Diagnosis and Assessment of Symptomatic Sexually Transmitted Infections

Overview

This Guidelines summary covers evidence-based recommendations from the World Health Organization (WHO)’s guideline on managing and treating symptomatic sexually transmitted infections (STIs) in men and women.

This summary includes recommendations on case management for people with STIs and examination findings for urethral discharge syndrome, vaginal discharge syndrome, genital ulcer disease syndrome, and anorectal discharge.

Information on clinical presentations and laboratory diagnosis for each condition are not included in this summary. For a complete set of recommendations, refer to the full guideline.

For recommendations on management, including useful treatment tables, view our related summary on the management and treatment of symptomatic STIs. 

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Case Management for People with STIs

History-taking and Risk Assessment

• History-taking, with emphasis on sexual history, is important in establishing an understanding of the person’s likelihood of being infected with an STI. During history-taking, the patient should be asked about the last unprotected sexual contact and whether it was with a regular or casual sex partner
• Healthcare providers should be non-judgemental in their approach to history-taking and make their patients feel comfortable to discuss personal and intimate issues about their sex life
• Healthcare providers need to integrate history-taking of common health risk factors with sexual history risk factors.

Clinical Examination of People with STI-related Symptoms

• Once the medical and sexual history has been taken and the risk of STIs duly assessed, the person must be physically examined
• The examination must particularly focus on the anogenital area, but a general examination must also look for other manifestations of STIs, such as lymphadenopathy, cutaneous manifestations of some STIs (such as syphilis and human immunodeficiency virus [HIV]), and abdominal abnormalities, especially for women with pelvic inflammatory disease.

For steps to follow when examining men and women, how to perform a speculum examination, how to perform an anoscopy examination, and establishing a diagnosis, refer to the full guideline.

For recommendations on partner notification and treatment, see our second summary on the management and treatment of symptomatic STIs.

Urethral Discharge Syndrome

Examination Findings—Signs

• Most men with urethritis have urethral discharge, which may range in quantity from being scanty to copious and in character from being clear to purulent
• Distinguishing between discharge caused by gonorrhoea, chlamydia, or any other cause of urethritis is not clinically possible.

For recommendations on clinical presentation and laboratory diagnosis of urethral discharge syndrome, refer to the full guideline.

For recommendations on managing and treating urethral discharge, see our second summary on the management and treatment of symptomatic STIs.

Vaginal Discharge Syndrome

Trichomonas vaginalis

Examination Findings—Signs

• On examination, vulval erythema and oedema may be noted
• On speculum examination, a discharge of variable colour can be seen in the vagina—classically described as yellow or greenish and may be frothy
• The vaginal walls may be erythematous
• The cervix may have punctate haemorrhages, giving rise to what has been referred to as a ‘strawberry cervix’. Although this finding is uncommon, it is highly indicative of trichomoniasis.

Candidiasis

Examination Findings—Signs

• On examination, the vulva may be erythematous and excoriated
• The vulva and the labia may be swollen
• Some pimples with pus-filled (pustulopapular) lesions peripheral to the erythematous area of the vulva may be present
• Speculum examination shows the vaginal wall to be erythematous, and an adherent discharge may be seen, either curd-like or homogeneously white. The cervix looks normal.

Bacterial Vaginosis

Examination Findings—Signs

• On external visual examination and digital examination of the vagina, the thin, white, homogenous discharge may be observed externally on the posterior fourchette of the vulva or the labia
• If speculum examination is feasible, the homogeneous discharge may be observed to be adherent to the vaginal wall, and the cervix is usually normal in appearance.

Cervical Infection—Gonococcal and/or Chlamydial Cervicitis

Examination Findings—Signs

• Speculum examination may reveal a normal-looking cervix in the presence of endocervical infection
• For those with abnormalities, the cervix may be erythematous or severely eroded and associated with a mucopurulent cervical discharge. The cervix may be friable and bleed easily on contact.

For recommendations on clinical presentation, microscopy, molecular detection, culture methods, laboratory diagnosis of bacterial vaginosis, and risk factors for STI-related cervical infections, refer to the full guideline.

For recommendations on managing and treating vaginal discharge, vaginal infections, and lower abdominal pain, see our second summary on the management and treatment of symptomatic STIs.

Genital Ulcer Disease Syndrome

Herpes Simplex Virus

Examination Findings—Signs

• Among both men and women, a cluster of vesicopustular or ulcerative lesions is observed on the external genitalia (penis, urethral meatus, scrotum, pubic area, and vulva) or on the anal and perianal areas (anus and buttocks)
• The patients may describe them as having started as papules or vesicles that spread rapidly. Multiple small vesicular lesions may coalesce into large ulcers
• Most people with herpes simplex virus 2 (HSV-2) infection present at later stages of ulceration and hardly show the typical vesicles of early HSV-2 manifestation. However, when a person has a typical appearance of a crop of vesicles or gives a history of recurrent ulcers, a presumptive diagnosis of genital herpes can be made and treatment tailored appropriately
• Among immunosuppressed individuals, these ulcers may persist and continue to expand laterally and superficially for a considerable period of time if not treated
• Since the ulceration of herpes is shallow (intraepidermal), residual scarring from these lesions is uncommon.

For recommendations on clinical presentation, molecular testing, culture methods, and serology for herpes simplex virus, refer to the full guideline.

Syphilis

Examination Findings—Signs

Primary Syphilis

• Primary syphilis comprises one or more ulcerated lesions called the chancre of syphilis at the site of initial infection. The lesions are minimally tender or nontender and may have characteristically indurated edges with a clean base
• Regional lymph nodes may be felt within the first week
• The mouth and anus must also be examined for ulcers. Ulcers heal even without treatment in 2–10 weeks.

Secondary Syphilis

• Secondary syphilis presents with signs of disseminated syphilis, about 3–6 weeks after infection, but this can be as long as 6 months. The manifestations may include any of the following:
  • a generalised maculo-papular rash that is usually asymptomatic or mildly itchy and may also be seen on the palms and plantar surfaces of feet
  • patchy alopecia
  • generalised lymphadenopathy
  • condylomata lata—hypertrophic lesions resembling flat warts in the moist areas, such as the labia and perineum, the folds of the foreskin, and around the anus that are teeming with spirochaetes and are therefore highly contagious, and
  • painless, shallow ulcers of the oral or genital mucous membranes (mucous patches) that are highly contagious.

For information on clinical presentation and diagnostics tests for primary and secondary syphilis, and on early and late latent syphilis, refer to the full guideline.

Haemophilus ducreyi (chancroid)

Examination Findings

• There are generally single or multiple ulcers on the penile shaft, the foreskin, or the glans penis, usually deep with an irregular edge and a red margin. There is usually no induration, and the base is granular or purulent. The ulcers are normally tender when being examined or when walking. Men may have unilateral or bilateral inguinal buboes
• However, chancroid ulcers often have atypical clinical appearances and may dispel suspicion of chancroid, with some small ulcers mimicking infected genital herpes
• In HIV infection, the ulcers may be less purulent and resemble syphilitic chancres. Also, people with immunosuppression may have rapidly aggressive and erosive chancroid ulcers to the point of anatomically destroying the genital organs.

For recommendations on clinical presentation and laboratory diagnosis of H. ducreyi, refer to the full guideline.

For recommendations on managing and treating genital ulcer disease, see our second summary on the management and treatment of symptomatic STIs.

Anorectal Discharge

Examination

• An examination for anal infections includes an external examination of the anus and, where available, an anoscopy. However, an anoscope is not available in most primary point-of-care settings, and an external examination may be the only practical procedure to observe a discharge, ulcers, or external warts.

For recommendations on managing and treating anorectal discharge, see our second summary on the management and treatment of symptomatic STIs.