Sexually transmitted infection syndromes

Organism

There are many causes of anal and rectal inflammation. The Silver Book is limited to sexually transmitted causes, but surgical (e.g. fistulae or haemorrhoids) and inflammatory conditions (e.g. Crohn's disease) should always be considered.

Proctitis caused by sexually transmitted organisms is associated with anal sex and is usually caused by Neisseria gonorrhoeae orHerpes simplex virus (HSV).

In men who have sex with men (MSM), Shigella and Campylobacter jejuni infections and sometimes parasitic gastro-intestinal infections may be acquired from sexual activities, and proctitis may occur as part of an infective enteritis caused by these organisms.

While Chlamydia trachomatis does not usually cause an acute proctitis, rates of rectal chlamydia are increasing and Lymphogranuloma Venereum (LGV) proctitis (usually symptomatic) has been documented as an ongoing epidemic amongst MSM. Mycoplasm Genitalium (M. genitalium) is an emerging cause of ano-rectal infections in MSM.

Clinical presentation

Proctitis is suggested by anal discharge, blood and/or mucus in stools, and pain during defecation. Herpes often causes ulceration and accompanying anal pain, itch and discomfort, while gonorrhoea causes a more generalised inflammation and exudate. A primary herpes proctitis tends to be extremely painful and uncomfortable. LGV is usually symptomatic while a gonococcal proctitis is only rarely the cause of much discomfort.

STI Atlas (external site)

Investigations

In suspected proctitis, proctoscopy should be performed unless patient discomfort makes this impossible, and the following investigations are suggested:

• Rectal swab of purulent exudate for Gram-stained smear, culture and sensitivities using swab, glass slide and charcoal (black) or non-charcoal (clear) agar gel transport medium.
• Rectal swab for C. trachomatis and  N. gonorrhoeae and M. genitalium NAAT.
• Rectal swab for HSV NAAT.
• Faeces culture for enteric pathogens if history suggests infective cause.
• Test for other STIs including HIV, syphilis, and hepatitis serology, and chlamydia and gonorrhoea screening from FVU and throat (if appropriate).
• If rectal NAAT for chlamydia is positive, discuss with the laboratory to ensure further testing of the specimen for LGV serovars to enable diagnosis of LGV.
• Consider investigating for non-infection causes such as inflammatory bowel disease in those without risk of STI or whose STI tests are negative. 
• Investigations for non-infectious proctitis may include sigmoidoscopy or colonoscopy.

Treatment

In cases where a sexually transmitted cause is suspected, treatment should be given immediately before the results of tests are available. Treat for both gonorrhoea and chlamydia and consider the need for specific herpes therapy.

For syndromic treatment of nonspecific proctitis:

• Doxycycline 100mg orally, twice daily for 21 days

PLUS

• Ceftriaxone 500 mg in 2 mL 1% lignocaine given by intramuscular injection, as a single dose.

PLUS

• Valaciclovir 500mg orally, twice daily for 5-10 days

Vaginal discharge may originate from the vagina, cervix or upper genital tract. Vaginal discharges are commonly due to bacterial vaginosis, candidiasis and trichomoniasis (although the latter is rare in urban areas).

Vaginitis

Symptoms

• There may be an odour (as in the case of bacterial vaginosis or trichomoniasis) or itch (candidiasis) or vulval swelling or soreness (trichomoniasis or candidiasis).
• Vaginal infections (as opposed to cervical infections) may cause increased volume of vaginal discharge usually noticed by the patient, i.e. is symptomatic.

Signs

On examination there is usually increased discharge noted at the introitus and, on inserting a speculum, a pooling of vaginal discharge in the posterior fornix or adherent to the vaginal walls. It is important to note the colour and consistency of the discharge, its odour, and whether the vaginal walls are inflamed.

STI Atlas (external site)

Cervicitis

Cervicitis is defined as >30 white blood cells per high-powered field (WBC/HPF) microbiologically and clinically as inflammation (redness, swelling, contact bleeding, discharge).

Symptoms

• Cervical discharge is usually more scanty and may not be noticed by the patient, i.e. asymptomatic, although the patient may notice a change in colour to yellow as the discharge becomes purulent or mucopurulent.
• Cervical discharge may be due to STIs such as gonorrhoea, chlamydia or genital herpes. Alternatively, they may be due to physiological causes such as hormones or exposed columnar epithelium (ectopy) causing increased mucoid or mucopurulent discharge at the cervix.
• Coexisting urethral infection can occur in women with sexually acquired cervicitis. A history of dysuria without urinary frequency is an important clue to the possible presence of an STI.

Signs

• On speculum examination a purulent or mucopurulent discharge from the endocervical canal is an important sign as most cases are likely to be due to gonorrhoea or chlamydia.
• Often this is associated with an inflamed, oedematous cervix with contact bleeding when taking swabs or smears.
• Often a previously unnoted cervical discharge is seen on the tip of the swab.
• Note: most cases of cervicitis are asymptomatic and may also not have any signs, i.e. the cervix can look entirely normal in cases of gonorrhoea and chlamydia.
• Other organisms associated with cervicitis include Herpes simplex virus (HSV), Trichomonas vaginalis, and anaerobes. In some cases of clinically evident mucopurulent cervicitis, no pathogens are able to be isolated.

Investigations and specimen collection

Laboratory tests allow precise diagnosis, and should be performed. If the patient complains of or shows signs of a vaginal discharge:

• Take a medical history and undertake a physical examination.
• Examine the urethra and vulva for redness and discharge. If urethral discharge (pus) is present, swab for culture.
• Pass a speculum, and visualise the vagina and cervix.
• Collect a high vaginal swab.
• Test vaginal pH on indicator paper (normal is pH <4.5). Note if there is a fishy odour.
• If pus is present or the cervix is inflamed, collect endocervical smear for MC&S using swab, glass slide and charcoal (black) or non-charcoal (clear) agar gel transport medium.
• Collect endocervical specimens for gonorrhoea and chlamydia using a swab or NAAT (no transport medium).
• If the patient has urinary frequency, take a mid-stream specimen for culture and sensitivity.
• If ulcers are also present, take a swab from the ulcers for NAAT (no transport medium). 
• Perform a pelvic examination on every new patient where there is abdominal pain, or clinical cervicitis.

Special considerations

• History of receptive anal intercourse and no anal symptoms: Take blind ano-rectal swab for NAAT (no transport medium) 
• History of receptive anal intercourse and anal symptoms present: A proctoscope needs to be inserted if possible and the swabs obtained under direct vision. If the patient declines or proctoscope not available, patients can be instructed how to take blind ano-rectal swabs themselves. Also collect two throat swabs (one for culture and sensitivity [charcoal or non-charcoal agar gel transport medium] and one for NAAT [no transport medium]) if there is a history of receptive oral sex. No slide is necessary for microscopy. 
• Collect blood for serological tests – syphilis, HIV and hepatitis B. Also test for hepatitis C if there is a history of injecting drug use.
• If GeneXpert point-of-care test available, see specimen collection for more information.

Immediate treatment

Without waiting for laboratory results, proceed as follows:

Vaginitis

• If itchy, reddened vaginal walls, soreness or reddened or swollen vulva and a normal or low pH (<4.5), treat for candidiasis.
• If vulval soreness, redness, copious greenish discharge, and reddened vaginal walls and cervix, a fishy odour and a raised pH >4.5, treat for trichomoniasis.
• If vulva and vaginal walls are not inflamed or sore or itchy, a slight homogenous grey-white discharge with a fishy odour, and a raised pH >4.5, treat for bacterial vaginosis.
• If the vaginal pH is >4.5, treat as for bacterial vaginosis or trichomoniasis.

Cervicitis

• If a purulent cervicitis is seen, treat for both gonorrhoea and chlamydia.
• If shallow painful ulcerative lesions are seen on the vulva and there is cervicitis, treat for genital herpes.
• If abdominal pains accompany the cervicitis, treat for pelvic inflammatory disease (PID).
• In all cases, educate the patient about safer sex practices and promote condom use.
• Partner(s) should be investigated and treated as soon as possible, preferably within 24 hours.
• Advise return visit for review and discussion of results.
• Patients should be advised not to have sex for a week and until their partner has also completed treatment.
• If GeneXpert point-of-care test available, treat the infection detected. If neither chlamydia nor gonorrhoea detected, treat as for chlamydia to cover Mycoplasma and other infections.

• Symptoms and signs described in urethral discharge syndrome vary and may include urethral discharge, dysuria, and meatal inflammation without urinary frequency. See STI Atlas (external site)
• Urethritis is defined as >5 WBC/HPF on a smear.
• There may be white cells or bacteria in the urethral exudate seen on a smear on a glass slide, or Chlamydia trachomatis andNeisseria gonorrhoeae may be isolated from urethral swabs or from FVU.
• Laboratory testing is always required to confirm the diagnosis and to identify the infecting pathogen.
• If there are symptoms of urinary frequency, then a urinary tract infection may also be possible (although it is uncommon in men under 40 years of age).
• Other organisms associated with urethritis include Mycoplasma genitalium (M. genitalium), Herpes simplex virus (HSV), Trichomonas vaginalis, adenoviruses, Ureaplasma urealyticum and anaerobes. However, U. urealyticum and anaerobes may also exist as normal urethral flora in many men. Testing for U. urealyticum is not generally recommended, testing for the other organisms is considered second-line (see NSU section).
• In many cases of clinically evident and laboratory-proven urethritis, no pathogens are able to be isolated.

Investigations and specimen collection

• If discharge is present collect discharge specimen for antimicrobial sensitivity testing using swab, and glass slide and charcoal or agar gel transport medium. Smear first onto a glass slide for microscopy then place swab in transport medium.
• Collect FVU for chlamydia, gonorrhoea and M. genitalium NAAT.
• If chlamydia, gonorrhoea and M. genitalium were not detected and symptoms persist after empirical treatment, consider testing of FVU for herpes simplex virus (HSV) and adenovirus, and microscopy for non-gonococcal urethritis. Consider seeking specialist advice if these investigations are not available.
• If there is urinary frequency, collect a midstream urine specimen for culture and sensitivity.

Special considerations

• History of receptive anal sex, oro-anal sex, rimming or fingering and no anal symptoms: Patients can be instructed how to take blind ano-rectal swabs themselves for NAAT (no transport medium). Refer to the STI self-testing card (PDF 716KB) for instructions.
• History of receptive anal sex, oro-anal sex or fingering and anal symptoms present: A proctoscope needs to be inserted if possible and the swabs obtained under direct vision. If the patient declines or proctoscope not available, patients can be instructed how to take blind ano-rectal swabs themselves. Also collect two throat swabs (one for culture and sensitivity [charcoal or non-charcoal agar gel transport medium] and one for NAAT [no transport medium]) if there is a history of receptive oral sex. No slide is necessary for microscopy. 
• Collect blood for serological tests – syphilis, HIV and hepatitis B. Also test for hepatitis A if symptomatic or if there is a history of male-to-male and/or oro-anal sex and if there is an intention to vaccinate if not immune. Test for hepatitis C if there is a history of injecting drug use. Refer to hepatitis A and hepatitis B regarding who should receive vaccine.
• If GeneXpert point-of-care test available, see information on specimen collection.

Immediate treatment

Where NGU likely

• Doxycycline 100mg orally, twice daily for 7 days (preferred treatment)

OR

• Azithromycin 1g orally, stat

Where gonorrhoea likely

• Ceftriaxone 500mg in 2mL of 1% lignocaine, given by intramuscular injection

PLUS

• Azithromycin 1g orally, as a single dose

OR

• Doxycycline 100mg orally, twice daily for 7 days

For treatment of adults and mature minors (aged 14 years or older) with urethral discharge/dysuria where gonorrhoea is suspected under a Structured Administration and Supply Arrangement, see Structured Administration and Supply Arrangement - CEO of Health SASA. This is suitable for use by Registered Nurses and Aboriginal Health Practitioners employed by a health service operated or managed by a Health Service Provider of the WA Department of Health, or contracted entity.

Where M. genitalium likely

• After completing doxycycline, use either azithromycin or moxifloxacin or seek specialist advice. See Mycoplasma Genitalium.

• If discharge is present or if there is a good symptomatic history, treat for both gonorrhoea and chlamydia.
• In all cases, educate the patient about behaviour change, i.e. safer sex practices, and promote condom use.
• Partner(s) should be investigated and treated as soon as possible, preferably within 24 hours.
• Advise return visit, if necessary, to check that symptoms have settled.
• Patients should be advised not to have sex for a week and until one week after their partner has also completed treatment.
• If GeneXpert point-of-care test available, treat the infection detected. If neither chlamydia nor gonorrhoea detected, treat with Doxycycline 100mg orally, twice daily for 7 days to cover M. genitalium and other infections.

• Genital herpes (Herpes simplex virus (HSV) infection) is the most common STI causing genital ulceration in Australia. Symptomatic infection causes multiple painful, shallow irregular-edged ulcers or blisters anywhere in the anogenital region. They usually produce painful inguinal lymphadenopathy on the same side as the lesion. However, lesions may be more like linear splits or minor abrasions. Primary genital herpes (no prior exposure to the herpes virus) may present with systemic symptoms as well, e.g. fever, malaise, myalgia.
• Primary syphilis is increasing, in urban Australia. It must always be excluded if a solitary, long-lasting, painless thickened indurated ulcerative lesion is present, especially if there has been recent sexual contact with the MSM population or in remote Australian Aboriginal communities, or in South-East Asia or Africa. Occasionally there are two kissing lesions that touch each other in a flexure. There is usually rubbery inguinal adenopathy on the same side as the lesion.
• Donovanosis is found in northern and central Australia, and may produce beefy, smelly, painless red lesions, beginning as a nodule or nodules which then slowly erode and enlarge; it is very rare in Australia.
• Chancroid produces single or multiple painful lesions with secondary infection and purulent sloughing, and may produce very large painful inguinal adenopathy leading to ulceration (a bubo). It is not endemic to Australia and should be considered in patients with sexual contact in Africa, India or South-East Asia.
• Lymphogranuloma venereum (LGV) is rare, and seen in men who have sex with men in urban Australia or in those with sexual contacts in countries where these infections are endemic, such as South-East Asia, India and Africa. It classically produces a small, painless, transient genital ulcer, and then painful enlargement of the inguinal nodes (bubo) both above and below the inguinal ligament. However, in recent years cases in men who have sex with men have generally presented an acute proctitis. Subsequently, abscess formation and fistulae develop and finally blockage of the lymphatics and oedema occurs.
• Diagnostic procedures for, and management of, genital ulceration, when the diagnosis is uncertain or the patient has recently returned from overseas, should be done by or in consultation with a specialised STI or sexual health service or a sexual health physician.
• Pyogenic infections, trauma, drug eruptions, secondarily infected scabies, candidiasis, Behcet's disease, other dermatological conditions and neoplasms sometimes cause ulcerative lesions and may present diagnostic difficulties.

Investigations and specimen collection

If a patient complains of a genital sore or ulcer:

• Take a medical history especially about travel, sex in high-risk areas, male-to-male sex and length of time the ulcer has been present.
• Examine the ulcer, check for a rolled edge and induration or thickening of the ulcer base, or inguinal adenopathy.
• Collect an HSV PCR (NAAT) swab from the genital lesion to exclude herpes. Note: The HSV PCR (NAAT) swab detects viral shedding from a herpes lesion. Viral shedding occurs during the early stages of a lesion. Therefore, a negative HSV PCR (NAAT) test result on an older herpes lesion does not preclude a diagnosis of herpes.
• If the ulcer is clinically suggestive of donovanosis or syphilis:
  • Clean the ulcer with saline if required. From the inside edge of the ulcer/nodule take a dry swab. Send this swab to test for NAAT for donovanosis, syphilis and HSV by specifying the likely diagnosis or diagnoses.
  • Collect an impression smear (scrape and slide) or any other confirmatory tests for Donovan bodies (Giemsa staining must be requested).
  • HSV serology may be considered if the ulcer appears old or mostly healed, or if there are episodes of recurrent ulceration or known contact with infection. (Remember serology is not a substitute for the PCR swab and window periods may apply to the interpretation of results).
  • Take blood for syphilis serology, and offer HIV and hepatitis B serology.

Immediate treatment

• If syphilis or donovanosis is suspected, take NAAT swabs and syphilis serology before commencing any treatment.
• If multiple painful, shallow irregular-edged ulcers or multiple recurrent vesicular lesions are evident, treat for herpes.
• Primary health care practitioners not experienced in the clinical management of genital ulcers should refer all suspected cases of syphilis, donovanosis or chancroid to a specialist centre, or discuss management with a sexual health or infectious diseases specialist.
• Where painless ulcers are evident, treatment for syphilis should be commenced in areas where laboratory diagnosis is likely to be delayed:
  • benzathine penicillin 1.8 g (=2,400,000 units) intramuscularly, as a single dose
• In all cases, educate the patient about safer sex practices and promote condom use. Give out condoms.
• Partner(s) should be investigated and treated as appropriate.
• Stress importance of a return visit in one week.
• Patients should be advised to avoid sex until ulcers have healed and partners have also been investigated and treated if necessary.
• If rectal LGV is suspected, three weeks of antibiotic therapy such as doxycycline 100mg 12-hourly is recommended.

For treatment of adults and mature minors (aged 14 years or older) genital ulceration where syphilis is suspected under a Structured Administration and Supply Arrangement, see Structured Administration and Supply Arrangement - CEO of Health SASA (conditions). This is suitable for use by Registered Nurses and Aboriginal Health Practitioners employed by a health service operated or managed by a Health Service Provider of the WA Department of Health, or contracted entity, or a health service that is a member of the Aboriginal Health Council of Western Australia.

Women often present with lower abdominal pain. The causes range from minor but uncomfortable problems such as constipation or period pain, to life-threatening problems such as a ruptured ectopic pregnancy or appendicitis.

Important principles when managing lower abdominal pain include:

• Take a sexual history
• Always do a pregnancy test on women of child-bearing age to exclude ectopic pregnancy which needs urgent gynaecology referral.
• Think past an obvious cause of the pain, e.g. many women have an abnormal dipstick urine test, but urinary infection (even if present) may not be the cause of the pain.
• Consider PID as a differential diagnosis in cases of suspected appendicitis, gastroenteritis, colitis, endometriosis or ovarian cyst.
• PID due to chlamydia and/or gonorrhoea is a common cause of lower abdominal pain in WA. Mycoplasma genitalium (M. gentialium) is an emerging cause of lower abdominal pain and PID in women.
• Always think about PID as a possible diagnosis and treat early to avoid complications especially if the patient is at risk of infertility (e.g. young, recent change of partner or multiple partners, recurrent STIs, past infertility, following termination of pregnancy or other instrumentation).
• Negative test results for gonorrhoea, chlamydia or M. genitalium do not exclude a diagnosis of PID.

See PID

The term PID refers to infections of the female upper genital tract – uterus, fallopian tubes, ovaries or pelvic cavity. It can be caused by gonorrhoea, chlamydia or anaerobic bacteria, or a variety of bacteria commonly found in the vagina, such as the different bacteria that can cause bacterial vaginosis, especially post-instrumentation.

Symptoms include constant pain in the lower abdomen that worsens with movement such as running or going up and down stairs, or pain with intercourse (deep dyspareunia). There can be fever or raised temperature, malaise, irregular or heavy periods, or pain can start after a recent period.

Signs on pelvic examination include a cervical discharge and/or vaginal discharge, cervical excitation (pain on rocking the cervix), tenderness and swelling in the fornices. Abdominal examination can show tenderness in the iliac fossae, guarding or rebound tenderness.

Clinical examination, investigations and specimen collection

If the patient has a temperature (>38 °C), rebound tenderness, guarding, pain during examination and/or vaginal discharge, consider PID in the differential diagnosis of an acute abdomen. The following investigations should be performed where PID is considered:

• Examine the urethra and vulva for redness and discharge.
• Pass a speculum and visualise the vagina and cervix.
• On examination any vaginal discharge should be noted as that may indicate an ascending infection.
• Collect high vaginal swab for MC&S using swab, glass slide and charcoal (black) or non-charcoal (clear) transport medium.
• Test vaginal pH on indicator paper (normal is pH < 4.5). Note if there is a fishy odour.
• On examination, the cervix should be observed carefully as any purulent discharge is significant.
• Collect endocervical smear for MC&S using swab, glass slide and charcoal (black) or non-charcoal (clear) agar gel transport medium. This specimen is suitable for culture of gonococci, anaerobes, Mycoplasma spp. and other endogenous flora.
• Collect endocervical smear for gonorrhoea, chlamydia and M.genitalium NAAT, using swab (no transport medium). Note that point-of-care testing for chlamydia and gonorrhoea is not indicated in patients with PID as it will not alter the treatment required or the need for contact tracing of sexual partners.
• Perform a pelvic examination to check the pelvic area for masses, heat, tenderness, or fullness in the adnexa. An important sign is cervical excitation.
• If the patient has urinary frequency, take a mid-stream specimen for culture and sensitivity.
• Do a pregnancy test.
• Pelvic ultrasound may be required.
• Take a full blood picture and measure erythrocyte sedimentation rate (ESR) as well as C reactive protein.

Immediate treatment

• Assess disease severity and consider hospitalisation.
• If PID is considered, treat immediately.
• Ensure the patient understands that their condition is likely to be the result of an STI and that recent partners may be asymptomatically infected.
• Undertake contact tracing and treatment of partner(s).
• Advise return visit in three days to ensure improvement and test of cure.
• Patients should be advised no sexual contact for 7 days after completion of treatment and to avoid sexual contact with partners from the last 6 months until 7 days after they have been tested and treated.
• In all cases, educate the patient about safe sexual behaviour.