Genital Ulcer

Etiology of STI in
Namibia, 1994
Gonorrhea
Chlamydia
Trichomonas
Candida
Bacterial
Vaginosis
Syphilis
HIV
Unit 3: Sexually Transmitted Infections (STIs)
Slide 1
Chancroid
Syphilis
Herpes
LGV
Chancroid & syphilis
Chancroid & Herpes
Chancroid & syphilis & Herpes
+/1 LGV
Syphilis & LGV
Syphilis & Herpes
Unknown
HIV
Slide 2
STI Management
Syndromic management
Presumptive treatment of the most
likely diagnoses
Addresses high rate of co-infections
Avoids unnecessary screening tests
Individual and public health benefit

Etiologic evaluation for complex cases
after failure of syndromic management
Most STIs require treatment of partner
even if asymptomatic
Always educate about transmission and
promote condom use
HIV +/- RPR testing should be offered to
all patients with STIs
If HIV negative, repeat in 3 months
Slide 3
Topics Covered in
this Unit
Genital ulcers
Syphilis
Inguinal buboes
Male urethral discharge
Scrotal swelling
Female vaginal discharge
Lower abdominal pain and
Pelvic Inflammatory Disease
Men who have sex with men
Counselling about safer sex
Slide 4
Genital Ulcer
Disease (GUD)
Each ulcer-causing condition has
typical features, but patients often
present with atypical features or
multiple simultaneous conditions.
Without rigorous laboratory
testing, we cannot be certain of
the etiology.
Syndromic management is
directed at the most common
curable conditions.
Slide 5
Genital Ulcer Disease (GUD):

Differential Diagnoses
Infectious
Non-infectious
Syphilis*
Chancroid*
Lymphogranuloma
venereum
Granuloma
inguinale
Herpes simplex*
Pyoderma
Cutaneous amoeba
Trauma
Fixed drug
eruption
Erythema
multiforme
Squamous cell
cancer
Autoimmune
ulcers
Bechets
syndrome
Reiters
syndrome
STIs in red
Slide 6
Treatment of Genital
Ulcers
Primary Syphilis (Treponema
pallidum)
Benzathine penicillin 2.4 million

units IM once
Chancroid (Haemophilus
ducreyi)
Ceftriaxone 250 mg IM once
Alternatives*:
Erythromycin 500 mg po qd for 7
days (Preferred by some for HIV+
patients)
Ciprofloxacin 500 mg po bd for 3
days
Azithromycin 1.0 gram po once
*The 1999 Namibian guidelines recommend only
ceftriaxone
Slide 7
Genital Ulcer
No
Blisters and
recurrent
blisters
Genital ulcer
Penicillin IM
Ceftriaxone IM
Health Ed
Partner Treatment
Condoms
HIV testing
Yes
Multiple blisters
Clean lesions
Health Ed
Condoms
HIV testing
Secondary infection:
Cotrimoxazole
No improvement?
Reinfection?
No
Refer
Re-evaluate
Yes
Treat partner
Repeat protocol
Refer to Handout 3.1 or

Section 4.4 (page 13) of the
MoHSS Guidelines for the
Syndromic Management of
STDs.
Slide 8
Primary Syphilis in Men:

Chancres
Source: Wellcome Trust, 2003
Frenulum
Coronal sulcus
Also shaft and
inner side of
prepuce
(foreskin)
Corona
Slide 9
Primary Syphilis in
Women
Primary syphilis is often
asymptomatic in women
The most common sites of
chancres are the labia,
fourchette, and cervix.
Labia
Slide 10
Uncommon Locations
of Chancres
Mouth and lips

Anal area and buttocks
Fingers
Nipples of non-immune
woman breast feeding an
infant with congenital syphilis
Slide 11
Syphilis Natural History

Characterized by episodes of
active disease and periods of
latent infection
Primary disease involves skin and
mucosal surfaces
Secondary disease involves skin,
mucous membranes, and many
other organs
Latent disease has no signs or
symptoms
Tertiary syphilis causes disease of
the aorta or masses (gummas) in
any organ
Neurosyphilis can occur at any
stage
Slide 12
Secondary Syphilis
Signs and Symptoms
Rash: often on palms and
soles of feet, trunk
Malaise
Generalized lymphadenopathy
Mucous patches (oral cavity,
pharynx, larynx, genitals)
Condylomata lata
Alopecia
Neurosyphilis
Slide 13
Rash of Secondary
Syphilis in a Pregnant
Woman
Slide 14
Condylomata Lata:
Mucosal Lesions of
Secondary Syphilis
Painless warty lesions on moist

skin
May have fever, adenopathy, rash
Teeming with spirochetes
Highly infectious
Slide 15
Syphilis
Signs and Symptoms
Latent
No clinical manifestations
Only evidence is positive
serologic test
Early Latent
<1 year duration
Late Latent
>1 year duration or unknown
Slide 16
Neurosyphilis
Symptomatic neurosyphilis
may present as:
Lymphocytic meningitis
Stroke syndromes
Seizure disorders
Progressive dementia
Psychosis
Spinal cord dysfunction (tabes
dorsalis)
Slide 17
Tertiary Syphilis
Some untreated patients
develop other effects of
syphilis 15-25 years or more
after infection
Benign tertiary syphilis
(gummas): liver masses, skin
disorders, eye lesions, bone
deterioration (6%)
Syphilis of the heart and great
vessels (4%).
Slide 18
Serologic Diagnosis
of Syphilis
Non-Treponemal Antibody:
3 names, same test
RPR (rapid plasma reagen)
VDRL (venereal disease research
laboratory)
WR (Wasserman reaction)
Detects the immune reaction, but not an
antibody test
RPR may be negative in primary
syphilis
Titre is high in secondary disease and
drops over time and after treatment
Antibody Test: Treponema Pallidum
Haemagglutination (THPA)
Done to confirm RPR (+) tests
Slide 19
Diagnosis of
Neurosyphilis
Positive serum RPR or
treponemal antibody test
Abnormal CSF
increased WBC
increased protein
positive CSF VDRL (not RPR)
Many false-negative tests occur
In Namibia, patients with a

positive serum RPR, a
compatible clinical syndrome,
and an abnormal CSF should
be treated for neurosyphilis
Slide 20
Syphilis
Treatment
Primary, secondary, early
latent:
Benzathine penicillin 2.4 million
units IM once
Latent or tertiary syphilis

Benzathine penicillin 2.4
million units IM once weekly
for 3 weeks (3 injections)
Neurosyphilis
Penicillin G 2-4 million units IV
q4 hourly for 10-14 days
Slide 21
Syphilis and HIV

In general, manage as in HIV
uninfected patients.
Primary syphilis may not have
classical appearance
Unusual serologic responses
may occur.
Neurologic complications in
early syphilis more frequent
If symptoms, RPR + and
CSF abnormal treat for
neurosyphilis
Slide 22
Chancroid in Men
Painful
Soft edge
Clean, sharp
edges
Yellow exudate
in base
May be multiple
Most common
locations:
foreskin,
corona,
frenulum
Slide 23
Chancroid in Women
Painful
Soft edges
Clean, sharp
edges
Yellow
exudate in
base

May be
multiple
Most common
locations:
Labia,
fourchette,
clitoris,
introitus
Slide 24
Chancroid and HIV

More likely to have multiple
ulcers
May respond more slowly to
treatment
Ceftriaxone IM
Some recommend multiple
dose treatment erythromycin for
7 days
Buboes require drainage
Chancroid increases HIV

transmission
Slide 25
GUD Case Study

A 22 year old
woman has 3
days of painful
urination,
vulvar pain,
and fever.
She has
recently
become
sexually active
with a new
partner.
She has had no prior episodes of
this condition, and has otherwise
been healthy.
Slide 26
Painful GUD:
Differential
Clustered painful vesicles and
ulcers are typical of Herpes
Simplex Virus (HSV)
Recurrent clustered painful
vesicles very typical of HSV
Other painful genital ulcers:
Chancroid: can be multiple
especially with HIV co-infection
Bacterial super-infection of any
other genital ulcer
Slide 27
Treatment of HSV
Clean lesions and keep dry

Health Education/counselling
Condom promotion
HIV/RPR testing
For secondary infection
Cotrimoxazole 800/160 bd x 7 days
If severe and prolonged, consider

Acyclovir* 200 mg 5x day x 7 days or
Acyclovir* 400 mg 3x day for 7 days
*Acyclovir is not part of the 1999 Namibian

guidelines
Slide 28
HSV and HIV

Very common co-infection
HIV causes HSV to be more
severe, more prolonged, and
sometimes very large persistent
painful ulcers occur
HSV thought to be a very
important factor in increasing HIV
transmission
HSV can be transmitted even
when no lesions are visible
Study in Kenya to learn if chronic
suppressive therapy of HSV can
reduce HIV transmission
Slide 29
Painful Ulcers:
Chancroid or HSV?
Slide 30
Painful Ulcers:
Chancroid or HSV?
Chancroid: multiple ulcers on
foreskin with edema.
Oval, well defined, granular base,
yellow exudate

Slide 31
Other Causes of
Genital Ulcers
Slide 32
Lymphogranuloma
venereum (C. trachomatis
L1, L2 or L3)
Starts as papule
May cause painless ulcer
Papule/ulcer often
unapparent and heals
spontaneously
Cause inguinal
lymphadenopathy and
buboes
Treatment 14 days doxycline
or erythromicin
Slide 33
Granuloma Inguinale
Caused by
Calymmatobacterium
granulomatis
Uncommon
Large chronic
ulcers
Painless
Beefy red
Bleed easily
Treatment
21 days of
Doxycycline 100 mg bd
OR
Erythromycin 500 mg 4x day
Slide 34
Inguinal Bubo
No
Genital
Ulcer
present?
Doxycycline 100 mg bd
14 days
Health ed/Partner
treatment
HIV/RPR test
Aspirate bubo if needed
Condoms
Pregnancy: erythromycin
500 mg qid 14 days
Use flowchart for

Genital Ulcer
Improvement in 7 days?
No
Yes
Yes
Fluctuance?
Continue treatment
Continue treatment
No
Yes
Aspirate bubo
Continue treatment

Section 4.6 (page 17) of the
MoHSS Guidelines for the
Syndromic Management of
STDs.
Slide 35
Inguinal Bubo (2)

Swelling of lymph nodes in
groin area
Painful or painless
Unilateral or bilateral
Often bubo implies that the
swollen nodes are filled with
pus or are draining pus
Slide 36
Inguinal Adenopathy:
Differential Diagnosis
Chancroid
Lymphogranuloma venereum
Leg infections
Hernia
Inguinal or femoral
Cancer
Slide 37
Chancroid with Bubo

Ulcer typical of chancroid
30-50% have lymphadenopathy
10-30% have fluctuant or
draining nodes
Treated like Chancroid:
Cetriaxone 250 mg IM
Aspirate
bubo if
needed.
HIV and
RPR tests.
Slide 38
Lymphogranuloma
venereum
Aspirate
bubo if
needed.
HIV and
RPR tests.
No active papule or ulcer in this

case
Bubo has ruptured
Doxycycline 100 mg bd x 14 days
OR (in pregnancy) Erythromycin
500 mg 4 times daily x 14 days
Sometimes longer treatment is
needed
Slide 39
Male Urethral
Discharge

Section 4.2 (page 9) of
the MoHSS Guidelines for
the Syndromic
Management of STDs.
Ciprofloxacin 500 mg po stat

Doxycycline 100 mg bd for 7 days
Health education
Partner treatment
Condoms
HIV testing
Return if symptoms persist
Re-infection?
Repeat Protocol
Treat Partner
Poor adherence?
Neither?
Extend doxycycline
to 10 days
Refer
Symptoms persist?
Slide 40
Male Urethral
Discharge (2)
Gonorrhea
Neisseria
gonorrhea
Non-Gonococcal
Urethritis (NGU)

Chlamydia
trachomatis
Mycoplasma
genitalis
Ureaplasma
urealiticum
Others
Slide 41
Male Urethral
Discharge (3)
Treats gonorrhea
Doxycycline 100 mg bd for 7

days
Treats NGU, especially
Chlamydia
Health education
Partner treatment
Condoms
HIV and RPR testing
Slide 42
Scrotal Swelling
Acute onset of pain
and / or swelling?
History of trauma?
Refer urgently
Ciprofloxacin 500mg po stat

Doxycycline 100mg bd for 10 days
Health education
Partner treatment
Condoms
HIV / RPR tests
Continue
treatment
Improved in 5 days?
Refer

Section 4.5 (page 15) of
the MoHSS Guidelines for
the Syndromic
Management of STDs.
Slide 43
Scrotal Swelling:
differential diagnosis
Acute Epididymo-orchitis
May have urethritis, also
Chronic Epididymo-orchitis
Testicular torsion
Acute severe pain, elevating
testes may greatly reduce pain
Trauma
history
Hernia
Swelling originates in inguinal
ring, bowel sounds?, reducible?
Slide 44
Scrotal Swelling:
differential diagnosis (2)
Acute Epididymo-orchitis < 35
years old
Neisseria gonorrhoea
Chlamydia trachomatis
Acute Epididymo-orchitis > 35

years old
May include enteric organisms
from urinary tract
Chronic Epididymo-orchitis
Tuberculosis
Slide 45
Treatment of
Epididymo-Orchitis
Docycycline 100 mg po bd for
10 days
Health education
Partner treatment
Condoms
HIV test
RPR test
Slide 46
Vaginal Discharge
Yes
Low risk for STD

No
Treat for cervicitis & vaginitis

Ciprofloxacin
Doxycycline
Metronidazole
Health education
Partner treatment
Condoms
HIV testing
Re-infection?
Repeat Protocol
Treat Partner
Treat for vaginitis only

Metronidazole
Clotrimazole pessary
Return if symptoms
persist
Return if symptoms
persist
Poor adherence
Good adherence
Repeat
Doxycycline
7 days
Clotrimazole
pessary 500 mg
stat
Symptoms persist
Refer
Refer to Handout 3.5 or Section 4.1 (page 7) of the MoHSS

Guidelines for the Syndromic Management of STDs.
Slide 47
Vaginal Discharge (2)

Vaginitis
Cervicitis
Urethritis
Candida
GC*
GC*
Bacterial
vaginosis
Chlamydia*
Chlamydia
(NGU)*
Trichomonas* Trichomonas*
(HSV*)
(Syphilis*)
*Sexually transmitted infections

*Partner should be treated
Slide 48
Treatment of Vaginal
Discharge
Low Risk Women:
Treat for vaginitis
Candidiasis
Bacterial vaginosis
High Risk Women

Treat for vaginitis
Bacterial vaginosis
Trichomoniasis
Treat for cervicitis and urethritis

Gonorrhoea
Chlamydia
Slide 49
Vulvovaginal Candidiasis
Clotrimazole 500 mg intravaginal pessary once

Severe recurrence:
oral fluconazole 200 mg
3 doses in first week then
once weekly
Slide 50
Bacterial Vaginosis (BV)
Metronidazole
400 mg bd x 7 days most
effective
400 mg 5 tabs once (same as
Trichomoniasis therapy)
Slide 51
Treatment of Women
at risk for STD
All women with
Age < 25 years
Sexual partner with STD
symptoms
New sexual partner in last 3
months
Sexual partner had other
partners in last 3 months
Slide 52
Trichomoniasis
Metronidazole
400 mg 5 tabs once
OR
400 mg bd x 7 days
Slide 53
Gonorrhoea and NGU

Same organisms as in male
urethritis
Ciprofloxacin 500 mg po once
and Doxycycline 100 mg bd x 7
days

Slide 54
Vaginal Discharge in
Pregnancy
Substitute
With
Doxycycline
Erythromycin 500mg 4x daily

for 7 days
Ciprofloxacin
Ceftriaxone 250mg IM stat
Metronidazole Clotrimazole pessary 500 mg

once
May give metronidazole 400
mg bd x 7 days for persistent
symptoms after first trimester
*Pregnant women should have an RPR checked as

well.
*Not in 1999 MOHSS guidelines
Slide 55
Lower Abdominal
Pain in Women
Yes
Rebound tenderness?
Guarding?
Refer
No
Overdue menses?
Abnormal vaginal bleeding?
Recent delivery/labour?
No
Yes
Yes
Suprapubic tenderness?
Vaginal discharge?
Fever?
PID risk factor?
Ciprofloxacin
500mg stat
Doxycycline
100 mg bd x 10 d
Metronidazole
400 mg tds x 7 d
Health education
Condoms
Partner treatment
HIV testing
No
Treat according to history
and other clinical findings
Refer to Handout 3.6 or Section 4.3
(page117) of the MoHSS Guidelines for
the Syndromic Management of STDs.
Improved
in 2
days?
Yes
Continue
Treatment
No
Refer
Slide 56
Lower Abdominal Pain:

Differential Diagnosis
Pelvic inflammatory disease
Salpingitis
Endometritis
Tubo-ovarian abscess
Pelvic peritonitis
Ovarian cyst
Ectopic pregnancy
Septic abortion
Appendicitis
Cystitis and pyelonephritis
Mesenteric adenitis
Slide 57
Pelvic Inflammatory
Disease (PID)
Risk Factors
Intra-uterine contraceptive
devise (IUCD)
Sexual partner with STD
HIV infection
Slide 58
Factors Suggestive
of PID
Suspect with findings on gyn
exam:
Uterine or adnexal tenderness
Cervical motion tenderness
Clinical features
Fever 38.3C
Cervical or vaginal mucopurulent
discharge
WBCs on microscopic exam of saline
preparation of vaginal fluid
Elevated ESR or CRP
Laboratory documentation of N.
gonorrhea or C. trachomatis
Negative pregnancy test
Slide 59
Pelvic Inflammatory
Disease (PID)
Treatment for GC, chlamydia,
anaerobes also covers gram
negative enteric bacteria
Oral therapy of suspected mildmoderate PID
Doxycycline 100 mg po bd for 10
days
Metronidazole 400 mg po tds for 7
days
Case of severe illness or inability

to take pills
Ceftriaxone 250mg IM stat and refer
immediately
Slide 60
Severe PID is Treated

in the Hospital with
IV/IM Antibiotics
IV/IM meds until patient
improves 24-48 hours
Ceftriaxone IV/IM or
Cefoxitin IV
Doxycycline po +/metronidazole po
Starts in hospital and continues
after release
14 day total course of

parenteral and oral antibiotics
Surgical drainage of
abscesses as needed
Slide 61
Men who have Sex

with Men (MSM)
Certainly exists in Namibia
although rarely discussed
In many countries, MSM are
the most likely to have HIV
infection
Anal receptive intercourse
Practiced by MSM
Also sometimes practiced by
women
Highest risk of HIV transmission
of all sex practices
Slide 62
STDs Associated with

Anal Intercourse
Proctitis
GC and chlamydia most
common
Treat like epidydimitis
Perianal HSV and warts more

common
Urethritis with enteric
organisms
Treat like cystitis
Slide 63
Key Points
Use syndromic approach to

STIs in primary care and
initial visits
Further evaluation and other
therapy appropriate when
patients do not respond to
syndromic therapy
Persons with STIs should
have HIV testing
Improvement in STI
diagnosis and treatment can
reduce HIV transmission
Slide 64

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Etiology of STI in

Unit 3: Sexually Transmitted Infections (STIs)

Unit 3: Sexually Transmitted Infections (STIs)

Individual and public health benefit

Unit 3: Sexually Transmitted Infections (STIs)

Unit 3: Sexually Transmitted Infections (STIs)

Genital Ulcer Disease (GUD):

Unit 3: Sexually Transmitted Infections (STIs)

Benzathine penicillin 2.4 million

Refer to Handout 3.1 or

Primary Syphilis in Men:

Source: Wellcome Trust, 2003

Source: Wellcome Trust, 2003

Mouth and lips

Unit 3: Sexually Transmitted Infections (STIs)

Syphilis Natural History

Unit 3: Sexually Transmitted Infections (STIs)

Unit 3: Sexually Transmitted Infections (STIs)

Unit 3: Sexually Transmitted Infections (STIs)

Source: Wellcome Trust, 2003

Painless warty lesions on moist

Unit 3: Sexually Transmitted Infections (STIs)

Unit 3: Sexually Transmitted Infections (STIs)

Unit 3: Sexually Transmitted Infections (STIs)

Unit 3: Sexually Transmitted Infections (STIs)

In Namibia, patients with a

Latent or tertiary syphilis

Unit 3: Sexually Transmitted Infections (STIs)

Syphilis and HIV

Source: Wellcome Trust, 2003

Source: Wellcome Trust, 2003

Chancroid and HIV

Chancroid increases HIV

Unit 3: Sexually Transmitted Infections (STIs)

GUD Case Study

Unit 3: Sexually Transmitted Infections (STIs)

Clean lesions and keep dry

If severe and prolonged, consider

*Acyclovir is not part of the 1999 Namibian

Unit 3: Sexually Transmitted Infections (STIs)

HSV and HIV

Source: Wellcome Trust, 2003

Unit 3: Sexually Transmitted Infections (STIs)

Source: Wellcome Trust, 2003

Unit 3: Sexually Transmitted Infections (STIs)

Unit 3: Sexually Transmitted Infections (STIs)

Unit 3: Sexually Transmitted Infections (STIs)

Use flowchart for

Refer to Handout 3.2 or

Inguinal Bubo (2)

Unit 3: Sexually Transmitted Infections (STIs)

Unit 3: Sexually Transmitted Infections (STIs)

Chancroid with Bubo

No active papule or ulcer in this

Refer to Handout 3.3 or

Ciprofloxacin 500 mg po stat

Source: Wellcome Trust, 2003

Source: Wellcome Trust, 2003

Doxycycline 100 mg bd for 7

Unit 3: Sexually Transmitted Infections (STIs)

Ciprofloxacin 500mg po stat

Refer to Handout 3.4 or

Unit 3: Sexually Transmitted Infections (STIs)

Acute Epididymo-orchitis > 35