) /
CHLAMYDIA
 Clinical presentation : in men
 Asymptomatic (50-60%)
 Mucopurulent urethral discharge (30-40%)
 Signs of epididymo-orchitis and prostatitis
 Both Men and Women
 Dysuria
 Ano-rectal discomfort + discharge
 Arthralgia
 Pharyngeal infections
 conjunctivitis

22.  Diagnosis
 Specimens for testing :
 urethral/endocervical swab And or first void urine
 Lab Tests
 Gram stain : increase PMN> to 5 per high power in urethral
smear and >20 in endocervical smear/ /> 10 in first void
urine
 Cell culture : considered gold std but not recommended for
routine use
 Direct Fluorescent antibody test (DFAT)
 Enzyme immunoassays(EIA)
 Necleic acid amplification test (NAAT)

23.  TREATMENT
 Oral Doxycycline 100mg bd for 7 days or
 Oral Azithromycin 1 gm stat
 ALTERNATIVE
 Ofloxacin for 500 mg bd for 7 days or
 Oral Erythromycin stearate 500 mg qid for 7days or
 Oral Erythromycin ES 800mg QID for 7 days
 Advice
 To avoid sex and alcohol until cured

24.  TREATMENT in Pregnancy
 Oral Erythromycin stearate 500 mg qid for 7days or
 Oral Erythromycin ES 800mg QID for 7 days
 Amoxycilling 500mg tds for 7 days
 Oral Azithromycin 1 gm stat
 Advice
 To avoid sex for 7 days until they and their partners
have completed treatment

25.  Contact tracing
 Examine and investigate sex partner, treat if positive
 If testing not available or partners are unwilling for
examination : treat emperically
 Follow up
 After 2-3 weeks
 If remain symptomatic/do not complete their Rx/have unprotected
sex with untreated partner: retreated with appropriate contact
tracing
 Test of cure in asymptomatic individual not recommended

26. VAGINAL CANDIDIASIS
 Causative organism
 Candida albicans (80-92%)and other yeasts
 Clinical presentation
 Vaginal/vulva - Intense pruritis and erythema
 Vulva soreness
 Vaginal excoriation and edema
 Thick, white ‘ cheesy’ curdlike discharge
 Discomfort in coitus
 Dysuria
 In Men : rash on glans penis /fissures over
prepuce/oedema of prepuce

27. VAGINAL DISCHARGE
(CANDIDA ALBICANS)

28.  Predisposing factors
 Endogenous
 DM, AIDS, pregnancy, debilitating
diseases
 Exogenous
 OCP,antibiotics,immunosuppressant,
IUCD, tight fitting jeans, wet suit.

29.  Diagnosis
 Lateral wall of vagina /subpreputial smear :
 Gram stain (sensitivity 65-68%)
 10% KOH microscopy ( sensitivity 70%)
 Culture on Sabouraud’s agar
 Treatment (topical/oral)
 Clotrimazole vaginal pessary 200mg ON for 3 nights or
 Clotrimazole vaginal pessary 500mg ON stat
 alternative
 Nystatin pessary100,000 units ON for 2 weeks
 Tioconazole pessaries 200mg daily for 3 days

30.  Treatment
 Oral therapy
 Fluconazole 150mg stat dose
 Itraconazole 200mg bd for 1 day : contraindicated in
pregnancy
 Advice
 Avoid local irritants ; perume, soap, etc
 Avoid tight fitting synthetic clothings
 Follow up
 Repeat vaginal smear and culture after 7-14 days

31. TRICHOMONAS VAGINITIS
 Causative organism
 Trichomonas vaginalis
 Incubation period
 4 days-4 weeks

32.  Clinical presentation Female
 Profuse, malodorous, frothy, thin dc (grey to yellow
green in colour)
 Pruritis
 Dyspareunia
 Dysuria
 Diffuse erythema of cervix and vaginal walls
 Characteristic punctate appearances on cervix –
‘strawberry cervix’
 Lower abd discomfort
 Asymptomatic 10-50%

33.  Clinical presentation: male
 Usually contacts of infected women
 Scanty- moderate urethral discharge
 Rarely prostatis/balanoposthitis
 Asymptomatic 15-50%
 Complications :
 PROM
 Low birth weight
 Preterm delivery

34. T.VAGINALIS DISCHARGE

35. TRICHOMONAS VAGINALIS

36.  Diagnosis
 Saline wet mount – oval or pear shape
organism ( positive in 30%) : Must be
performed ASAP as motility diminishes with
time
 PCR
 Treatment
 Oral Metronodazole 400 mg bd for 5 days or
 Oral Metronidazole 2 gm stat dose or
 Tinidazole 2 g stat

37.  Pregnancy :
 Published data suggest no increased risk
of tetratogenicity in Normal doses
 High dose metronidazole ( 2g) not
recommended in pregnancy and breast
feeding ( metallic taste in breast milk)

38.  Advice
 No sex, alcohol until 1 week treatment
completed
 Contact tracing
 Examine and investigate sex partners, treat
sex partners epidemiologically
 Follow up
 7-10 days- repeat wet mount film

39. BACTERIAL / ANAEROBIC VAGINOSIS
 Causative organism
 Mixed flora consisting of Gardnerella
vaginalis and other anerobes such as
Mycoplasma hominis.
 Clinical presentation
 Characteristic – copious whitish grey dc,
malodorous
 No obvious vulvitis/vaginitis
 + Dysuria/dyspareunia
 + Pruritis
 50% asymptomatic

40.  Diagnosis:
 Amsel’s criteria, diagnosis is made by the
presence of any 3 out of the 4 features given
below :-
 Characteristic vaginal dc ie Homogeneous, thin, white
discharge that smoothly coats the vaginal walls
 Wet prep or gram stain- clue cells
 Amine Sniff test (Fishy odor of vaginal discharge
before or after addition of 10% KOH )
 Vaginal fluid PH > 4.5

41.  Recommended Treatment
 Oral Metronidazole 400 mg bd for 5days or
 Oral Metronidazole 2 gm stat dose or
 Alternative treatment
 Intravaginal metronidazole 0.75% gel once
daily for 5 days or
 Intravaginal clindamycin 2% cream once
daily for 7 days or
 Clindamycin 300 mg b.d. P.O. for 7 days

42. GENITAL HERPES
 Commonest genital ulcer
 50% recur but milder in form
 Causative organism
 Herpes simplex type 1 or 2
 Incubation period
 2-5 days

43.  Genital ulcer/sore
 Single/multiple
 Superficially ulcerated, scabbed, red edged
 PAINFUL
 Symptoms
 burning sensation at genital area – crops of
vesicles appears – burst after 24 hrs –
painful ulcers – scabs – heals + (may affect
buttock and thigh)
 enlarged glands in groin

44. GENITAL ULCER-HERPES
COMMON AREA
CORONAL SULCUS
GLANS
SHAFT
MAY HAVE VAG DC
25% IN CERVIX ONLY

45.  Diagnosis
 Direct IF for HSV Ag
 Serology- paired sera taken 2 weeks apart
 Tzank test for multinucleated giant cells
 Treatment
 Oral Acyclovir 200 mg 5x/daily for 5 days
 Start within first 3 days of onset of lesion
 Saline Sitz bath
 Analgesics

46. Syphillis
 CLASSIFICATION
 ACQUIRED
 EARLY SYPHILIS (<2 YEARS)
 PRIMARY SYPHILIS
 SECONDARY SYPHILIS
 EARLY LATENT SYPHILIS

47. Syphillis
 LATE SYPHILIS (>2 YEARS)
 LATE LATENT SYPHILIS
 TERTIARY SYPHILIS (GUMMA)
 CARDIOVASCULAR SYPHILIS
 NEUROSYPHILIS
 CONGENITAL
 EARLY (<2 YEARS OLD)
 LATE (> 2 YEARS OLD)

48. SYPHILIS
 Primary Syphilis
 Clinical presentation
- Usually single, NON TENDER sharply
demarcated ulcer with indurated edges
and clean base
- Local lymph nodes enlarged
 Diagnosis
- Dark ground microscopy
- VDRL/TPHA

49. GENITAL ULCER IN SYPHILIS

50. GENITAL ULCER

51. GENITAL ULCER

52.  Treatment
 IM Benzathine Penicilline 2.4 mega single dose
 Procaine penicillin G, 600,000 units I.M. daily
for 10 days

53. If allergic to Penicillin
 Oral Doxycycline 100mg bd for 14 days or
 Oral Erythromycin 500 mg qid for 14 days
 Erythromycin ethyl succinate 800 mg q.i.d.
P.O. x 14 days or
 Ceftriaxone 500 mg I.M. daily for 10 days (if
no anaphylaxis to penicillin
 Azithromycin 2 g single dose P.O (concerns
regarding intrinsic macrolide resistance)

54.  Contact tracing
 Examine and investigate sex partner
and treat when indicated
 Follow up
 VDRL titre at 1,3,6,12,18,24 months

55.  Secondary syphilis
 Incubation period
- 6-8 weeks after chancre appear
 Clinical presentation
- Rashes: macular/macular papular
usually symmetrical over palms and
soles

56. - Condylomata lata in moist areas
- Generalised lymphadenopathy, non
tender
 Diagnosis/Treatment/contact tracing/follow up
- As for primary syphilis

57.  Early Latent Syphilis
 Syphilis infection of less than 2 years duration
 Positive serology without sn and sx
 Usually detected by screening (STD, ANC,
blood donors, contact tracing)
 Treatment/Contact tracing/Follow up
- As for primary syphilis

58.  Late latent syphilis
 Syphilis infection of more than 2 years duration
 Positive serology without sn and sx
 Usually detected by screening or contact
tracing
 Investigation
- LP, CXR

59.  Treatment
- IM Benzathine Penicillin 2.4 mega units
weekly for 3 weeks
If allergic to Penicillin
- Oral Doxycycline 100 mg bd for 30 days or
- Oral Erythromycin 500 mg qid for 30 days
 Follow up
- VDRL titre 6 monthly for first 2 years, there
after anually until sero negative or stable at
low titres

60. MODIFIED SYNDROMIC APPROACH
 introduced in 1999 in all health centres in
Malaysia
 sexually transmitted diseases that have the
same symptoms are grouped into a syndrome
to ensure early treatment can be given to sti
patients.

61. ADVANTAGES OF MSA
 treating more than one infection at a time (estimated
60% of patients had > 1 infection at one time)
 treating patients at first visit
 client friendly services
 counseling and advise given to patients
 prevent self treatment
 reduced possibilities of drug resistance

62.  reduce complications and risk of transmitting
the disease to others.
 minimum lab investigations needed
 enable the paramedic to treat the disease*

63. SYNDROMES
 genital ulcer syndrome
 urethral discharges syndromes in men
 vaginal discharges syndrome (cervicitis &
vaginitis)
 neonatal conjunctivitis

64. CLIENT
REGISTRATION OF CLIENT
HISTORY TAKING AND PHYSICAL EXAMINATION
COMPLICATIONS??
NIL
TREAT ACCORDING TO MSA
DO SIMPLE LAB TEST
FILL IN MSA TREATMENT FORM
NOTIFICATION
GIVE 2 WEEKS APPOINTMENT
REFERYES

65. GENITAL ULCER SYNDROME
 GENITAL HERPES
 herpes simplex
 CHANCROID
 haemophilus ducreyi
 CHANCRE
 syphilis

66. Patient complains of genital ulcer or sore
HISTORY AND PHYSICAL EXAMINATION
ULCER PRESENT?
TREATMENT FOR SYPHILIS & CHANCROID
**IST CHOICE: I/M B. PENICILLIN 2.4 MILL
U/ WEEKLY FOR 2 WEEK ,
PLUS
AZITHROMYCIN 1 GM STAT
** 2ND CHOICE: I/m B. PENICILLIN 2.4 MILL
U/ WEEK FOR 2 WEEK
PLUS
1/M CEFTRIAXONE 250 MG STAT
If allergy to 1ST dose Benzathine penicillin,
-avoid 2nd dose.
-give Oral Doxycycline100 mg bd x 14days Or
Oral Erythromycin ES 800mg BDX14days
NB: Doxycline – NO in pregnancy and lactation
Erythromycin in pregnancy, Rx baby as Congenital
Syphilis
NO
MULTIPLE SUPERCIAL EROSIONS OR
VESICLES PRESENT?
GENITAL HERPES MANAGEMENT
EDUCATE FOR BEHAVIORAL CHANGE
TCA 2 WEEKS FOR REVIEW
YES

67. URETHRAL DISCHARGE
SYNDROME
 GONORRHOEA
 Neiserria gonorrhoea
 CHLAMYDIA TRACHOMATIS
 NON SPECIFIC URETHRITIS

68. Patient complains of urethral discharges/Dysuria in males
(1st time/ recurrences)
History and Physical Examination
INVESTIGATIONS NEEDED
* Urethral smear for GC
*Culture for GC/CHLAMYDIA
*VDRL<TPHA & HIV (after counseling)
DISCHARGE PRESENT?
YES
NO
DO 2 GLASS TEST
RESULT POSITIVE?
YES
TREATMENT OF GONORRHEA AND CHLAMYDIA
1ST CHOICE: AZITHROMYCIN 1 GM STAT
2ND CHOICE: I/M CEFTRIAXONE 250 MG STAT If Azithromycin and
plus Ceftriaxone NA
DOXYCLINE 100 MG BD x10-14 days use IM Spectinomycin
2 gm/dose
3RD CHOICE: 1/M CEFTRIAXONE 250 MG STAT
plus
ERYTHROMYCIN ES 800 MG BD X 10-14 DAYS
GC – STUARTS TRANSPORT
MEDIA
CHLAMYDIA – CHLAMYDIA
TRANSPORT MEDIA

69. VAGINAL DISCHARGE SYNDROME
 TRICHOMONIASIS
 Trichomonas vaginalis
 CANDIDIASIS
 Candida albicans
 GONORHHOEA
 NEISSERIA GONORRHOEA
 CHLAMYDIA
 BACTERIAL VAGINOSIS
 Gardnerella vaginalis

70. Patient complains of vaginal discharges
HISTORY AND PHYSICAL EXAMINATION
INVESTIGATIONS NEEDED
1. VAGINAL SWAB
@WET MOUNT FOR TRICHOMONAS VAGINALIS AND CLUE CELLS FOR BACT VAGINOSIS
@GRAM STAIN FOR CANDIDA ALBICANS
2. CERVICAL SWAB
@ GRAM STAIN FOR GC AND PUS CELLS
@ CULTURE FOR GC
3.VDRL,TPHA & HIV TEST
TREATMENT FOR :
CERVICITIS VAGINITIS
1ST CHOICE: AZITHROMYCIN 1 GM STAT METRONIDAZOLE 2 GM STAT
plus
2ND CHOICE: I/M CEFTRIAXONE 250 MG STAT Nystatin pessary 100,00 u daily x 14 days
plus or
DOXYCLINE 100 MG BDX 10-14 DAYS Clotrimazole pessary 200mg daily x 3 hari
3RD CHOICE: IM CEFTRIAXONE 250MG S
Plus
ERYTHROMYCIN 800MG BD X 10-14 DAYS
TREAT CONTACT/PARTNER

71. THANK YOU