Major genital infections (summary)

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    Last updated: July 2021

     

    Pathogens/ Infections

    Clinical features

    Investigations

    Treatment

    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

    Bacterial vaginosis
    (Gardnerella vaginalis and other associated bacteria)

    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
    tinidazole or metronidazole PO: 2 g single dose

    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
    Herpes simplex
    virus type 2
    (genital herpes)
    Many asymptomatic carriers. Multiple vesicles on genitals leading to painful ulcerations. In women, affects vulva, vagina and cervix; in males, penis and sometimes urethra. In primary episodes, fever (30%) and lymphadenopathy (50%). Recurrences in 1/3 of infections with shorter and milder symptoms. Diagnosis by culture, serology and PCR done exclusively at a reference laboratory.

    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.
    Treponema pallidum
    (syphilis)
    Single firm painless genital ulcer, often unnoticed.

    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 (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 14 days

    Treat also for chancroid.

    Haemophilus ducreyi
    (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.

    H. ducreyi bacillus is difficult to identify on microscopy or by culture.

    azithromycin PO: 1 g single dose
    or ceftriaxone IM: 250 mg single dose
    or ciprofloxacin PO (b) Citation b. 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.

    Human papillomavirus
    (venereal warts)
    Soft, raised, painless growths, sometimes clustered (acuminate condyloma) or macules (flat warts). Warts can be external (vulva, penis, scrotum, perineum, anus) and/or internal (vagina, cervix, urethra, rectum; oral cavity in HIV infected patients).

    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.
    • (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).
    • (b)Ciprofloxacin should be avoided in pregnant women.