Major genital infections (summary)

Neisseria gonorrhoeae
(gonorrhoea)

• In women:
  • vaginal discharge, cervicitis (mucopurulent cervical discharge), dysuria (50% of infections are asymptomatic);
  • UGTI (salpingitis, endometritis).
• In men: purulent urethral discharge and sometimes dysuria (5 to 50% of infections are asymptomatic).

• Best method is PCR (Xpert), if available.
• In men (not sensitive enough in women): Gram or methylene blue stain: intracellular diplococci and polymorphonuclear leukocytes (more than 4 per field).

ceftriaxone IM: 500 mg single dose
or, if not available,
cefixime PO: 400 mg single dose
Treat also for chlamydia.

In case of upper genital tract infection, see UGTI.

Chlamydia trachomatis
(chlamydia)

• In women:
  • vaginal discharge, cervicitis, and rarely dysuria (> 50% of infections are asymptomatic);
  • UGTI (salpingitis, endometritis).
• In men: mild urethral discharge and/or dysuria but up to 90% of infections are asymptomatic.

• The best method is PCR (Xpert), if available.

azithromycin PO: 1 g single dose
or doxycycline PO(a)Citation a.Doxycycline is contra-indicated in pregnant women. It should not be administered to breast-feeding women if the treatment exceeds 7 days (use erythromycin).: 200 mg daily for 7 days

Treat also for gonococcal infection (except when a Gram stain in males or PCR shows no N. gonorrhoeae).

In case of upper genital tract infection, see UGTI.

Trichomonas vaginalis
(trichomoniasis)

• In women: yellow-green vaginal discharge, sometimes foul smelling, vulvar irritation (10 to 50% of infections are asymptomatic).
• In men: most infections are asymptomatic. Can produce balanitis, urethritis with mild discharge and sometimes dysuria.

• Wet mount of fresh vaginal fluid shows motile trichomonas (low sensitivity).
• pH of urethral/vaginal fluid > 4.5.

tinidazole or metronidazole PO: 2 g single dose

Diagnosis is made in the presence of 3 of the following 4 signs:

• Homogenous grey-white adherent vaginal discharge
• pH of vaginal fluid > 4.5
• Vaginal fluid has an amine (fishy) odour, especially when mixed with 10% KOH
• Presence of clue cells in wet mount or Gram stain of vaginal fluid

Candida albicans
(candidiasis)

• Mainly seen in women: pruritus and vulvovaginitis, frequently creamy-white vaginal discharge, sometimes dysuria.
• In men: balanitis/balanoposthitis (inflammation of the glans/prepuce, erythema, pruritus, white pustules) and rarely urethritis

• Saline of KOH wet mount of fresh vaginal fluid shows budding yeast cells and pseudohyphae.
• pH of vaginal fluid: normal

• In women:
  clotrimazole 500 mg: one vaginal tablet single dose

• In men:
  miconazole 2% cream: 1 application 2 times daily for 7 days

Analgesics, local disinfection.
If available, aciclovir PO:

• Primary episode: 1200 mg daily for 7 days, given within 5 days after onset of lesions.
• Recurrent infections: same dose for 5 days, given within 24 hours after onset of lesions.

RPR/VDRL lack sensitivity and specificity, but may be useful for following treatment effectiveness (decrease in titer) or confirming re-infection (rise in titer).
Treponemal tests (TPHA, FTA-ABS, rapid tests such as SD Bioline®) are more sensitive and specific.

benzathine benzylpenicillin IM:
2.4 MIU per injection, single dose (syphylis < 12 months) or once weekly for 3 weeks (syphilis > 12 months or unknown duration)
or azithromycin PO: 2 g single dose
or erythromycin PO: 2 g daily for 14 days
or doxycycline PO(b)Citation b.Doxycycline is contra-indicated in pregnant women. It should not be administered to breast-feeding women if the treatment exceeds 7 days (use erythromycin).: 200 mg daily for 14 days

Treat also for chancroid.

Painful single (or multiple) genital ulcer (soft chancre, bleeds easily when touched).
Painful and voluminous inguinal lymphadenitis in 50%. Fistulae develop in 25% of cases.

azithromycin PO: 1 g single dose
or ceftriaxone IM: 250 mg single dose
or ciprofloxacin PO(c)Citation c.Ciprofloxacin should be avoided in pregnant women.: 1 g daily for 3 days

or erythromycin PO: 2 g daily for 7 days

Treat also for syphillis.

The diagnosis is based on clinical features.
It feasible in the context, the presence of genital warts in women in an indication to screen for pre-cancerous lesions of the cervix (visual inspection with acetic acid, or cervical smear, or other available techniques).

• External warts < 3 cm and vaginal warts: podophyllotoxin 0.5%
• External warts > 3 cm; cervical, intra-urethral, rectal and oral warts; warts in pregnant or breastfeeding women: surgical excision or cryotherapy or electrocoagulation.