Summary The management of STIs is multifactorial. We need to divide it into non-pharmacological and pharmacological management. Protocols vary according to country, institution, availability of drugs and patient factors. The South African guidelines also provide a different approach, the syndromic managemet of STIs. These guidelines divide the management according to "symptoms" while the management above tries to identify the most likely agent.

1. Non-Pharmacological

Counsel about sexual habits, condoms
Counsel for HPV Immunization

2. Pharmacological

PID and Male Urethritis

Basic Description: PID presents as lower abdominal pain with a characteristic per vaginal discharge. Male urethritis presents with discharge from the urethra with a other associated symptoms.
Treatment:

Ceftriaxone 250mg IMI stat AND
Azithromycin 1g PO single dose AND
Metronidazole 400mg PO BD for 7 days OR Metronidazole 2g PO stat (if compliance is an issue)

Bacterial Vaginosis

Basic Description: FISHY SMELL, grey in colour. Not very itchy.
Treatment: Metronidazole 400mg PO BD for 7 days

Candidiasis

Basic Description: In Males, there is a water white discharge adherent to the glands. In Females, there is a white thick/curd like, very itchy.

Treatment:

Females: Clotrimazole vaginal cream applied BD for 7 days or Clotrimazole vaginal pessary 500mg single dose nocte
Males: Clotrimazole Topical applied to the penis BD

Trichomoniasis

Basic Description: FROTHY, white-yellow discharge.
Treatment: Metronidazole 400mg PO BD for 7 days or Metronidazole 2g PO stat

Chancroid

Basic Description: Results in a persistent ulcer. Usually irregular borders, well demarcated, multiple with bleeding base. There is an associated tender lymphadenopathy.

Treatment: Erythromycin 500mg 6 hourly for 7 days or Co-trimoxazole 480mg (x2 tabs) PO BD for 5 days

Genital Herpes

Basic Description: Multiple vesicles, tender ulcers. The lesions come and go. The frequency increases with immunosuppression. Lymph node may be involved if there are secondary bacterial infection.

Lymphogranuloma Venerum

Basic description: This is a remitting painful ulcer accompanied by a Bubo. Groove sign!

Treatment: Doxycycline 100mg PO BD for 14 days OR as second line, Erythromycin 500mg PO 6 hourly for 14 days. The bubo may be aspirated and sent for MCS.

Granuloma Inguinale

Basic Description: Transient ulcer in the groin. The bubo enlarges and then ulcerates. This results in a fleshy ulcer.
Treatment: Doxycycline 100mg PO BD for 21 days OR Erythromycin 500mg PO 6 hourly for 21 days

Syphilis

Basic Description: It depends on the stage. Primary (painless ulcer, “soft chancre”), Secondary (Generalized maculo-papular rash, condyloma lata), Tertiary (Gummatous lesions, aortitis, coronary arteritis, tabes dorsalis, paresis).

Treatment: Primary (Benzathine Penicillin 2.4MU IM single dose), Secondary (Benzathine Penicillin 2.4MU IM single dose), Tertiary (Benzathine Penicillin 2.4MU IM weekly for 3 weeks)

Genital Warts

Basic Description: Warty-like lesions

Treatment: Medical (Podophylline ointment OR Imiquinode 3 times per week, leave for 6-10 hours then wash off). Surgical options (Surgical excision, Cauterization, Cryotherapy)

Public Lice

Basic Description: Itching, visible nits (lice eggs), lesions from scratching.

Treatment: Benzyl benzoid 25% lotion applied daily until symptoms subside. Patient should also trim/shave all hair.

Scabies

Treatment: Benzyl benzoid lotion. Change and wash clothes beds. You need to treat the family as well. The reason that we placed it here is that it is easily transmissible through contact.

Syndromic Management