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3

Common genital and urinary infections

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Contents

Objectives

When you have completed this chapter you should be able to:

Introduction to genital infections

3-1 What are genital infections?

They are infections of the vulva, vagina, cervix, uterus and Fallopian tubes (the female genital tract). The vulva, vagina and cervix form the lower genital tract while the uterus, Fallopian tubes and ovaries form the upper genital tract.

3-2 Why are genital infections important?

Because they are common and some can result in serious illness, sterility, and even death. However, many genital infections are mild and cause no symptoms or signs.

Genital infections can cause serious problems for the fetus if the woman is pregnant while she has the infection.

3-3 What are sexually transmitted infections?

Sexually transmitted infections (STIs) are genital tract infections which are usually transmitted by person-to-person sexual contact (vaginal, anal or oral sex). However, not all genital infections are sexually transmitted.

It has been estimated that 11 million South Africans each year are infected with a sexually transmitted illness.

Note
STIs are also known as sexually transmitted diseases (STDs). However, it is best to call them STIs to emphasise that they are infectious.

3-4 Which organisms cause genital infections?

Genital infections may be caused by a wide range of organisms including bacteria, viruses, fungi or protozoa.

Many different organisms can cause genital infections.

3-5 How are genital infections clinically recognised?

By their symptoms (what the patient complains of) and clinical signs (what the health worker observes on clinical examination). From the symptoms and signs it is sometimes possible to guess the most likely organism causing the infection. However the guess may be incorrect and there may be more than one type of organism causing a similar clinical presentation. Therefore treatment is based on the symptoms and signs rather than on identifying a specific organism.

Often the organism causing the genital infection cannot be identified by the clinical presentation.

3-6 How can the cause of a genital infection be confirmed?

By asking for the appropriate laboratory investigations or side-room tests. These laboratory and side-room tests require skilled staff and special equipment, and are often expensive. As a result, these investigations are often not available to primary-care nurses and doctors. Even when they are available, they may not identify the one organism or many organisms involved. Therefore treatment is seldom based on a laboratory diagnosis, even when these investigations are available.

Laboratory tests to identify the organisms causing genital infections may not be available or reliable.

3-7 How should genital infections be managed in a primary-care setting?

The best method of managing genital infections in a primary-care setting is the syndromic approach.

3-8 What is the syndromic approach to managing women with genital infections?

Genital infections can be grouped into a limited number of syndromes. Each syndrome presents with its own typical symptoms and signs although the syndrome may be caused by a number of different organisms. Treatment is based on the clinical presentation, and not on the results of laboratory investigations, and covers the whole range of organisms which can cause that particular syndrome. The syndromic approach treats the clinical presentation and not a specific disease. The aim of treatment is to provide rapid relief of symptoms, to treat all infections effectively and to prevent future genital infections in the patient and her partner.

The syndromic approach is used to treat women who present with a pattern of symptoms and clinical signs.

3-9 What are the advantages of a syndromic approach to genital infections?

The syndromic approach has many advantages. It does not rely on laboratory investigations to identify the organism causing the infection. It is simple, cheap, can be standardised and is easy to teach. The syndromic approach provides satisfactory treatment to most women with genital infections.

The syndromic approach does not require laboratory tests to identify the organism causing the infection.

Note
The World Health Organisation introduced and recommended the syndromic approach to managing STIs in 1991.

3-10 What are the common syndromes in women with genital infections?

Women with a genital infection usually complain of one of the following syndromes:

Each presentation (syndrome) is recognised on history and clinical examination alone without the need for laboratory or side-room tests. Each syndrome can occur on its own or in combination with one or more of the other syndromes.

Note
Sometimes these symptoms and signs are not due to a genital infection but due to another cause such as a malignancy, a complication of pregnancy or urinary tract infection.

Vaginal discharge

3-11 Is a vaginal discharge always abnormal?

No. A vaginal discharge may be normal and not a sign of infection. Many healthy women have a mild vaginal discharge which is normal and does not need to be treated. A normal vaginal discharge in healthy women is common after intercourse, during pregnancy and at the time of ovulation. Women rarely ask for treatment if they have a normal discharge.

A vaginal discharge may be normal.

3-12 When does a vaginal discharge suggest a genital infection?

The symptoms and signs of an abnormal vaginal discharge which suggests a genital infection are:

Women usually know if they have an abnormal vaginal discharge which is different from any normal discharge they are used to. They may also have discomfort on passing urine (dysuria) and itching or burning of the vulva.

An abnormal vaginal discharge may be due to infection of the vagina (vaginitis) or cervix (cervicitis) or both. It may also be a sign of upper genital tract infection (uterus and Fallopian tubes).

Vaginitis is common and usually not serious. Cervicitis and upper genital tract infections are less common, and may result in serious complications.

A blood-stained vaginal discharge, not around the time of menstruation, must always be investigated as it may be a sign of cancer of the cervix or uterus.

3-13 What are the common infectious causes of a vaginal discharge?

A vaginal discharge may have many different causes.

3-14 Are all organisms causing genital infections sexually transmitted?

No. Most are, but some infections of the vulva and vagina, such as candidiasis and bacterial vaginosis are not necessarily transmitted sexually.

Sexually transmitted infections such as Trichomonal infection, Chlamydial infection and gonorrhoea are very common in southern Africa.

3-15 What are the typical features of vaginal candidiasis?

Vaginal candidiasis (monilia or ‘thrush’) is a common cause of vaginitis which presents as a thick white discharge. It often does not cause much discomfort, but sometimes it can cause severe irritation and itching of the vulva (the skin around the opening of the vagina). Women may also complain of burning after passing urine. In this case the skin of the vulva can be red and often shows signs of scratching. Mild candidiasis is very common and causes little discomfort. It usually is not sexually transmitted, but may present after a woman has had a course of antibiotics. It may also be a sign of diabetes or HIV infection, especially if recurrent.

Candida infection is a common cause of vaginitis and presents with discharge and severe vulval itching.

Note
Candidiasis (moniliasis) of the vulva and vagina (vulvovaginitis) is caused by a fungus, Candida albicans. The discharge may appear cheesy and white patches may be seen on the vaginal walls on speculum examination. The vaginal epithelium and vulval skin appears red and inflamed. The clinical diagnosis can be confirmed by seeing fungi on microscopy of the discharge in a wet preparation with 5% potassium hydroxide. With the syndromic approach laboratory confirmation is not needed.

3-16 What are the typical features of trichomonal infection?

Trichomonal infection is another common cause of vaginitis and usually presents with an offensive (unpleasant) smell, burning, and a yellow-green discharge. There is often pain on passing urine (dysuria). It is usually sexually transmitted.

Note
The infection is caused by Trichomonas vaginalis, a protozoa which may be seen on microscopy of a wet preparation with normal saline of the discharge.

Trichomonal infection is a common causes of vaginitis and presents with an unpleasant-smelling discharge.

3-17 What are the typical features of gonorrhoea and chlamydia infection in a woman?

Gonorrhoea and chlamydia infection are both sexually spread and can cause similar symptoms and signs. It is therefore clinically difficult to decide which infection is present. As the two infections often occur together it is best to always treat for both. Both infections present with a vaginal discharge while gonorrhoea may also cause a painful abscess in the labia.

Note
Gonorrhoea is caused by Neisseria gonorrhoea and results in cervicitis. Diagnosis is confirmed by Gram’s stain or culture.

3-18 What are the dangerous complications caused by gonorrhoea and chlamydia infections?

Both gonorrhoea and chlamydia infection may spread to the Fallopian tubes and cause severe abdominal pain. This is a dangerous complication that requires urgent referral to hospital.

Gonorrhoea and chlamydia infection may both spread to the Fallopian tubes and cause severe complications.

3-19 What is bacterial vaginosis?

Bacterial vaginosis is a common cause of recurrent vaginal discharge. The discharge has a typical ‘fishy’ smell, especially after intercourse or during menstruation. Bacterial vaginosis is usually not sexually transmitted.

The discharge of bacterial vaginosis has a fishy smell.

Note
Bacterial vaginosis is caused by the overgrowth of Gardnerella vaginalis and other anaerobic bacteria which displace the normal vaginal flora. The vaginal pH is greater than 4.5, instead of being acidic. A normal acidic pH suppresses the growth of normal vaginal organisms.

3-20 How is cervicitis diagnosed?

Diagnosing cervicitis is not easy without an internal examination. Patients usually complain of vaginal discharge and may have pain during intercourse (dyspareunia) or an internal examination. Therefore, management of a vaginal discharge should cover both vaginitis and cervicitis.

Cervicitis is usually caused by gonorrhoea or chlamydia infection.

Note
On speculum examination the infected cervix appears red and swollen with a yellow discharge.

3-21 What is the syndromic management of women with an abnormal vaginal discharge?

Management should treat all the common causes of a vaginal and cervical infection. Therefore a combination of drugs is usually used. The choice of drugs depends on whether the patient is sexually active or not.

  1. If she has not had any vaginal sex in the past three months, she should be treated with metronidazole 2 g as a single dose. It is important that she should not drink any alcohol for 24 hours after the dose as a combination of metronidazole and alcohol causes severe nausea and vomiting.
  2. If she has had sex in the past three months, the presence of other organisms must be considered and she should be treated with a combination of:
    • A single dose of metronidazole 2 g orally
    • A single dose of cefixime 400 mg orally
    • Doxycycline 100 mg 12-hourly for 7 days. If she is pregnant or breastfeeding, amoxycillin 500 mg 8-hourly for 7 days should be used instead.
    • Her sexual partner should be treated with the same doses of cefixime and doxycycline
  3. If she has a thick white discharge or her vulva is red and itching, she should also receive:
    • One 500 mg clotrimoxazole tablet inserted vaginally or (if vaginal irritation is severe) clotrimoxazole vaginal cream applied twice a day until 3 days after the symptoms have disappeared.
  4. She should return in 7 days if the symptoms continue:
    • If the vulval redness and itching has not recovered, repeat the clotrimoxazole and screen her for diabetes.
    • If she still has a vaginal discharge, but no vulval redness and itching, refer to hospital for further investigation and treatment.

It is important to provide the correct treatment to women who present with the syndrome of vaginal discharge.

Note
Gonorrhoea is treated with cefixime, chlamydia with doxycycline, trichomonas and bacterial vaginosis with metronidazole, and candida with clotrimazole.

3-22 What are the danger signs in a woman with a vaginal discharge?

Any of these suggests acute pelvic inflammatory disease.

Note
Pain when the cervix is moved on vaginal examination also suggests acute pelvic inflammatory disease. Guarding or rebound tenderness of the lower abdomen may be present.

3-23 What is acute pelvic inflammatory disease?

Acute pelvic inflammatory disease is an infection of the upper genital tract. It is usually a complication of lower genital infection caused by gonorrhoea or chlamydia. Patients may present with fever, abdominal pain and an abdominal mass. Infection may spread to the peritoneum (peritonitis) or even cause septicaemia and spread to other parts of the body. This can be fatal and therefore needs urgent treatment.

A history of lower abdominal pain or fever is very important in women with vaginal discharge.

Lower abdominal pain and fever are important danger signs in women with vaginal discharge.

3-24 How should a woman with acute pelvic inflammatory disease be managed as an outpatient?

She should receive all of the following:

Note
Although most protocols give a 14-day course of treatment, 10 days of doxycycline for Chlamydia and 7 days of metronidazole for anaerobic bacteria should be adequate.

3-25 Which women should be referred to hospital?

Women should be urgently referred to the hospital if they:

It is very important to always do a pregnancy test on women presenting with lower abdominal pain. If she is pregnant she may have an ectopic pregnancy, a threatened miscarriage or a pregnancy complication such as septic miscarriage or post-partum uterine sepsis.

Note
Appendicitis or severe urinary tract infection may also cause fever, abdominal pain and severe illness.

Always do a pregnancy test in women with lower abdominal pain.

3-26 What long-term complication may result from acute pelvic inflammatory disease?

Pelvic inflammatory disease may increase the risk of an ectopic pregnancy or infertility due to damage to the Fallopian tubes, even if adequately treated.

Note
Gonorrhoea and chlamydial infection are important causes of infertility and ectopic pregnancy.

Genital ulcers

3-27 What is the clinical presentation of genital ulcers?

Women usually complain that they have an ulcer or sore on their genitalia. The ulcers or sores may be single or multiple, small or large, very painful or not painful at all. A single ulcer may not be obvious unless the labia are carefully examined.

Patients with genital ulcers may also have inguinal swelling (enlarged lymph nodes in the groin).

A syndromic approach is also used to manage patients with genital ulcers. However, the clinical presentation of genital ulcers often suggest which causative organism is involved. Therefore it is helpful to learn more about the typical presentations.

3-28 What are the common infections which present with genital ulcers?

Note
Less commonly lymphogranuloma venereum (due to Chlamydia trachomatis) and granuloma inguinale (due to Calymmatobacterium granulomatis) cause genital ulcers, often with marked inguinal lymphadenopathy. The lymph nodes may break down and suppurate.

Syphilis, herpes and chancroid all present with genital ulcers.

3-29 What is the typical presentation of syphilis?

Syphilis is a sexually transmitted infection which usually presents as a painless, firm ulcer somewhere on the genitalia. Soon afterwards painless swellings can be felt in both inguinal regions.

This may be followed 6 to 8 weeks later by a generalised skin rash or flat, moist warts (condyloma lata) on the genitalia. The patient may also be generally unwell.

However, some patients with syphilis may not present with typical symptoms or signs or may remain clinically well for many years.

Note
Syphilis is caused by Treponema pallidum. In primary syphilis (the first stage of syphilis), an ulcer (chancre) develops 2 to 4 weeks after infection. If untreated this may be followed by secondary syphilis with fever, macular rash, flat genital warts and general illness. These lesions must not be confused with genital warts caused by human papillomavirus. With no treatment, this can be followed many years later by tertiary syphilis with cardiac and neurological disease.

3-30 How is the clinical diagnosis of syphilis is confirmed?

The VDRL or RPR tests can be used to screen for syphilis. If positive, they must be confirmed with a Rapid syphilis test, TPHA or FTA test. If both screening and confirming tests are positive, the patient has syphilis.

A positive VDRL test suggests syphilis.

All patients with a sexually transmitted disease should be screened for syphilis.

Note
The VDRL (Venereal Disease Research Laboratory) and RPR (Rapid Plasma Reagin) tests may still be negative in patients with primary syphilis but not with secondary syphilis. The Rapid syphilis test, TPHA (Treponema pallidum hemagglutination assay) and FTA (Fluorescent Treponema Antibody Absorption) tests remain positive for life even after syphilis has been successfully treated. Primary and secondary syphilis are treated with a single intramuscular injection of benzathine penicillin 2.4 million units. If allergic to penicillin, treat with erythromycin 500 mg 4 times a day for 14 days.

3-31 What is the typical presentation of herpes ulcers?

Herpes is a sexually transmitted infection which presents with many small, very painful ulcers on the genitalia. There may also be painful inguinal swelling on both sides and the patient feels generally ill. The ulcers start to heal after one to three weeks.

Some women have repeated attacks of genital herpes which start as an itching or burning feeling followed by painful ulcers which heal after a week or two. Recurrent herpes ulcers may appear even if the women has not had sex recently.

Genital herpes presents with many small, very painful ulcers.

Note
Genital herpes is caused by the Herpes simplex virus and presents a few days after infection. The diagnosis is usually made clinically and treated with analgesia and oral acyclovir 400 mg 8-hourly for 7 days. The lesions must also be kept clean and dry. Pain relief can be provided with paracetamol and if secondary infection is present also add erythromycin 500 mg 4 times a day for 7 days. Recurrent attacks of genital herpes can be a problem as they may present a long time after the initial infection.

3-32 What is the typical presentation of chancroid?

Chancroid is a sexually transmitted infection which presents with multiple painful papules (pimples) on the external genitalia. These soon break down into ulcers which may be painful or painless. They bleed easily if touched. A few days to weeks later, a painful, red inguinal swelling may develop on one side (bubo). This can become an abscess.

Note
Chancroid is caused by Haemophilus ducreyi. The diagnosis is usually made clinically. Treatment is ciprofloxacin 500 mg 12-hourly for three days. A fluctuant inguinal swelling should be aspirated.

3-33 What is the syndromic management of women with genital ulcers?

Both the patient and her partner should be treated with the following:

If the patient is allergic to penicillin, replace benzathine penicillin with ciprofloxacin 500mg orally 12-hourly for 3 days. If there is painful, red inguinal swelling (bubo), also treat for inguinal swelling.

If there is no improvement or the symptoms worsen after 7 days, refer for further investigation and treatment.

Note
Syphilis is treated with penicillin while herpes is treated with acyclovir. Women who are diagnosed with syphilis in pregnancy should get 3 doses of benzathine penicillin at weekly intervals. If they are allergic to penicillin treat with erythromycin 500 mg 6-hourly for 4 weeks.

Inguinal swelling

3-34 What is the clinical presentation of an inguinal swelling?

A lump or swelling in the groin (where the upper leg joins the abdomen). It is often warm, painful and tender when palpated. The swelling may only be on one side or may be on both sides. Usually the swelling is firm and has only been present for a few days. Sometimes the swelling is soft (fluctuates) and may form an abscess or discharge pus.

Note
The swelling is due to one or more inflamed inguinal lymph nodes. These nodes may also swell due to an infection of the foot or leg, which should be looked for.

3-35 What are the common causes of an inguinal swelling associated with genital ulcers?

However, in some patients the presentation may not be typical. Therefore the syndromic approach to management is used.

Note
Other causes are lymphogranuloma venereum and granuloma inguinale.

3-36 What is the syndromic approach of inguinal swelling associated with genital ulcers?

Syndromic treatment should be given for the genital ulcer. If bubo is present, both the patient and her partner should in addition be treated with both the following:

Note
Ciprofloxacin, doxycycline and erythromycin treats Haemophilus ducreyi.

3-37 Can genital infections spread to the fetus or newborn infant?

Syphilis may affect the fetus, causing stillbirth or severe disease in the newborn infant. Both gonorrhoea and chlamydia infection may cause neonatal conjunctivitis.

Other sexually transmitted viral infections

3-38 Can HIV infection cause genital syndromes?

No. HIV is a very important sexually transmitted infection, but it does not cause vaginal discharge or genital ulcers. Generalised lymph node enlargement is a common early clinical sign of HIV disease.

Because a number of genital infections are often transmitted at the same time, if one is diagnosed always look for others. Therefore it is advisable to screen all women with a genital infection for HIV, as they will be at increased risk.

3-39 Can genital syndromes increase the risk of HIV infection?

Infections of the lower genital tract presenting with vaginal discharge and genital ulcers make it easier for HIV to gain entry into the body and infect the woman. The risk of HIV infection is increased by genital syndromes.

3-40 Can hepatitis be caused by a sexually transmitted infection?

Yes. Hepatitis B virus is usually sexually transmitted in adults and is an important cause of both hepatitis and liver cancer. All children should be immunised against hepatitis B virus infection.

3-41 What are genital warts?

Common warts may occur on the vulva. They are caused by a wart virus which can be sexually spread. Small common warts are treated by applying 20% tincture of podophyllin solution directly to the wart and then washing it off after 4 hours. Repeat weekly until the warts have cleared. Make sure that the podophyllin does not get onto normal skin as it can be absorbed. Women with large warts (more than 10 mm) should be referred for treatment.

Flat, moist, ulcerating warts are a sign of secondary syphilis.

Pubic itch

3-42 Which parasites can cause itching in the pubic area?

Two common causes of itching in the pubic area are:

Both lice and scabies can be spread from person to person by close contact.

Counselling women with sexually transmitted infections

3-43 How can sexually transmitted infections be prevented?

An important part of managing women with genital infections is to prevent further infections in themselves and their partner or partners. Therefore all patients need counselling to reduce the risk of recurrence and the risk of spreading the infection to others. It is very important that the complete course of treatment is taken and that she does not have sex until the treatment is completed.

The best way of preventing genital infections is to abstain from sexual intercourse altogether, only have sex with one uninfected partner, or always use a condom (Abstain, Be faithful, Condomise). Sex with multiple partners is a dangerous practice and is a very important risk factor for sexually transmitted infections. This needs to be discussed in a non-judgemental way while promoting safer sex practices.

3-44 Should partners of infected women also be treated?

Yes. If a woman presents with a sexually transmitted genital infection, her partner or partners must also be treated, whether or not they have any symptoms or signs of genital infection. A urethral discharge and pain on passing urine are important symptoms of genital infection in men. The treatment of a partner without symptoms should be guided by the clinical presentation of the woman. Partners with symptoms should be treated according to the syndromic approach for men. She should not have sex with her partner until both are fully treated.

It is important that partners are also treated for sexually transmitted infections.

Acute urinary tract infections

3-45 What is a urinary tract infection?

The urinary tract consists of the kidneys, ureters, bladder and urethra. An infection of any part of the urinary tract is called a urinary tract infection (UTI).

3-46 What causes urinary tract infections?

Urinary tract infections are usually caused by bacteria commonly found in the bowel. The commonest bacteria causing an infection is E coli (Escherichia coli).

3-47 Are urinary tract infections common?

Yes. They are common especially in women. The reason is probably that women have a shorter urethra than men and therefore it is easier for bacteria to reach the bladder.

3-48 What are the common types of acute urinary tract infection?

There are two common types of acute urinary tract infection:

Note
Acute cystitis and acute pyelonephritis are also called uncomplicated UTI. A UTI becomes complicated when it occurs in patients who are catheterised, have an abnormal urinary tract or when it results in septicaemia (often with septic shock). Severe sepsis has a high mortality of 20-40%. UTI in pregnancy is also dangerous, and UTI screening and treatment must form part of antenatal care.

3-49 What is acute cystitis?

Infection of the bladder. This is the commonest form of urinary tract infection. While cystitis is usually a single event, repeated attacks of cystitis may occur. Occasionally the infection can become chronic.

Note
Chronic cystitis may be caused by tuberculosis or bilharzia

Acute cystitis is common in women.

3-50 What is the clinical presentation of acute cystitis?

The woman is generally well but complains of:

On examination there may be tenderness over the bladder.

3-51 How is the clinical diagnosis of acute cystitis made?

The diagnosis of acute cystitis can be made on clinical grounds. Women who complain of dysuria, frequency, nocturia and urgency and who do not have an abnormal vaginal discharge can be confidently diagnosed as having acute cystitis.

Acute cystitis can be diagnosed clinically

Where available a urine dipstick test can be done to look for pyuria (pus in the urine) and bacteriuria. However a urine dipstick test is not needed to confirm a clinical diagnosis of acute cystitis.

Note
The urine dipstick tests for the presence of white cells (leukocyte esterase) and bacteria (nitrites) in the urine. Positive results suggest a UTI but negative tests do not exclude a UTI.

3-52 What is the purpose of a urine culture?

A urine culture confirms the presence of bacteria in the urine and their susceptibility to antibiotics. Urine cultures should be performed in women who have suspected acute pyelonephritis or recurrent UTIs but they are not necessary in women with acute cystitis.

It is important to collect a clean catch mid-stream urine sample when sending urine for culture.

3-53 What is the management of acute cystitis?

Acute uncomplicated cystitis should be treated with a short course of oral antibiotics. The main purpose is to rapidly improve symptoms as even in the absence of antibiotics the infection usually goes away. In addition women should be encouraged to drink a lot of water.

There are several antibiotics which are suitable for the treatment of acute cystitis. Many hospitals have guidelines and these should be consulted to ensure that the correct agent is used and to avoid the development of antibiotic resistance. A common recommendation is the use of oral ciprofloxacin 500 mg as a single once off dose.

3-54 What is the cause of recurrent acute cystitis?

3-55 What is the management of recurrent cystitis?

Women with recurrent UTI require a urine culture to identify the type of bacteria and ensure that a correct antibiotic is given. Women with repeated episodes should be referred to a specialist if possible.

The risk of recurrent cystitis may be reduced by:

Note
Recurrent urinary tract infection which does not respond to standard treatment may indicate a congenital abnormality in the urinary tract.

3-56 What symptoms suggest acute pyelonephritis?

Most patients with acute pyelonephritis have severe general symptoms:

3-57 What physical signs are usually found in a patient with acute pyelonephritis?

The woman is acutely ill.

3-58 What is the management of a patient with acute pyelonephritis?

Note
If the bacterial culture from the urine is positive, the antibiotic may need to be changed, depending on the sensitivity of the bacteria.

All women with acute pyelonephritis during pregnancy must be admitted to hospital for treatment with a broad spectrum antibiotic intravenously.

3-59 Why is acute pyelonephritis a serious infection?

Because serious complications can result:

Septic shock usually presents with continuing hypotension in spite of adequate intravenous fluids. There is also failure of the clinical signs of acute pyelonephritis to improve rapidly within the first 72 hours of antibiotic treatment. If septic shock is diagnosed, intravenous gentamicin 80 mg must be given immediately, followed by a further 80 mg every 8 hours. Gentamicin must be added to any other antibiotic already given. The patient must also be transferred to a level 3 hospital.

Case study 1

A young woman presents at a primary-care clinic with a one-week history of an offensive yellow vaginal discharge. She is generally well and has recently started a new sexual relationship with an older man who has had a number of partners in the past two years. She also complains of pubic itch.

1. What is your clinical diagnosis?

She has a genital infection presenting as an abnormal vaginal discharge together with a pubic itch, probably caused by a parasite.

2. Why has she developed this problem?

The vaginal discharge is probably due to a sexually transmitted infection such as gonorrhoea or chlamydia. She has become infected by her new sexual partner who in turn may have been infected by a previous partner.

3. What is the best way of treating an abnormal vaginal discharge?

The syndromic approach should be used. This will make sure that the organism or organisms causing the infection will be correctly treated. The description of her vaginal discharge suggests gonorrhoea or a chlamydia infection or both. The discharge could be caused by another organism.

4. What treatment should be given for the vaginal discharge?

She should be treated with a single oral dose of metronidazole and cefixime as well as oral doxycycline 12-hourly for 7 days. She should return in 7 days if the vaginal discharge has not cleared. Her partner should also be treated.

5. What two parasites may cause pubic itch?

Lice and scabies.

6. What is the treatment of pubic lice or scabies?

She should be treated with local 25% benzyl benzoate.

7. What counselling must she receive?

Both her and her partner should be counselled about ways to prevent further sexually transmitted genital infections. They should also be screened for syphilis and HIV infection.

Case study 2

An older obese woman gives a two-week history of a thick white vaginal discharge. She also complains of severe vaginal itching. On examination her labia are very red. She has not had a sexual relationship since her husband died five years back.

1. What is the likely cause of her vaginal discharge?

Probably candidiasis which typically causes an irritating thick white discharge. As she has not had a sexual relationship for many years this will not be a sexually transmitted infection.

2. Is this a common cause of vaginal discharge?

Yes. It is often mild and causes few problems. Sometimes vaginal candidiasis follows a course of antibiotics.

3. How should this woman be treated?

With vaginal clotrimoxazole. As she has not had sex recently she needs no other treatment.

4. Could this woman have a medical condition?

Diabetes may present with severe or recurrent vaginal candidiasis. She may also be HIV positive.

5. What other infections commonly cause a vaginal discharge?

Trichomonal infection and bacterial vaginosis. While trichomonal infection is usually sexually spread, bacterial vaginosis often occurs in women who are not in a sexual relationship.

6. What infection causes a vaginal discharge with a fishy smell and how is it treated?

Bacterial vaginosis. It is treated using the syndromic approach with multiple antibiotics.

Case study 3

A commercial sex worker presents with a number of small, very painful ulcers on her vulva. She is feeling generally unwell and also has painful inguinal swelling on both sides.

1. What is the most likely diagnosis?

Genital herpes, which is a sexually transmitted infection.

2. Can this also cause inguinal swelling?

Yes. Herpes typically causes painful inguinal swelling.

3. Could this be syphilis?

Very unlikely, as a syphilic ulcer is usually firm, single and is not painful. Inguinal swelling with syphilis is also not painful. However it would be wise to screen this woman for syphilis as more than one sexually transmitted disease often occur in the same patient.

4. What test is used for screening for syphilis.

The VDRL or RPR test.

5. How should she be treated?

With the syndromic approach to a genital ulcer. This consists of a single intramuscular dose of benzathine penicillin and 7 days of both oral erythromycin and acyclovir. Refer for further investigation and treatment if she has not improved after 7 days.

6. Which genital infection causes painful red inguinal swellings?

This is called bubo and is caused by chancroid. The inguinal swelling may become an abscess.

Case study 4

A woman with a yellow vaginal discharge for the past week presents with a one-day history of fever and abdominal pain.

1. What is her clinical problem?

She probably has a lower genital tract infection which has spread to the upper genital tract.

2. What is this complication called?

Acute pelvic inflammatory disease. These patients may become seriously ill if the infection spreads to the peritoneum to give peritonitis.

3. How is it treated?

With a single dose of ceftriaxone together with 14 days of oral doxycycline and metronidazole. Seriously ill patients or patients with no response after 72 hours of treatment must be referred to hospital for further investigation and treatment.

4. What are chronic complications of this condition?

Ectopic pregnancy, infertility and chronic abdominal pain.

5. Can HIV cause a genital infection?

No, but genital discharge or ulcer increases the risk of infection if the woman has sexual intercourse with an HIV-positive partner.

6. How can the risk of genital infection be reduced?

Abstain from sexual intercourse, only have intercourse with one uninfected partner and always use a condom.

7. Which genital infections can result in infection in a newborn infant?

Syphilis, gonorrhoea and chlamydia.

Case study 5

A young, sexually active woman presents at a local clinic complaining of pain when passing urine and having to pass urine more frequently than usual, especially at night. She is generally well with no fever or vaginal discharge.

1. What is the most likely clinical diagnosis?

Acute cystitis as dysuria, frequency and nocturia are the usual presenting symptoms. This is a common condition in sexually active women.

2. Could she have acute pyelonephritis?

This would be very unlikely as women with acute pyelonephritis are generally ill with a high fever. They often have pain and tenderness over the kidney area.

3. Does this woman need any special investigations?

No as acute cystitis is usually a clinical diagnosis. Urine dipsticks analysis is of little value in deciding whether to treat or not. A mid stream urine sample for culture is only indicated if you suspect that the patient has acute pyelonephritis.

4. Could these symptoms be due to a vaginal infection?

This is unlikely as she has no vaginal discharge.

5. What treatment is needed?

Oral ciprofloxacin 500 mg as a single once off dose is usually used.

6. How may the risk of acute cystitis be reduced in this woman?