Management and Treatment 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 management and treatment recommendations for urethral discharge syndrome, vaginal discharge syndrome, lower abdominal pain, 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 diagnosis and assessment, including examination findings, view our related summary on the diagnosis and assessment 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

Partner Notification and Treatment

• There are several approaches to partner notification for STIs:
  • the patient can be issued a contact-tracing card to give to the sexual partner(s) to invite them to attend for an assessment for STIs and be treated accordingly (patient referral partner notification)
  • the healthcare provider can obtain contact details from the index patient and then attempt to contact the sexual partners (provider referral partner notification)
  • the index case may be given a prescription or medicines to give to their sexual partners without the healthcare provider having the opportunity to examine the sexual partner (expedited partner therapy)
  • an agreement can be made between the service provider and the index patient that the latter will reach the sexual partner(s) within an agreed time frame, after which the healthcare provider will then try to contact the sexual partner if the agreement period has elapsed without the sexual partners presenting for examination and treatment (sometimes referred to as a contractual partner referral)
• Regardless of which method of partner notification and treatment is followed, confidentiality, non-judgemental attitudes, and the absence of coercion must be observed.

For recommendations on healthcare education and counselling, follow-up and referral, diagnostic tests for asymptomatic and symptomatic people with STIs, and implementing the syndromic approach for the management of STIs, refer to the full guideline.

For recommendations on history-taking, risk assessment, and clinical examination of people with STI-related symptoms, see our summary on the diagnosis and assessment of symptomatic STIs.

Urethral Discharge Syndrome

For recommendations on examination findings for urethral discharge, see our summary on the diagnosis and assessment of symptomatic STIs.

Recommendations for the Management of Urethral Discharge

• For people with symptoms of urethral discharge from the penis, management is recommended to be based on the results of quality-assured molecular assays. However, in settings with limited or no molecular tests or laboratory capacity, WHO recommends syndromic treatment to ensure treatment on the same day of the visit (strong recommendation; moderate-certainty evidence)
• Good practice includes:
  • taking a medical and sexual history and assessing the risk of STIs
  • performing a physical examination of the genital and anal areas, and
  • offering HIV and syphilis testing and other preventive services as recommended in other guidelines.

Settings with quality-assured molecular testing in a laboratory with a fully operational quality-management system and results available on the same day of the visit

• WHO recommends the following (strong recommendation; moderate-certainty evidence):

1. Perform molecular assays such as nucleic acid amplification testing (NAAT) to confirm or exclude Neisseria gonorrhoeae and Chlamydia trachomatis
2. Treat according to the test results on the same day. If urethral discharge is present but tests are negative, treat for non-gonococcal and non-chlamydial urethritis (such as Mycoplasma genitalium or Trichomonas vaginalis)
3. When treatment based on molecular assays is not feasible on the same day of the visit, WHO recommends syndromic treatment of infection with N. gonorrhoeae and C. trachomatis and using the test results to support managing the partner when tests are available
4. Treat people with recurrent or persistent urethral discharge based on a repeat molecular assay (such as NAAT) after 21 days, testing for N. gonorrhoeae, C. trachomatis, M. genitalium, and T. vaginalis, and antimicrobial-resistant N. gonorrhoeae. 

Settings in which same-day treatment is not feasible with molecular testing or with limited or no molecular testing

• WHO suggests the following (conditional recommendation; low-certainty evidence):

1. Treat people who have urethral discharge confirmed on examination for N. gonorrhoeae and C. trachomatis to ensure same-day treatment
2. Treat people with recurrent or persistent urethral discharge for treatment failure based on WHO guidelines and review

• Good practice includes:
  • if symptoms persist at review, checking partner notification and treatment history, and
  • for people with recurrent or persistent urethral discharge, referring people to a centre with laboratory capacity to diagnose N. gonorrhoeae, C. trachomatis, M. genitalium, and T. vaginalis, and to test for antimicrobial-resistant N. gonorrhoeae and M. genitalium.

Table 1: Treatment Recommendations for Urethral Discharge

Vaginal Discharge Syndrome

For recommendations on examination findings for vaginal discharge syndrome, see our summary on the diagnosis and assessment of symptomatic STIs.

Recommendations for the Management of Vaginal Discharge

• For people with symptoms of vaginal discharge, WHO recommends treatment for N. gonorrhoeae and/or C. trachomatis, and/or T. vaginalis on the same visit. WHO suggests treatment based on the results of quality-assured molecular assays for N. gonorrhoeae and/or C. trachomatis, and/or T. vaginalis. In settings in which treatment based on the results of molecular assay in the same visit is not feasible or that have limited or no molecular testing, WHO suggests treatment based on testing with quality-assured rapid point-of-care tests or syndromic treatment (strong recommendation; moderate-certainty evidence)
• For people with symptoms of vaginal discharge, good practice includes:
  • taking a medical and sexual history and assessing the risk of STIs
  • performing a physical examination (including abdominal and pelvic examination) to assess for pelvic inflammatory disease, surgical conditions, or pregnancy, and an external vulvovaginal examination to visualise any lesions, overt genital discharge, or vulval erythema and excoriations
  • bimanual digital examination of the vagina to assess for:
    • cervical motion tenderness or pain with palpation of the pelvic area to exclude pelvic inflammatory disease, and 
    • the presence of vaginal discharge and the colour and consistency of the discharge on the glove
  • offering HIV and syphilis testing and other preventive services as recommended in other guidelines.

Settings in which treatment is based on quality-assured molecular assays in a laboratory with a fully operational quality-management system and results available on the same day of the visit

1. WHO recommends treating N. gonorrhoeae and/or C. trachomatis, and/or T. vaginalis based on the results of quality-assured molecular assays on a self-collected, or clinician-collected, vaginal swab or on a urine specimen (strong recommendation; moderate-certainty evidence)
2. WHO suggests treating for bacterial vaginosis if vaginal discharge is present (for example, tenacious or thin) or based on the results of microscopy, if available (strong recommendation; moderate-certainty evidence)
3. WHO suggests treating for candidiasis where indicated by type of discharge (such as curd-like with vaginal itching) or by the results of microscopy, if available (strong recommendation; moderate-certainty evidence).

Settings in which same-day treatment is not feasible with molecular testing or with limited or no molecular testing

• WHO suggests the following (conditional recommendation; low-certainty evidence):

1. Treating based on a quality-assured rapid test with a minimum sensitivity of 80% and specificity of 90%, if available, to confirm or exclude infection with N. gonorrhoeae and C. trachomatis 
2. If the availability of a low-cost rapid test or molecular assay is limited, consider performing a speculum examination, treating for N. gonorrhoeae and C. trachomatis if there is evidence of cervicitis, and performing a low-cost rapid test or molecular assay for people with a negative speculum examination who are at high risk of infection with N. gonorrhoeae and C. trachomatis and treating based on the test results
3. If a rapid test is not available, treat people who have signs of cervicitis on speculum examination for infection with N. gonorrhoeae and C. trachomatis
4. If a rapid test is not available and a speculum examination is not feasible or acceptable, treat people for N. gonorrhoeae and C. trachomatis, all people at high risk of STIs, and all people who have vaginal discharge on genital examination
5. Treating people for bacterial vaginosis and T. vaginalis if vaginal discharge is present or based on the results of microscopy, if available
6. Treating people for candidiasis, where indicated, by type of discharge (such as curd-like with vaginal itching) or by the results of microscopy, if available

• Good practice includes the following:
  • for people with recurrent or persistent vaginal discharge, good practice includes referring to a centre with laboratory capacity to diagnose infection with N. gonorrhoeae, C. trachomatis, M. genitalium, and T. vaginalis, as well as bacterial vaginosis, and to test for antimicrobial-resistant N. gonorrhoeae and M. genitalium (if there is a test), or for a specialist’s assessment (STI expert and physician or a gynaecologist), when no such testing is available in primary healthcare centres.

Table 2: Treatment Options for Vaginal Infections

Table 3: Treatment Options for Cervical Infection

Lower Abdominal Pain

Recommendations for the Management of Lower Abdominal Pain Among Women

• For sexually active women with symptoms of lower abdominal pain, WHO suggests assessing for pelvic inflammatory disease and treating syndromically (conditional recommendation; low-certainty evidence)
• Good practice includes:
  • taking a medical and sexual history and assessing the risk of STIs
  • performing a physical examination (including abdominal and pelvic examination) to assess for pelvic inflammatory disease, surgical conditions, or pregnancy, and a vulvovaginal examination to visualize any lesions, overt genital discharge, vulval erythema, and excoriations
  • performing a bimanual digital examination of the vagina to:
    • assess for cervical motion tenderness or pain with palpation of the pelvic area to exclude pelvic inflammatory disease, and
    • assess for the presence of vaginal discharge and the colour and consistency of the discharge on the glove
  • offering HIV and syphilis testing and other preventive services as recommended in other guidelines
• For sexually active women with lower abdominal pain and either cervical motion tenderness or lower abdominal tenderness on clinical examination (bimanual palpation), WHO suggests the following (conditional recommendations; moderate-certainty evidence):
  • treat pelvic inflammatory disease on the same visit
  • test for infection with N. gonorrhoeae and C. trachomatis, and if available, M. genitalium, to support partner management when tests are available
  • schedule a follow-up assessment 3 days later to assess for clinical improvement, and if the woman has not improved, refer for further assessment
• For women with lower abdominal pain and any of the following conditions, good practice includes referral to surgical or gynaecological assessment:
  • missed or overdue period
  • recent delivery, abortion, or miscarriage
  • abdominal guarding and/or rebound tenderness
  • abnormal vaginal bleeding in excess of spotting
  • abdominal mass, and
  • detection of a suspected cervical lesion.

Table 4: Treatment Options for Pelvic Inflammatory Disease

• Hospitalisation of people with acute pelvic inflammatory disease should be seriously considered under the following circumstances:
  • the diagnosis is uncertain
  • surgical emergencies, such as appendicitis and ectopic pregnancy, cannot be ruled out
  • a pelvic abscess is suspected
  • severe illness precludes management on an outpatient basis
  • the person is pregnant
  • the person is unable to follow or tolerate an outpatient regimen, or
  • the person has failed to respond to outpatient therapy.

Genital Ulcer Disease Syndrome

For recommendations on examination findings for genital ulcer disease syndrome, see our summary on the diagnosis and assessment of symptomatic STIs.

Recommendations for the Management of Genital Ulcer Disease, Including Anorectal Ulcers

• For people who present with genital ulcers (including anorectal ulcers), WHO recommends treatment based on quality-assured molecular assays of the ulcer. However, in settings with limited or no molecular tests or laboratory capacity, WHO recommends syndromic treatment to ensure treatment on the same day of the visit (strong recommendation; moderate-certainty evidence)
• Good practice includes:
  • taking a medical and sexual history and assessing the risk of STIs
  • performing a physical examination of the genital and anal areas
  • offering HIV and syphilis testing and other preventive services as recommended in other guidelines, and
  • providing analgesics for pain.

Settings with quality-assured molecular testing in a laboratory with a fully operational quality-management system and results available on the same day of the visit

• For people with confirmed anogenital ulcers, WHO recommends the following (strong recommendation; moderate-certainty evidence):

1. Perform molecular assays (NAAT) from anogenital lesions to confirm or exclude herpes simplex virus and Treponema pallidum (syphilis)
2. Perform molecular assays from anogenital lesions to confirm lymphogranuloma venereum in the geographical settings and/or populations in which cases are reported or emerging
3. Perform serological tests for syphilis, with appropriate interpretation for management depending on the test or tests used
4. Treat for syphilis and/or herpes simplex virus according to the results available on the same day of the visit, or treat syndromically and revise management according to the results when available
5. Treat for lymphogranuloma venereum when the results are positive
6. Treat for chancroid only in geographical settings where cases are reported or emerging.

Settings in which same-day treatment is not feasible with molecular testing or with limited or no molecular testing

• For people with confirmed anogenital ulcers, WHO suggests the following (conditional recommendation; moderate-certainty evidence):

1. Treat syndromically for syphilis and herpes simplex virus on the same day
2. Treat for herpes simplex virus if the ulcer is recurrent or vesicular, and treat for syphilis if the person has no history of recent treatment for syphilis (in the past 3 months)
3. Treat for chancroid only in geographical settings where cases are reported or emerging

• Good practice includes:
  • performing serological tests for syphilis, including a rapid plasma reagin equivalent test, if available, to attempt to identify active syphilis and for monitoring the response to treatment, and
  • referring men with persistent anogenital ulcers to a centre with laboratory capacity and expertise to diagnose herpes or less common pathogens (lymphogranuloma venereum, donovanosis, and chancroid) and other genital or gastrointestinal conditions.

Table 5: Treatment of Genital Ulcer Disease, Including Anorectal Ulcers

Anorectal Discharge

For recommendations on examination of anorectal discharge, see our summary on the diagnosis and assessment of symptomatic STIs.

Recommendations for the Management of Anorectal Discharge

• For people with symptoms of anorectal discharge and who report receptive anal sex, WHO recommends management based on the results of quality-assured molecular assays. However, in settings with limited or no molecular tests or laboratory capacity, WHO recommends syndromic treatment to ensure treatment on the same day of the visit (strong recommendation; moderate-certainty evidence)
• Good practice includes:
  • taking a medical and sexual history and assessing the risk of STIs
  • performing a physical examination of the genital and perianal areas and a digital rectal examination, if acceptable (and anoscopy, if available and acceptable)
  • offering HIV and syphilis testing and other preventive services as recommended in other guidelines, and
  • referring for other investigations when anorectal discharge is unrelated to an STI, such as other gastrointestinal conditions.

Settings with quality-assured molecular testing in a laboratory with a fully operational quality-management system and results available on the same day of the visit

WHO recommends the following (strong recommendation; moderate-certainty evidence):

1. Perform molecular assays (NAAT) using a self-collected or clinician-collected anorectal swab to confirm or exclude infection with N. gonorrhoeae and/or C. trachomatis and treat the individual infections detected
2. Treat, additionally, for herpes simplex virus if there is anorectal pain
3. Follow the genital ulcer guidelines if ulceration is present.

Settings in which same-day treatment is not feasible with molecular testing or with limited or no molecular testing

WHO suggests the following (conditional recommendation; moderate-certainty evidence):

1. Treat for N. gonorrhoeae and C. trachomatis if discharge is present
2. Treat, additionally, for herpes simplex virus if there is anorectal pain

• Good practice includes:
  • following the genital ulcer guidelines if ulceration is present, and
  • referring people with persistent anorectal discharge to a centre with laboratory capacity to diagnose N. gonorrhoeae, C. trachomatis (including lymphogranuloma venereum serovars), and M. genitalium and determine antimicrobial resistance for N. gonorrhoeae and M. genitalium.

Table 6: Treatment Options for People with Anorectal Discharge