UNIT 9

SEXUALLY TRANSMITTED
INFECTIONS (STIS)

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 Key Signs and Symptoms
of STIs in Women
• Vaginal discharge (color, amount,
consistency) or pruritus (itching)
• Genital ulcer
• Lower abdominal pain

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 Causes of discharge
• Candidiasis.
• Trichomoniasis.
• Gonorrhea.
• Chlamydia
• Bacterial vaginosis.
• Genital herpes.

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 Causes of genital ulcer
• Chancroid
• Syphilis
• Lymphogranuloma venerum (LGC)
• Granuloma inguinale
• Genital herpes
• Genital warts

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Causes of Lower Abdominal Pain
in Women

• Pelvic inflammatory disease (PID),

caused by gonorrhea, chlamydia,
and/or anaerobes.
• Surgical conditions, such as
appendicitis.
• Obstetric emergency, such as ectopic
pregnancy.
• Urinary tract infection.

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 Cervicitis
• It is the inflammation of the tissue
of the cervix.
• The cervix may look swollen,
reddened, and “beefy.”
• There may be mucopurulent or
copious discharge seen in the
cervical os.
• Cervical mucosa may bleed
easily when touched with a
swab.
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MINISTRY OF HEALTH
 Vaginitis

• There is swollen and inflamed

tissue in the vagina or on the
vulva; copious discharge may be
present.

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 Rapid Office Diagnosis:
Vaginitis Bacterial
Symptom/sign Candidiasis Trichomoniasis vaginosis
Pruritus + + –
Odor – + +
Discharge Cheesy Purulent Grey*
Inflammation + + –
pH 4.5 >4.5 >4.5*
KOH test result – –/+ +*
Specific findings Yeast T. vaginalis Clue cells*
hyphae and
buds
Polymorphonucle ++ +++ –
ar leukocytes
Lactobacilli + – –
*If three of these four are
present, bacterial vaginosis
is likely.
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Candidiasis: predisposing
factors
• Systemic • Antibiotics
disorders • Corticosteroids
• Diabetes • Oral
mellitus contraceptives
• HIV • Anticancer
• Obesity drugs
• Pregnancy • Chronic ill
health.

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 Candidiasis
• Intense vulval itching
• Vaginal discharge - white, curdlike
and cheesy
• Burning sensation on urination
• They may have red and swollen
vulvar and vaginal tissue.

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 Trichomoniasis
• Vulval itching
• Sometimes pain with intercourse
• Profuse greenish-grey or watery
vaginal discharge. May be foul
smelling
• Discharge may be frothy or contain
small bubbles.
• Vaginal mucosa and cervix shows
multiple small red patches
(strawberry sports).
• Wet preparation under the micro
scope shows motile protozoa with
beating flagella.
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 Multiple red spots
(“strawberry cervix”)
typical of Trichomonas
cervicitis.

After application of
Lugol’s iodine, the
cervix has a “leopard
skin” appearance.

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T. vaginalis

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 Bacterial Vaginosis
• Grayish vaginal discharge with a fishy
smell.
• Mainly infects vaginal epithelium
• There is loss of lactobacilli with
consequent elevation of vaginal PH
(>4.5).
• Diagnosis.
– Presence of clue cells on wet saline
preparation
– These are exfoliated vaginal epithelial
cells covered with bacteria.

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Signs of Bacterial Vaginosis

• Note the grey, milky

discharge evenly coating
the vulvar and vaginal
surfaces.

• There may be a slight

odor from the discharge.

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Gonorrhea: sites of infection.
• Columnar and transitional
epithelium of the genital tract
– Cervix
– Urethra
– Skenes glands
– Bartholin’s
• Other sites include:-
– Oropharynx
– Conjunctiva
– Ano-rectal region.

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Bacterial Vaginosis—
the Clue Cell
Microscopic examination
of the discharge shows
that the normal
lactobacilli, which keep
the vagina healthy (by
producing an acid
environment), are
lacking.

Numerous gram-negative
to gram-variable rods are
covering the surface of
the epithelial cell. These
are called clue cells.
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Gonorrhea: Clinical features
• Purulent vaginal discharge
excessive and irritating.
• Urinary symptoms e.g. dysuria or
frequency
• Pain or swelling of Bartholin’s
glands.
• Rectal discomfort.

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Chlamydia: Site of infection

• Columnar and transition epithelium

of the genital tract.
– Cervix
– Urethra
– Bartholin’s glands.
• Rapidly ascends upwards to cause
acute PID (75% cases)

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 Chlamydia: Clinical features
Produces few symptoms even with
upper genital tract infection
• Dysuria
• Dyspareunia
• Post coital bleeding
• Inter-menstrual bleeding
• Mucopurulent vaginal discharge
• Lower abdominal pain

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 Cervicitis—Chlamydia or
Gonorrhea

Note
mucosal
bleeding
where
purulent
discharge
has been
wiped
away.

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 Genital Ulcer Disease

GUD is usually caused by:

• Chancroid
• Syphilis
• Genital herpes
GUD is associated with an increased
risk of HIV infection.

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 Genital Herpes
• It starts as a red painful inflammatory
area on the genital area.
• Followed by multiple vesicles.
• These burst to curve swollen ulcers
which are very painful.
• They clear in about 3 weeks but
infection can be recurrent.
• Infection can be accompanied by a
watery vaginal discharge.
• Syphilis must be excluded

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 Types of Genital Herpes
Episodes
• First episode: primary infection,
nonprimary infection
• Recurrent episode
• Asymptomatic episode

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Genital Herpes—First
Episode

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Genital Herpes—
Recurrent

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Cervicitis—Recurrent
Genital Herpes

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Genital Herpes—Recurrence
on the Buttocks

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 Treatment for Herpes
Simplex Virus Infection
• No curative treatment for the
chronic infection.
• Treat symptomatically with cool
salt-water compresses, sitbaths,
and analgesics.
• If a patient can afford it, oral
acyclovir effectively prevents or
shortens the duration and severity
of episodes.

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 Chancroid
• It is the commonest cause of genital ulcer
disease.
• Starts as painful multiple pustule over the
vulvar, vaginal or cervix.
• It then sloughs to form swollen ulcer
surrounded by an area of in duration.
• The lesions are tender and have foul smelling
purulent haemorrhagic discharge (Dirty
ulcer).
• There may be unilateral tender inguinal
adenopathy.
• Syphilis has to be ruled out.

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Chancroid—“Dirty” Ulcer

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 Syphilis:Primary
• Starts as a small painless papule that
quickly erodes to form a painless clean
ulcer.
• The (CHANCRE) ulcer does not have
surrounding indurations.
• It may be found on the vulva, labia,
vagina, or cervix, anus or nipples.
• There is painless inguinal lymph node
enlargement.
• This chancre heals spontaneously in 1 -8
weeks leaving behind a scar. in women.

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 Primary Syphilis—
“Clean” Ulcer on Penis

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 Syphilis: Secondary
• Starts within 6 weeks to 6 months after
the primary infection.
• In the vulva – condyloma lata (These
are flat, moist coarse necrotic lesions)
• Systematic symptoms:-
– Fever
– Sore throat
– Maculopapular skin rashes on the
palms and sores
– Generalized skin rash
– Mucosal ulcers
– Alopecia
– Headache

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 Tertiary syphilis.

Affects arteries in the body

especially in the heart, great
vessels and brain.

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 Pelvic Inflammatory Disease
The signs and symptoms of PID:
• Lower abdominal pain
• Pain during intercourse; pain with
motion of the cervix during
examination
• Fever, temperature >38 degrees C
• Vaginal discharge

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 Treatment of genital tract
infections
Disease Treatment
Candidiasis Nystatin, clotrimazole pessaries

Trichomoniasis Metronidazole
Bacterial Vaginosis Metronidazole
Gonorrhea Cetriaxone, Kanamycin, Spectinomycin

Chlamydia Tetracycline, Erythromycin

chancroid Erythromycin, Ceftriaxone,
Spectinomycin
Syphillis Benzathine Penicillin, Tetracycline,
Erythromycin

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 Syndromic STI Management
in Women
The syndromic approach relies on
assessing the clinical features of a
patient:
• Symptoms with which the person
presents.
• Clinical signs and symptoms that a
clinician uses to arrive at a
diagnosis.

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