Department of Reproductive Health and Research (RHR), World Health Organization
Sexually transmitted and other reproductive tract infections
A guide to essential practice
Some people with an STI/RTI have symptoms and seek treatment, while others do not (Figure 3.1). Promoting symptom recognition and early use of health care services is an important way of reducing the burden of STI/RTI.
Many women and men with an STI/RTI do not have symptoms, however, or have minimal symptoms and do not realize that anything is wrong. They may visit a clinic for other reasons or not at all. Yet identifying and treating such patients prevent the development of complications for the individual patient and help reduce transmission in the community.
Figure 3.1. Barriers to STI/RTI control—finding people with an STI/RTI
In women, silent asymptomatic infections can be more serious than symptomatic ones. Syphilis, gonorrhoea and chlamydia have serious consequences, yet are often asymptomatic (see Chapter 1). Even PID frequently has mild or no symptoms.
Reproductive health services have an important role to play in detecting asymptomatic STI/RTI. Since many women attend reproductive health clinics for family planning, antenatal services and postpartum care, there is an opportunity to identify women with an STI/RTI who would benefit from treatment. This chapter presents some strategies for identifying STI/RTI in patients who come to the clinic for other reasons. Table 3.1 and Table 3.2 give some examples of these approaches.
Reproductive health services should reach out to men whenever possible. While men are more likely to have symptoms than women, asymptomatic STI is possible. More commonly, men may ignore symptoms if they are not severe. Health care providers can raise awareness about symptoms and encourage men to come for check-ups if they have symptoms. More information on examining men and women is given in Annex 1.
Table 3.1. Some examples of STI/RTI detection and treatment strategies
Some reproductive health settings have the resources to screen for asymptomatic infections. One example is the “well woman clinic”, which may include speculum and bimanual examination to look for signs of cervical infection or PID, a Pap smear for early diagnosis of cervical cancer, or screening tests for syphilis or gonorrhoea. Even where this is not possible, however, detection and treatment of STI/RTI can be improved with minimal additional cost and effort. A no-missed-opportunities approach—using strategies in Table 3.1—should be taken. This means that health care providers look for evidence of STI/RTI whenever they do examinations for other reasons.
Table 3.2 provides more information on some common screening tests that can be performed in some situations. Syphilis tests, gonorrhoea culture and Pap smears can detect more than 80% of silent infections. Other tests detect fewer asymptomatic cases, but may still be useful if health care providers understand their limitations. It is better to detect 40–60% of women with cervical infection, using speculum examination, for example, than none at all.
The remainder of this chapter gives recommendations for detecting specific STIs/RTIs.
a. RPR (rapid plasma reagin), VDRL (Venereal Disease Research Laboratory) tests.
b. For example, ELISA (enzyme-linked immunosorbent assay) or direct immunofluorescence test.
c. Under ideal conditions and depending on stage of disease. Field performance usually lower.
It is important to keep in mind some issues that may come up when screening or presumptively treating for STI/RTI. Women who have come to the clinic for other reasons may not be prepared to hear that they may have an infection especially one that is sexually transmitted. They may be even more upset if they are told that they have to inform their sexual partner. Such situations must be handled carefully to avoid losing the patient’s trust and damaging the reputation of the clinic in the community. It is important to remember that no screening test is 100% accurate, and many are much less so. This should be carefully explained to patients and the possibility of error should be acknowledged. Most importantly, health care providers should avoid labelling problems as sexually transmitted when this is uncertain. A more cautious approach—and one often more acceptable to patients and their partners—is to explain that many symptoms are nonspecific; treatment can then be offered as a precaution to prevent complications, preserve fertility and protect pregnancy. These and other counselling issues are covered in Chapter 4. Recommendations for partner notification and treatment can be found in Chapter 8.
Infections of the male and female reproductive tract and their consequences:
Preventing STIs/RTIs and their complications
STI/RTI education and counselling
Promoting prevention of STI/RTI and use of services
STI/RTI Assessment during Routine Family Planning Visits
STI/RTI Assessment in pregnancy, childbirth and the postpartum period
Management of symptomatic STIs/RTIs
STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period
Annex 1. Clinical skills needed for STI/RTI
Annex 2. Disinfection and universal precautions
Annex 3. Laboratory tests for RTI
Annex 4. Medications