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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



Management of STIs/RTIs
Chapter 8. Management of symptomatic STIs/RTIs


Syndromic management of STI/RTI

Many STIs/RTIs can be identified and treated on the basis of characteristic symptoms and signs. Symptoms and signs can be grouped together into syndromes —upper respiratory infection, gastroenteritis and vaginal discharge are examples of common syndromes. It is often difficult to know exactly what organism is causing the syndrome, however, and treatment may need to cover several possible infections.

Syndromic management refers to the approach of treating STI/RTI symptoms and signs based on the organisms most commonly responsible for each syndrome. A more definite or etiological diagnosis may be possible in some settings with sophisticated laboratory facilities, but this is often problematic. Laboratory tests require resources, add to the cost of treatment, may require clients to make extra visits to the clinic and almost always result in delays in treatment. For these reasons, syndromic management guidelines are widely used for syndromes such as lower abdominal pain, urethral discharge and genital ulcer (Table 8.1), even in developed countries with advanced laboratory facilities.

WHO has developed simple flowcharts (also called algorithms) to guide health care providers in using the syndromic approach to manage seven syndromes. Five of these algorithms (for vaginal discharge, lower abdominal pain, genital ulcer, inguinal bubo and urethral discharge) are included in this chapter, adapted where needed for application in reproductive health settings. Additional algorithms dealing with STI/RTI in pregnancy are given in Chapter 9. The syndromic approach is widely used to manage STIs/RTIs. The algorithms may change from country to country depending on the prevalence of disease, the cost of drugs, and microbial resistance patterns.


Table 8.1. The syndromic approach—strengths and limitations

Syndromic algorithm

Rationale for use

Syndromic algorithms for urethral discharge in men and genital ulcers in men and women are both effective and practical.

Gonorrhoea and chlamydia are among the important causes of urethral discharge. Syphilis and chancroid are among the important causes of genital ulcers.

Properly used, these algorithms permit health care workers to provide effective treatment for symptomatic patients. They are simple and can be used even in remote areas as long as the necessary medicines are available. Equally important, syndromic management of these problems prevents new infections by providing curative treatment without delay and breaking the chain of infection.

The syndromic approach to lower abdominal pain in women is widely used, even in developed countries.

Gonorrhoea and chlamydia are among the important causes of lower abdominal pain in women.

This approach is designed to offer effective treatment to women with symptoms that could indicate pelvic inflammatory disease. Health care providers should realize that some women managed with this algorithm might not actually have PID (false positives). Treatment is justified, however, because of the severe consequences—including infertility and ectopic pregnancy—that often follow PID that is left untreated or not treated early.

Syndromic algorithms for women with symptoms/signs of vaginal discharge work well for vaginal infections, but not generally for cervical infections.

Vaginal infection (bacterial vaginosis, trichomoniasis or yeast infection) is the main cause of vaginal discharge.

Vaginal discharge algorithms are not designed to detect the more serious and often asymptomatic cervical infections. At present, accurate detection of gonococcal and chlamydial cervicitis requires expensive laboratory tests, which are not available in most settings (see Chapter 3 for advice on detecting cervical infections). In some special situations, treatment for cervical infection is justified.


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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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