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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



STI/RTI basics
Chapter 3. Detecting STI/RTI


Key points

  • Health care providers should know how to identify people with signs, symptoms or risk of STI/RTI.
  • Screening for syphilis is an effective strategy for preventing congenital syphilis and is part of the essential package of antenatal care.
  • Women with previous spontaneous abortion, stillbirth or preterm delivery should be screened for bacterial vaginosis and trichomoniasis in addition to syphilis.

  • Every opportunity should be taken to detect cervical infections by careful speculum examination and, when possible, laboratory tests.
  • Pap smear for early detection of cervical cancer should be done at least once for women around 40 years old.
  • HIV voluntary counselling and testing (VCT) services should be developed where HIV infection is common.


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

People with STI/RTI



Seek care

Do not seek care     

Accurate diagnosis

Correct treatment

Completed treatment



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


Example—no missed opportunities


Ask about STI/RTI symptoms or concerns at each reproductive health visit.

Clinical screening

Speculum and bimanual examination to look for signs of STI/RTI not noticed by the patient.

Laboratory screening

Serological screening for syphilis.

Pap smear for early detection of cervical cancer.

Voluntary counselling and testing for HIV.

Presumptive treatment on basis of risk criteria

Treatment of partners of STI patients, sex workers who have had unprotected exposure, etc.

Survivors of sexual violence.

Treatment of women having a transcervical procedure.

Combination strategies

Presumptive treatment of sex workers at first visit followed by regular visits for speculum/bimanual examination and Gram stain of cervical smear.


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.


Table 3.2. Examples of STI/RTI screening options for women


Screening method

In 100 cases, number that will be detectedc



Non-treponemal specific serological screening testsa

80–86 (primary infection)

100 (secondary)

80 (latent infection)

71–73 (late stage)

Positive test indicates a high likelihood of syphilis infection, although not necessarily current, active disease. Patients who test positive should receive treatment. Confirmatory test with a treponemal specific test can also be done where available.

Cervical infection

(gonorrhoea and/or chlamydia)

Culture for gonorrhoea


Accurate; requires laboratory with CO2 jars, incubator and culture media.

Chlamydia testb


Expensive; misses many cases (false negatives).

Chlamydia PCR


Very expensive; high technology.

Clinical examination


Inexpensive; misses many cases (false negatives).

Cervical dysplasia

Pap smear



Effective for early detection and prevention of cervical cancer.

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.


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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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