Syndromic Approach

Sexually Transmitted Infection

STI are linked to the spread of HIV/AIDS

Early diagnosis and treatment of STI play an
important role in its prevention and
management

Consequences of STI can be serious. In view of
these, effective accessible and acceptable STI
case management is important.
STI
HIV
Early Diagnosis
Prevention
STI are linked to the spread of HIV/AIDS

Consequences of STI can be serious. In view of
these, effective, accessible and acceptable STI
case management is important.
Objectives
General:

Improve the knowledge and develop the
skills of health workers on syndromic
approach to STI management
Specific
Discuss the status of STI Syndromic
Management in clinical and community
settings including problems and gaps
encountered;
Discuss other approaches to STI case
management: clinical and etiologic diagnosis
Scope of STI
Acute disease process
Complications
Permanent
consequences
Acute disease process
Spectrum
GONORRHEA CERVICITIS SALPINGITIS INFERTILITY
As infection A disease A complication A sequel
GONORRHEA
Common STI
Bacterial Viral Protozoal Fungal
Skin
Parasites
Gonorrhea

Syphilis

Chlamydial
Infection

Chancroid
Genital
Herpes

Genital
Warts

Genital
Molluscom

HIV

Hepatitis B
Trichomonas Candidiasis
Pubic Lice

Scabies

*passed on
by close
body
contact and
do not
require
actual
penetrative
intercourse
STI Data (Physical)
10-30% of men who had gonorrhea developed
epididymitis before antibiotics were available
and 20-40% of men with epididymitis became
infertile

An estimated 8-20% of women with untreated
cervical gonorrhea infection develpo pelvic
inflammatory disease ( inflammation of the
uterus, fallopian tubes, ovaries or other pelvic
structures)
STI Data
Without treatment 55-85% of women with
pelvic inflammatory disease may become
infertile

Pelvic inflammatory disease increases
womens risk of having an ectopic pregnancy
7-10 fold due to permanent scarring and
narrowing of the fallopian tube.
STI Data (Social)

Abandonment of women


Discrimination
STI Case Management (Objectives)
Provide treatment
Obtain cure
Reduce infectivity
Prevent, or at least reduce, future risky
behavior
Make sure sexual partners are appropriately
treated
To achieve the objectives
1. Correct Diagnosis
2. Effective Treatment
3. Education and counseling on risk reduction,
treatment instruction and the promotion
(and revision) of condoms
4. Encouragement to notify sexual partners, and
5. Clinical follow up where necessary

Approaches to STI Diagnosis
1. Etiologic Diagnosis

2. Clinical Diagnosis

3. Syndromic Diagnosis
Advantages of STI Syndromic Management
Simple and cheap since it does not require
expensive investigations;
Can be done by health workers at any level of
the health system and requires minimal
training;
Allows for diagnosis and therefore treatment
of the client at the first visit;
Any concurrent infections are cured;
Will receive education and counseling on
reducing the risk of another infection, how to
use a condom and the need for his/her
partner(s) to be treated.
Criticism STI Syndromic Approach
1. Not Specific

2. Too simple for a physician to use it is more
appropriate for nurses

3. Does not use a health workers clinical skills
and experience
4. Some over-treatment because not all clients
will have concurrent infections

5. Promotes the development of antibiotic
resistance

6. Not sufficient, good, simple laboratory tests,
such as Gram stain, should be included in STI
diagnosis
Six Common Syndromes:
Urethral
Discharge
Scrotal
Swelling
MALE FEMALE
Genital
Ulcer
Vaginal
Discharge
Vaginal
Discharge
INFANT
Eye
Infection
Syndromic STI Case Management
History taking and Physical Examination
Required Information
General details about the client
Description of present illness
medical History
Sexual History
Importance of Communication in History
Taking and Physical Examination
1. Verbal Skills
greeting client
avoiding common problems in verbal
communication
Asking openand losedquestions
effectively
2. Non-verbal skills
provide privacy and confidentiality
listen carefully to the client
posture

3. Verbal communication skills
Facilitating
Directing
Summarizing and checking
Showing empathy
Reassurance
Expressing partnership
Risk Assessment
For Women:
The woman is 25 years old or less
Had sexual intercourse with more than one
partner in the past 3 months
Woman suspects that her sexual partner had
intercourse with other partners
Woman reports that she has sex with a partner
within 7 days of his return from travel outside the
town of residence during the last 3 months
For Men:
Multiple sexual partner
New sexual partner during the last 3 months
Sex partner has s/s of STI
Clinical Examination

ensure privacy at all time
Explain what is to be done, and why it is
important
Approach the examination in a confident way,
never showing uncertainty or embarrassment
Never be rough or conduct an examination
against someones will
Use of all communication skills discussed
previously

Be professional Reassure the client
Syndromic Case Management Flow
Chart
Parts
This shape indicates the clients
presenting complaints
Clients of complains of
This shape indicates an instruction do this
e.g. examine the client
This shape indicates a question
e.g., is there
a discharge
yes
no
Every flow chart will start
with this shape it has one
exit only
It has one entry arrow and
one exit arrow
It has one entry arrow and
two exits - a es exit and a
noexit
Patient complaints of urethral discharge and/or burning
Take medical and sexual history
Positive risk
assessment
No
Examine: Milk urethra if necessary
1. Treat for Discharge
(Gonorrhea/Chlamydia)
2. 4 Cs
Symptom
Persist?
Refer
Yes
7 days
Discharge
present
Reassure
2Cs
URETHRAL DISCHARGE
Patient with
vaginal
discharge
Take History
Sexual partner
with urethral
discharge in past
3 mos.?
1. Treat for cervicitis
2. Treat for vagintis
3. 4 Cs
A
B
1. Review History 2. Examine with speculum
One clinical
and one
behavioral
positive?
Yes
G
No
C
D
1. Treat for
vaginitis
2. 3 Cs
Yes

4 Cs
Counseling
Condom
Compliance
Contact Tracing
3 Cs
Counseling
Condoms
Compliance
2 Cs
Counseling
Condoms

E
No
Vaginal Discharge
No speculum examination