- Most infected females are asymptomatic; possible symptoms are:
- Vaginal discharge
- Dysuria
- Lower abdominal pain
- Abnormal vaginal bleeding (postcoital or intermenstrual) or breakthrough bleeding
- Dyspareunia
- Conjunctivitis
- Proctitis
- Reactive arthritis
Evaluation
- Finding of lower abdominal tenderness or cervical motion tenderness should prompt the attending physician to evaluate the patient for salpingitis &/or endometritis which are part of PID
- Treat patient accordingly (See Pelvic Inflammatory Disease Management Chart for details)
- Differential diagnoses may also include other surgical or gynecological conditions
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Diagnosis
- Syndromic management approach may be used in health care facilities where equipment & trained personnel for determining STI etiology are not available
- Syndromic management is based on consistent groups of symptoms & easily recognized signs, & treatment will cover the most common or serious organisms involved in causing the syndrome
- Using syndromic management in cases of vaginal discharge is limited esp if cervical infections are the cause (gonococcal or Chlamydia)
Clinical Observations Associated w/ Cervical Infections
- Cervical mucopus
- Cervical ectropion
- Cervical friability
- Bleeding between menses or during sexual intercourse
Lab Tests
- If resources permit, lab tests to screen women w/ vaginal discharge should be considered
- In patients who undergo a speculum exam, endocervical or vaginal swabs may be sent for testing
- If a speculum exam is not done, consider sending self-obtained low vaginal swab or 1st-void urine for testing
- Urine or rectal swab specimen may also be used, if appropriate
- Test utilized will depend on available resources
- Diagnosis is confirmed if C trachomatis is isolated by culture or demonstrated in a specimen through antigen or nucleic acid detection
Lab Exams for C trachomatis
- Nucleic acid amplification tests (NAAT)
- Recommended test for detection of chlamydial infection of genital tract
- Most sensitive (90-95%) & specific
- Test of choice for cervical, urethral, 1st-void urine specimens
- Recommended specimen from women is a self- or physician-obtained vaginal swab
- Cell culture
- Recommended for throat & rectal specimens
- May be used when blood & mucus interfere w/ NAAT result
- Though highly specific, high cost & low sensitivity (60-80%) preclude routine use
- Routine use of the following lab tests is not recommended:
- Direct fluorescent antibody test: Not to be used for routine testing of specimen from the genital tract
- Nucleic acid hybridization or probe test: Assays are not widely available
- Enzyme immunoassays: False-positive results may occur due to cross-reactivity among chlamydial species
- Serological test: Not to be used for screening since prior chlamydial infection may or may not generate a systemic antibody response
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Diagnosis of Lymphogranuloma Venereum (lgv)
- Clinical signs & symptoms as described in clinical presentation
- Bubo aspiration
- Milky fluid in aspirate
- May require sterile saline injection for aspiration
- Direct detection by NAAT, culture, or direct immunofluorescence
- Genital lesion swab, rectal swab or bubo aspirate may be used
- Culture is the most specific test but may not be widely available
- Serology
- High antibody titers are suggestive of LGV in a patient w/ symptoms consistent w/ LGV, but low titers do not rule out the diagnosis
- Complement fixation titer of ≥1:64 in the relevant clinical setting is consistent w/ LGV
- Exclusion of other causes of inguinal lymphadenopathy
- Non-sexually transmitted local & systemic infections (eg those of the lower limb or TB lymphadenopathy) can also cause inflammation of the inguinal lymph nodes
- Because definite diagnostic testing is lacking, patients w/ symptoms consistent w/ LGV (ie proctocolitis or genital ulcer w/ lymphadenopathy) should receive treatment for LGV
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