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Department of Reproductive Health and Research (RHR), World Health Organization

Sexually transmitted and other reproductive tract infections

A guide to essential practice



Annex 1. Clinical skills needed for STI/RTI management


History taking

Because of the stigma associated with STI/RTI, patients are often reluctant to talk about their condition. To make patients feel more comfortable during the history-taking and examination, health care providers should be interested and sympathetic, not distracted or judgemental.

  • Welcome your patient.
  • Encourage your patient to talk.
  • Look at your patient.
  • Listen to your patient.

A sexual history can provide useful information for guiding decisions about STI/RTI management, or additional examinations or tests that might benefit the patient. In a private place where no one else can hear, the patient should be asked about:

  • the reason for her or his visit;
  • social history, including factors that may increase STI/RTI risk;
  • medical history, including any medications or drug allergies;
  • previous pregnancies, last menstrual period, menstrual pattern, contraception;
  • sexual history, including any behaviour that may suggest increased risk;
  • symptoms related to the present complaint;
  • symptoms of STI/RTI.


Common STI/RTI

Many patients with an RTI complain of symptoms associated with specific syndromes. Health care providers can use the syndrome algorithms in Chapter 8 and Chapter 9 for guidance on management.




Vaginal discharge that is abnormal in colour, odour, amount or consistency. Itching or irritation of the vulva or vagina.

Vaginal discharge
(Flowcharts 1 and 9)

Urethral discharge

Painful urination (dysuria)

Urethral discharge
(Flowchart 5)

Lower abdominal pain

Lower abdominal pain
(Flowchart 2)

Genital ulcers, sores or blisters

Genital ulcer (Flowchart 3)

Swelling, lumps or ulcer in the groin area

Inguinal bubo (Flowchart 4)

Other symptoms and signs that may suggest RTI or may influence management are outlined below:

  • Painful urination (dysuria) in women may indicate a vaginal or cervical infection, or urinary tract infection (UTI). If vaginal discharge is also present, use the vaginal discharge flowchart. If not, examination or tests for cervical infection or UTI may be needed.
  • Signs of infection accompanied by a missed period (amenorrhoea) or irregular bleeding may indicate pregnancy. Women should be managed according to the appropriate flowchart in Chapter 9.
  • Discharge, sores or warts in and around the anus can be caused by many of the STIs that cause genital infection. Treatment is the same as for genital infection.
  • Ulcers and other lesions in and around the mouth may be signs of syphilis or herpes.
  • Throat infection (pharyngeal gonorrhoea) is also possible. Single-dose treatment with ceftriaxone (125 mg), cefixime (400 mg), ciprofloxacin (500 mg), or ofloxacin (400 mg) is recommended (see Treatment table 8).


Examining patients1

Patients should be examined in the same conditions of privacy as those in which the history was taken. Patients should feel comfortable that no one will walk into the room while they are undressing or lying on the examination table. When examining patients of the opposite sex, it is usually advisable to have an assistant of the same sex as the patient present.

All examinations should begin with a general assessment, including vital signs and inspection of the skin, to detect signs of systemic disease. It is beyond the scope of these guidelines to cover all aspects of the physical examination.

There are three components to the female genital examination, depending on available equipment and supplies.

  • external genital examination;
  • speculum examination;
  • bimanual examination.


The external genital examination for women

Before you start:

  • Ensure that the examination can be conducted in privacy.
  • Ask the woman to pass urine.
  • Wash your hands well with clean water and soap.
  • Ask the woman to loosen her clothing. Use a sheet or clothing to cover her.
  • Have her lie on her back, with her heels close to her bottom and her knees up. Explain what you are about to do.
  • Put a clean glove on the hand you will put inside the vagina.


Carry out the examination in good light. Look at the outside genitals including perineum and anus—using the gloved hand to gently touch the woman, look for lumps, swelling, unusual discharge, sores, tears and scars around the genitals and in between the skin folds of the vulva.

Signs to look for when doing an external examination


Discharge and redness of the vulva are common signs of vaginitis. When the discharge is white and curd-like, yeast infection is likely.

Vaginal discharge, Flowchart 1
(for pregnant women, Flowchart 9)

Ulcers, sores or blisters.

Genital ulcer, Flowchart 3

Swelling or lumps in the groin
(inguinal lymphadenopathy).

Inguinal bubo, Flowchart 4


How to do a speculum examination

  • Be sure the speculum has been properly disinfected or sterilized before you use it (see Annex 2). Wet the speculum with clean warm water or a lubricant, if available, before inserting it.
  •  Insert the first finger of your gloved hand in the opening of the woman’s vagina (some clinicians use the tip of the speculum instead of a finger for this step). As you put your finger in, push gently downward on the muscle surrounding the vagina. Proceed slowly, waiting for the woman to relax her muscles.
  • With the other hand, hold the speculum blades together between the pointing finger and the middle finger. Turn the blades sideways and slip them into the vagina. Be careful not to press on the urethra or clitoris because these areas are very sensitive. When the speculum is halfway in, turn it so the handle is down. Note: on some examination couches, there is not enough room to insert the speculum handle down —in this case, turn it handle up.
  • Gently open the blades a little and look for the cervix. Move the speculum slowly and gently until you can see the cervix between the blades. Tighten the screw (or otherwise lock on the speculum) so it will stay in place.
  • Check the cervix, which should look pink, round and smooth. There may be small yellowish cysts, areas of redness around the opening (cervical os) or a clear mucoid discharge; these are normal findings. Look for signs of cervical infection by checking for yellowish discharge or easy bleeding when the cervix is touched with a swab. Note any abnormal growths or sores.
  • Notice if the cervical os is open or closed, and whether there is any discharge or bleeding. If you are examining the woman because she is bleeding from the vagina after birth, induced abortion or miscarriage, look for tissue coming from the opening of the cervix.
  • To remove the speculum, gently pull it towards you until the blades are clear of the cervix. Then bring the blades together and gently pull back, turning the speculum gently to look at the walls of the vagina.
  • Be sure to disinfect your speculum after each examination.


Signs to look for when doing a speculum examination


Vaginal discharge and redness of the vaginal walls are common signs of vaginitis. When the discharge is white and curd-like, yeast infection is likely.

Vaginal discharge, Flowchart 1
(for pregnant women, Flowchart 9)

Ulcers, sores or blisters.

Genital ulcer, Flowchart 3

If the cervix bleeds easily when touched or the discharge appears mucopurulent with discoloration, cervical infection is likely.

Treatment table 2

If you are examining the woman after birth, induced abortion or miscarriage, look for bleeding from the vagina or tissue fragments and check whether the cervix is normal.

Complications of abortion, Flowchart 6

Tumours or other abnormal-looking tissue on the cervix.

Refer for Pap smear or cytology


How to feel the reproductive parts inside the abdomen: bimanual examination


  • Test for cervical motion tenderness. Put the pointing finger of your gloved hand in the woman’s vagina. As you put your finger in, push gently downward on the muscles surrounding the vagina. When the muscles relax, put the middle finger in too. Turn the palm of your hand up.
  • Feel the opening of her womb (cervix) to see if it is firm and round. Then put one finger on either side of the cervix and move the cervix gently while watching the woman’s facial expression. It should move easily without causing pain. If it does cause pain (you may see her grimace), this sign is called cervical motion tenderness, and she may have an infection of the womb, tubes or ovaries. If her cervix feels soft, she may be pregnant.
  • Feel the womb by gently pushing on her lower abdomen with your outside hand. This moves the inside parts (womb, tubes and ovaries) closer to your inside hand. The womb may be tipped forward or backward. If you do not feel it in front of the cervix, gently lift the cervix and feel around it for the body of the womb. If you feel it under the cervix, it is pointed back.
  • When you find the womb, feel for its size and shape. Do this by moving your inside fingers to the sides of the cervix, and then “walk” your outside fingers around the womb. It should feel firm, smooth and smaller than a lemon.

- If the womb feels soft and large, she is probably pregnant.

- If it feels lumpy and hard, she may have a fibroid or other growth.

- If it hurts when you touch it, she may have an infection inside.

- If it does not move freely, she could have scars from an old infection.


  • Feel the tubes and ovaries. If these are normal, they will be hard to feel. If you feel any lumps that are bigger than an almond or that cause severe pain, she could have an infection or other emergency. If she has a painful lump, and her period is late, she could have an ectopic pregnancy and needs medical help right away.
  • Move your finger and feel along the inside of the vagina. Make sure there are no unusual lumps, tears or sores.
  • Have the woman cough or push down as if she were passing stool. Watch to see if something bulges out of the vagina. If it does, she could have a fallen womb or fallen bladder (prolapse).
  • When you are finished, clean and disinfect your glove if it will be reused. Wash your hands well with soap and water.






Signs to look for when doing a bimanual examination


Lower abdominal tenderness when pressing down over the uterus with the outside hand.

Use the lower abdominal pain flowchart (Flowchart 2) if any tenderness is detected on abdominal or bimanual examination.

Cervical motion tenderness (often evident from facial expression) when the cervix is moved from side to side with the fingers of the gloved hand in the vagina.

Uterine or adnexal tenderness when pressing the outside and inside hands together over the uterus (centre) and adnexae (each side of uterus).

Any abnormal growth or hardness to the touch.

Refer for Pap smear or cytology



Symptoms and signs of RTIs in women




Vaginitis (Flowchart 1)

Vaginal discharge that is abnormal in colour, odour, amount or consistency.

Itching or irritation of the vulva or vagina.

Vulvovaginal redness

Vaginal discharge seen on external or speculum examination

(Treatment table 2)

Usually none. Sometimes burning on urination or spotting of blood after intercourse

Mucopurulent cervical discharge

Cervical bleeding to touch

Lower abdominal pain (Flowchart 2)

Lower abdominal pain

Pain on intercourse

Lower abdominal tenderness on abdominal examination

Cervical motion tenderness on bimanual examination

Uterine or adnexal tenderness on bimanual examination

Genital ulcer (Flowchart 3)

Genital ulcers, sores or blisters

Inguinal bubo (Flowchart 4)

Swelling, lumps or ulcers in the groin area


Examining a male patient

  • Wash your hands before the examination and put on clean gloves.
  • Tell the patient what you are going to do as you do each step of the examination.
  • Ask the patient to stand up and lower his underpants to his knees. Some providers prefer the man to lie down during the examination.
  • Palpate the inguinal region (groin) looking for enlarged lymph nodes and buboes.
  • Palpate the scrotum, feeling for the testis, epididymis, and spermatic cord on each side.
  • Examine the penis, noting any rashes or sores.
  • Ask the patient to pull back the foreskin if present and look at the glans penis and urethral meatus.
  • If you do not see any obvious discharge, ask the patient to milk the urethra.
  • Ask the patient to turn his back to you and bend over, spreading his buttocks slightly. This can also be done with the patient lying on his side with the top leg flexed up towards his chest.
  • Examine the anus for ulcers, warts, rashes, or discharge.
  • Wash your hands following the examination.
  • Record findings, including the presence or absence of ulcers, buboes, genital warts, and urethral discharge, noting colour and amount.


Signs to look for when examining men

Signs to look for


Urethral discharge

Urethral discharge, Flowchart 5

Ulcers, sores or blisters

Genital ulcer, Flowchart 3

Swelling or lumps in the groin (inguinal lymphadenopathy) and swelling of testicles.

Inguinal bubo, Flowchart 4



1 Much of this section is adapted from Burns et al. Where women have no doctor. Berkeley, CA, USA, Hesperian Foundation, 1997.


html files


Infections of the male and female reproductive tract and their consequences:

What are RTIs?

Why STI/RTIs are important?

What can be done about RTIs?

The role of clinical services in reducing the burden of STI/RTI

Preventing STIs/RTIs and their complications

How to prevent STI

How to prevent iatrogenic infections

How to prevent endogenous infections

Detecting STI/RTI

Detecting STI/RTI


Vaginal infections

Cervical infections

Pelvic inflammatory disease

HIV counselling and testing

STI/RTI education and counselling

Key points

Privacy and confidentiality

General skills for STI/RTI education and counselling

Health education


Promoting prevention of STI/RTI and use of services

Key points

Reducing barriers to use of services

Raising awareness and promoting services

Reaching groups that do not typically use reproductive health services

STI/RTI Assessment during Routine Family Planning Visits

Key points

Integrating STI/RTI assessment into routine FP services

Family planning methods and STIs/RTIs

STI/RTI Assessment in pregnancy, childbirth and the postpartum period

Key points

Management of symptomatic STIs/RTIs

Syndromic management of STI/RTI

Management of common syndromes

STI case management and prevention of new infections

STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period

Key points

Infection in early pregnancy

Infection in lated pregnancy

Infection following childbirth

Vaginal discharge in pregnancy and the postpartum period

Sexual violence

Key points

Medical and other care for survivors of sexual assault

Annex 1. Clinical skills needed for STI/RTI


Common STI/RTI symptoms

Examining patients

Annex 2. Disinfection and universal precautions

Preventing infection in clinical settings

High-level disinfection: three steps

Universal precautions

Annex 3. Laboratory tests for RTI

Interpreting syphilis test results

Clinical criteria for bacterial vaginosis (BV)

Wet mount microscopy

Gram stain microscopy of vaginal smears

Use of Gram stain for diagnosis of cervical infection

Annex 4. Medications

Medications in pregnancy

Antibiotic treatments for gonorrhoa

Annex 5.

STI/RTI reference table


Additionnal resources


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