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Neisseria gonorrhoeae
(gonorrhoea)
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- 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).
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- 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).
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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.
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Chlamydia trachomatis
(chlamydia)
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- 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.
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- The best method is PCR (Xpert), if available.
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azithromycin PO: 1 g single dose
or doxycycline PO
: 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.
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Trichomonas vaginalis
(trichomoniasis)
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- 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.
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- Wet mount of fresh vaginal fluid shows motile trichomonas (low sensitivity).
- pH of urethral/vaginal fluid > 4.5.
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tinidazole or metronidazole PO: 2 g single dose
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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
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tinidazole or metronidazole PO: 2 g single dose |
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Candida albicans
(candidiasis)
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- 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
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- Saline of KOH wet mount of fresh vaginal fluid shows budding yeast cells and pseudohyphae.
- pH of vaginal fluid: normal
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- In women:
clotrimazole 500 mg: one vaginal tablet single dose
- In men:
miconazole 2% cream: 1 application 2 times daily for 7 days
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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.
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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.
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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
: 200 mg daily for 14 days
Treat also for chancroid.
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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.
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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
: 1 g daily for 3 days
or erythromycin PO: 2 g daily for 7 days
Treat also for syphillis.
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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).
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- 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.
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