The diagnosis and treatment of genital infections (GI) present several difficulties: clinical features are not specific; many infections are asymptomatic; laboratory tests available in the field are not always reliable; mixed infections are common; partners need to be treated simultaneously in case of sexually transmitted infections1 and the risk of recurrence or treatment failure is increased in HIV-infected patients.
Thus, the WHO has introduced the syndromic management of GI and developed standardised case management flowcharts: based on the identification of consistent groups of signs and symptoms (syndromes), patients are treated for the pathogens/ infections2 that may cause each syndrome.
Look for a GI if a patient complains of:
Abnormal vaginal discharge
Genital blisters or sores
Skin growths in the genital (or anal) area
Lower abdominal pain (in women)
Basic principles of GI management
– The patient can be effectively treated without laboratory testing. Some tests may help in diagnosing vaginal and urethral discharge, but they should never delay treatment (results should be available within one hour).
– The patient should be treated at his/her first encounter with the health care provider (no patient should be sent home without treatment, e.g. while waiting for laboratory results).
– Single dose regimens are preferred when indicated.
– In the case of urethral discharge, abnormal vaginal discharge (except candidiasis), genital ulcers (except herpes) and sexually transmitted upper genital tract infection, the sexual partner should receive a treatment. In the case of candidiasis, genital herpes and venereal warts, the partner is treated only if symptomatic.
– Patients with sexually transmitted infections should receive information on their disease(s) and treatment and be counselled on risk reduction and HIV testing. Condoms should be provided for the duration of treatment.
Special situation: sexual violence
Taking into consideration the physical, psychological, legal and social consequences of sexual violence, medical care is not limited to the diagnosis and treatment of genital lesions or infections.
Care includes listening to the victim’s story, a complete physical examination, laboratory tests if available, and completion of a medical certificate.
During the consultation, prophylactic or curative treatments must be proposed to the patient.
– Prophylactic treatment:
• priority is given to:
a) the risk of HIV transmission. Start antiretroviral therapy as early as possible if the patient is seen within 48-72 hours after exposure (see HIV infection and AIDS, Chapter 8);
b) the risk of pregnancy resulting from rape. Administer emergency contraception as soon as possible, ideally within 72 hours after the rape: levonorgestrel PO, one 1.5 mg tablet single dose (including in women receiving HIV post-exposure prophylaxis)3 ; double the dose (3 mg) only if the patient was already taking enzyme-inducing drug(s) (e.g. rifampicin, carbamazepine, certain antiretrovirals) before the rape;
• prevention of sexually transmitted infections includes a single dose treatment with azithromycin PO 2 g + ceftriaxone IM 250 mg (or, if ceftriaxone is not available, cefixime PO 400 mg). If necessary, treatment of trichomoniasis may be started later than the other treatments (tinidazole or metronidazole PO, 2 g single dose);
• vaccination against hepatitis B (accelerated vaccination schedule, see Viral hepatitis, Chapter 8).
– Curative treatment:
• of wounds,
• of any related pathologies/infections if the assault is not recent.
Mental health care is necessary irrespective of any delay between the event and the patient arriving for a consultation. Care is based on immediate attention (one-on-one reception and listening) and if necessary, follow-up care with a view to detecting and treating any psychological and/or psychiatric sequelae (anxiety, depression, post-traumatic stress disorder, etc.). See Chapter 11.
|1||GI may be sexually transmitted (e.g. gonorrhoea, chlamydia) or not (e.g. most cases of candidiasis).|
|2||Keep in mind that in Schistosoma haematobium endemic areas, genital symptoms may also be due to, or associated with, genitourinary schistosomiasis (see Schistosomiasis, Chapter 6).|
Nevertheless, between 72 and 120 hours (5 days) after the rape, emergency contraception is still sufficiently effective to be administered.