Annexes
Annex 1. Clinical skills needed for STI/RTI management

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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.

Women	Men	Syndrome
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	Management
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	Management
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	Management
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

Syndrome	Symptoms	Signs
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
Cervicitis (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	Management
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

 

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