Described below are examples of syndromic case management protocols developed by a variety of countries in Latin America and the Caribbean.16 The original WHO flowcharts were developed for six syndromes: urethral discharge, vaginal discharge, pelvic inflammatory disease, genital ulcer disease, swollen scrotum, and neonatal conjunctivitis. The first four are discussed below. Most people with genital herpes do not know they have the disease, so diagnostic rates significantly underestimate prevalence. In recent years, however, as diagnostic techniques for chlamydia have become more sensitive, the role of chlamydial and mixed infections in causing urethritis in developing countries is also becoming better defined. gonorrhoeae, DFA for C. trachomatis, and EIA, amplified, and non-amplified nucleic-acid based tests for both pathogens. – Dark field, direct fluorescent antibody test, culture for Haemophilus ducreyi, HSV culture or antigen detection test, and polymerase chain reaction (PCR) for T.
pallidum, H. ducreyi, and HSV available in some settings. Selection of populations for assessing syndrome etiologies depends on the number of cases available for examination at a single site. However, because of a large proportion of missed chlamydial infections, and because many patients fail to come back, this approach can no longer be recommended. As a practical matter, for countries that have minimal infrastructure it is useful to begin with assessment of etiology of urethral discharge and genital ulcer disease at a single specialised STI clinic that has good quality Gram stain microscopy and that can perform syphilis serologic testing. In most such countries, reliable dark field microscopy is usually unavailable. Collaboration with a well-equipped laboratory can help to further assess the contribution of chlamydial infection to urethral discharge, and chancroid and herpes to genital ulcer disease.
A flowchart including Gram stain can only be considered when laboratory facilities are available. Results should be given within a reasonable time so patients do not have to return to the health facility for treatment the next day. This approach reduces the risk of serious complications, acute morbidity associated with either gonorrhea or chlamydia, and further transmission of the causative organism. -Host factor: -Female: short urethra, sexual intercourse, age. Abnormal (in amount, color or odor) vaginal discharge is the symptom most commonly presented, but it is more predictive for vaginitis than for cervicitis.18,19 The sensitivity of the symptom vaginal discharge for cervicitis varies from 25 percent (prostitutes in Zaire) to 48 percent (STD patients in USA). Children may also suffer from vaginal or rectal gonorrhea and in these cases, sexual abuse has to be considered. SA occupies most of the Arabian Peninsula with an area of about 2,240,000 sq km.
Figure 4 is a flowchart for situations in which a speculum examination is not possible. The most probable cause of a woman complaining of vaginal discharge is vaginitis. Cervicitis is a less frequent cause of consultation for vaginal discharge, but the complications of untreated cervicitis are much more serious. In situations where a speculum examination is possible, the clinician can try to differentiate between various etiologies of vaginal discharge. It is now clear, however, that either type of herpes virus can be found in the genital or oral areas (or other sites). Figure 5 is an example of a flowchart utilizing a speculum exam and a risk assessment. An example of a clinical flowchart for detecting PID is shown in Figure 6.
Because of the serious complications of PID, the flowchart should start with a very sensitive symptom. Lower abdominal pain is more sensitive for PID than fever. It is important that surgical and obstetrical emergencies, such as peritonitis and extra-uterine pregnancy, are immediately referred. Many studies have tried to describe a “typical” clinical picture for the different etiological diagnoses of genital ulcer disease (GUD) but have failed. Descriptions, such as regular shape, smooth base, undermined edge, friability, tenderness and purulence, are not sufficiently discriminatory (even for experienced clinicians) to make an etiological diagnosis in most cases. In a study in South Africa of 210 patients with genital ulcers, clinical diagnosis was compared with a gold standard laboratory test. Clinical diagnosis had a positive predictive value of 89 percent for chancroid, 47 percent for syphilis, and 19 percent for genital herpes.13 Dual infections were common, making an etiological diagnosis even more difficult.
Without sophisticated laboratory tests, an etiological diagnosis of GUD is impossible. An antiviral therapy for herpes is not available in most primary health care settings in developing worlds. It is important to treat for chancroid and syphilis, even if some of the genital ulcers treated are actually caused by herpes. In Rwanda, three different approaches were compared for the management of syphilis and/or chancroid. The syndromic approach adopted by most developing countries, illustrated in Figure 7, resulted in 99 percent of the patients with syphilis and/or chancroid correctly managed. -Diphtheroids, Staph, anaerobes. Including an RPR test in a hierarchic model is not an improvement in genital ulcer case management because many chancroid cases are missed.
However, based on the Rwanda data, including an RPR test in a syndromic approach (treating all RPR positive patients for both syphilis and chancroid, and all RPR negative patients for chancroid alone), leads to a reduction in unnecessary syphilis treatment of patients and their partners.