Sexually Transmitted Infections
This guideline aims to assist healthcare workers with antibiotic prescribing for common clinical syndromes in adult patients in South Africa, utilizing Local and International guidelines, key publications, and expert opinion.
Vaginal discharge
Urethritis
Genital ulcer syndrome (GUS)
Vaginal Discharge
Definitions
Vaginal and occasionally cervical infection characterised by discharge, itching or odour.
Common aetiologies
- Bacterial vaginosis (BV): replacement of normal flora by polymicrobial overgrowth
- Trichomoniasis: T. vaginalis
- Candidiasis: Candida albicans
- Cervicitis: C. trachomatis and N. gonorrhoeae
Tests
No tests are necessary to confirm specific causes at the initial presentation.
For recurrent or persistent symptoms, attempt to confirm diagnosis by office tests:
- Bacterial vaginosis
- Clue cells on microscopy
- pH of vaginal fluid > 4.5
- Whiff test: fishy odour after addition of KOH to vaginal fluid
- Trichomoniasis
- Wet prep slide to visualise motile organisms (sensitivity 70%)
- Candidiasis
- Wet prep slide with KOH demonstrating yeasts and pseudohyphae
Diagnosis and management
Penicillin allergy (severe)
Omit ceftriaxone and increase azithromycin: 2 g po single dose
Urethritis
Definition
Urethral inflammation from infectious and non-‐infectious causes
Common aetiologies
- Gonococcal urethritis (N. gonorrhoeae)
- Non-gonococcal urethritis (NGU)
- Chlamydia (C. trachomatis)
- Non-chlamydial NGU: usually no pathogen found
Tests
Usually requires no special investigations.
Diagnosis and management
Genital ulcer syndrome (GUS)
Definition
New genital, anal or perianal lesion after recent sexual activity.
Common aetiologies
Sexually transmitted
- HSV and syphilis most common
- H. ducreyi (chancroid)
- C. trachomatis (LGV)
Non-sexually transmitted
- Infectious: folliculitis, candida, tuberculosis
- Non-infectious: trauma, malignancy, eczema, psoriasis, contact dermatitis (latex allergy), aphthous ulcers
Diagnosis
It is not possible to distinguish the causes on clinical grounds alone. Do not diagnose a venereal cause of GUS if no sexual activity in the past 3 months (except for reactivated HSV).
| Recurrent | Herpes simplex reactivation |
| Painless | Primary syphilis Lymphogranuloma venerum (LGV) |
| Painful | Herpes simplex (HSV) Chancroid |
| Lymphadenopathy | Syphilis HSV LGV (massive, often unilateral) Chancroid |
Tests
Usually requires no investigations.
Management
