Who / when
- Adults and adolescents with urethral or vaginal discharge, genital or anal ulcers, or (women) lower abdominal pain.
- Take a sexual history in private and assess STI risk. Examine the genital and anal areas (with a chaperone if wanted).
- Children with genital symptoms, or anyone who may have been assaulted: follow your safeguarding and clinical care after sexual violence guidance.
Red flags: refer now
Woman with lower abdominal pain plus any of these: refer for surgical or gynaecological assessment
- Missed or overdue period (possible ectopic pregnancy).
- Recent delivery, miscarriage or abortion.
- Guarding or rebound tenderness; abdominal mass.
- Vaginal bleeding heavier than spotting; a suspicious cervical lesion.
Also refer for admission: PID in pregnancy, suspected pelvic abscess, diagnosis uncertain, too ill for outpatient care, or unable to take or tolerate oral treatment.
Assess
- Look: discharge, ulcers (painful or painless, vesicles), inguinal nodes, warts, rash.
- Women: abdominal and bimanual examination for cervical motion tenderness; speculum if acceptable (cervicitis: mucopus, easy bleeding).
- Ask about pregnancy and allergies.
- Offer HIV and syphilis testing to everyone; hepatitis B and vaccination where available.
- Recurrent symptoms: ask about partner treatment and adherence.
Classify
| Syndrome | Treat for (no same-day test) |
|---|
| Urethral discharge (men) | Gonorrhoea + chlamydia |
| Vaginal discharge | Bacterial vaginosis + trichomonas; candida if curd-like with itching; add gonorrhoea + chlamydia if cervicitis on speculum, high STI risk, or no speculum possible |
| Genital or anal ulcer | Syphilis + herpes (herpes alone if recurrent or vesicles and syphilis treated in last 3 months); chancroid only where it is reported |
| Lower abdominal pain with cervical motion or lower abdominal tenderness | Pelvic inflammatory disease (PID): gonorrhoea + chlamydia + anaerobes; review in 3 days |
Treat
Doxycycline is not used in pregnancy or breastfeeding. Avoid metronidazole in the first trimester unless the benefit is clear. Late syphilis or unknown duration: benzathine penicillin 2.4 million units weekly for 3 weeks.| Infection | WHO first-line (adults and adolescents) |
|---|
| Gonorrhoea | Ceftriaxone 1 g IM single dose (also in pregnancy) |
| Chlamydia | Doxycycline 100 mg twice daily for 7 days; or azithromycin 1 g single dose. Pregnant or breastfeeding: azithromycin 1 g |
| Trichomonas, bacterial vaginosis | Metronidazole 400 or 500 mg twice daily for 7 days (trichomonas: or 2 g single dose) |
| Candida | Clotrimazole 100 mg vaginal tablet at night for 7 nights, or miconazole 200 mg pessary for 3 nights; or fluconazole 150 mg oral single dose (not in pregnancy) |
| Early syphilis | Benzathine penicillin G 2.4 million units IM single dose. Penicillin allergy (not pregnant): doxycycline 100 mg twice daily for 14 days |
| Herpes, first episode | Aciclovir 400 mg three times daily for 10 days (recurrence: 5 days) |
| PID (outpatient) | Gonorrhoea treatment plus doxycycline 100 mg twice daily for 14 days plus metronidazole 400 or 500 mg twice daily for 14 days |
Follow-up
- PID: review after 3 days; not better, refer.
- Urethral discharge that persists or recurs: check partner treatment and adherence, then treat for treatment failure or refer to a centre that can test for resistant gonorrhoea, M. genitalium and trichomonas.
- Ulcers not healing after treatment: refer.
- Pregnant women treated for syphilis: arrange treatment and follow-up of the baby at birth.
Counsel
- Take all the tablets. No sex until both you and your partners have finished treatment and symptoms have gone.
- Partners need treatment too, even without symptoms: give a notification slip or arrange partner treatment per national policy.
- Condoms every time; offer them. Discuss HIV pre-exposure prophylaxis where available.
- No alcohol while taking metronidazole.
This infection is easy to treat, but your partner must be treated too or it will come back. Please avoid sex until you have both finished the treatment, and use condoms after that.
When to refer
- Any red flag above, or a woman with PID who is pregnant or not improving after 3 days.
- Persistent or recurrent discharge or ulcers after correct treatment of patient and partner.
- Late or complicated syphilis (neurological, eye or heart signs), or a positive syphilis test in a newborn.
- Suspected sexual abuse of a child.
Sources
World Health Organization. Guidelines for the management of symptomatic sexually transmitted infections. 2021. World Health Organization. Updated recommendations for the treatment of Neisseria gonorrhoeae, Chlamydia trachomatis and Treponema pallidum (syphilis), and new recommendations on syphilis testing and partner services. 2024.