URETHRAL DISCHARGE Treat for Gonorrhoea and Chlamydia 4 Cs: TREATMENT OF GONORRHOEA Uncomplicated Anal/ Genital Infection Ciprofloxacin 500 mg orally once only (Ciprofloxacin is contraindicated in pregnancy and for children or adolescents) OR Cefixime 400 mg orally once only Ceftriaxone 125 mg IM once only Spectinomycin 2 gm IM once only Disseminated Gonococcal infection Ceftriaxone 1 gm IM or intravenous once daily for 7 days Spectinomycin 2 gm IM twice daily for 7 days URETHRAL DISCHARGE Use appropriate flow chart Yes Patient complains of urethral Discharge or dysuria Any other genital disease No 4 Cs Ask patient to return in 7 days if symptoms persist No Take history and examine. Milk urethra if necessary Discharge confirmed? TREATMENT OF CHLAMYDIA Uncomplicated Anal/ Genital Infection Doxycycline 100 mg orally twice daily for 7 days (Not to be used for pregnant women, children or adolescents) OR Azithromycin 1 gm orally once only Alternative Regimens Amoxycillin 500 mg orally 3 times a day for 7 days Erythromycin 500 mg 4 times a day for 7 days Ofloxacin 400 mg orally twice a day for 7 days Tetracycline 500 mg orally 4 times a day for 7 days Treat for Gonorrhoea and Chlamydia 4 Cs Ask patient to return in 7 days if symptoms persist 4 Cs: Compliance Counseling Promote & provide Condoms Counseling for STI prevention, HIV testing; Educate and Reassure patient Partner (Contact) treatment Yes

PERSISTENT URETHRAL DISCHARGE TREATMENT OF GONORRHOEA Uncomplicated Anal/ Genital Infection Ciprofloxacin 500 mg orally once only (Ciprofloxacin is contraindicated in pregnancy and for children or adolescents) OR Cefixime 400 mg orally once only Ceftriaxone 125 mg IM once only Spectinomycin 2 gm IM once only PERSISTENT URETHRAL DISCHARGE Use appropriate flow chart Patient complains of urethral Discharge or dysuria Yes Any other genital disease 4 Cs Ask patient to return in 7 days if symptoms persist No No Take history and examine. Milk urethra if necessary TREATMENT OF CHLAMYDIA Uncomplicated Anal/ Genital Infection Doxycycline 100 mg orally twice daily for 7 days (Not to be used for pregnant women, children or adolescents) OR Azithromycin 1 gm orally once only Alternative Regimens Amoxycillin 500 mg orally 3 times a day for 7 days Erythromycin 500 mg 4 times a day for 7 days Ofloxacin 400 mg orally twice a day for 7 days Tetracycline 500 mg orally 4 times a day for 7 days Treat for Trichomonas 4 Cs Ask patient to return in 7 days if symptoms persist No Discharge confirmed? Yes Refer for laboratory tests and Specialist Care 4 Cs: Compliance Counseling Promote & provide Condoms Counseling for STI prevention, HIV testing; Educate and Reassure patient Partner (Contact) treatment Not better Does History confirm re-infection or poor compliance Repeat Urethral Discharge Treatment Yes TREATMENT OF TRICHOMONAS Metronidazole 400 or 500 mg orally twice daily for 7 days OR Tinidazole 500 mg orally twice daily for 7 days

GENITAL ULCERS 4 Cs: No No No No Ulcer(s) healed Compliance Counseling TREATMENT OF HSV-2 Treatment of First Episode: Acyclovir 400 mg 3 times a day for 7 days Treatment of Recurrent Episodes: Acyclovir 400 mg 3 times a day for 5 days Suppressive therapy: Acyclovir 400 mg twice a day continuously Refer for laboratory testing and Specialist treatment Patient complains of genital ulcer Take history and examine Treat for HSV Test and Treat for syphilis 4 Cs Ask patient to return in 7 days if symptoms persist No TREATMENT OF SYPHILIS Early Syphilis (Primary, Secondary or Latent of less than 2 years duration) Benzathine Penicillin 2.4 million IU intramuscularly once (Due to large volume it is recommended that this dose be divided and given as 2 injections sites) For more detailed treatment of syphilis please see the attached sheet Ulcer(s) improving Only vesicles present Yes Yes No Ulcer(s) healed No Continue treatment for another 7 days Treat for syphilis AND HSV 4 Cs Ask patient to return in 7 days if symptoms persist Sore or ulcer present Yes 4 Cs: Compliance Counseling Promote & provide Condoms Counseling for STI prevention, HIV testing; Educate and Reassure patient Partner (Contact) treatment Yes No 4 Cs Reassure

SCROTAL SWELLING 4 Cs: Treat for Gonorrhoea and Chlamydia TREATMENT OF GONORRHOEA Uncomplicated Anal/ Genital Infection Ciprofloxacin 500 mg orally once only (Ciprofloxacin is contraindicated in pregnancy and for children or adolescents) OR Cefixime 400 mg orally once only Ceftriaxone 125 mg IM once only Spectinomycin 2 gm IM once only Disseminated Gonococcal infection Ceftriaxone 1 gm IM or intravenous once daily for 7 days Spectinomycin 2 gm IM twice daily for 7 days SCROTAL SWELLING Patient complains of Scrotal Swelling Reassure patient Provide analgesics if needed 4 Cs Treat for Gonorrhoea and Chlamydia 4 Cs Ask patient to return in 7 days if symptoms persist No No Swelling/ Pain Confirmed History and examination Testes rotated or elevated or history of trauma Yes TREATMENT OF CHLAMYDIA Uncomplicated Anal/ Genital Infection Doxycycline 100 mg orally twice daily for 7 days (Not to be used for pregnant women, children or adolescents) OR Azithromycin 1 gm orally once only Alternative Regimens Amoxycillin 500 mg orally 3 times a day for 7 days Erythromycin 500 mg 4 times a day for 7 days Ofloxacin 400 mg orally twice a day for 7 days Tetracycline 500 mg orally 4 times a day for 7 days Refer for surgical evaluation 4 Cs: Compliance Counseling Promote & provide Condoms Counseling for STI prevention, HIV testing; Educate and Reassure patient Partner (Contact) treatment Yes

ANAL SYMPTOMS 4 Cs: Discharge Confirmed No abnormality Anal symptoms TREATMENT OF GONORRHOEA Uncomplicated Anal/ Genital Infection Ciprofloxacin 500 mg orally once only OR Cefixime 400 mg orally once only Ceftriaxone 125 mg IM once only Spectinomycin 2 gm IM once only Disseminated Gonococcal infection Ceftriaxone 1 gm IM or intravenous once daily for 7 days Spectinomycin 2 gm IM twice daily for 7 days TREATMENT OF CHLAMYDIA Uncomplicated Anal/ Genital Infection Doxycycline 100 mg orally twice daily for 7 days OR Azithromycin 1 gm orally once only Alternative Regimens Amoxycillin 500 mg orally 3 times a day for 7 days Erythromycin 500 mg 4 times a day for 7 days Ofloxacin 400 mg orally twice a day for 7 days Tetracycline 500 mg orally 4 times a day for 7 days ANAL SYMPTOMS Treat for Gonorrhoea and Chlamydia Discharge Confirmed Yes Confirm on exam Discharge No abnormality No Supportive/ symptomatic care No Anal symptoms Ulcers or blisters seen Treat for HSV-2 Test and treat for Syphilis Examination (use proctoscope if cause not seen on inspection) Yes TREATMENT OF HSV-2 Treatment of First Episode: Acyclovir 400 mg 3 times a day for 7 days Treatment of Recurrent Episodes: Acyclovir 400 mg 3 times a day for 5 days Suppressive therapy: Acyclovir 400 mg twice a day continuously Pain Wart removal/ needs observation for cancer Warts 4 Cs: Compliance Counseling Promote & provide Condoms Counseling for STI prevention, HIV testing; Educate and Reassure patient Partner (Contact) treatment Treat for Hemorrhoids (piles) TREATMENT FOR WARTS Treatment is meant for external genitalia and vaginal. Please refer to gynaecologic specialist for cervical warts Provider administered: Podophyllin 10-25% in compound of tincture or benzoin. Apply carefully avoiding normal tissue. External genital genitalia should be washed thoroughly in 1-4 hours. Allow the applied medicine to dry before removing speculum. Repeat application weekly as needed. OR Cryotherapy (when available). Repeat after 1-2 weeks as needed Hemorrhoids (piles) seen Refer for Surgical evaluation Ano-Rectal Fissures

TREATMENT OF GONORRHOEA Uncomplicated Anal/ Genital Infection Ciprofloxacin 500 mg orally once only OR Cefixime 400 mg orally once only Ceftriaxone 125 mg IM once only Spectinomycin 2 gm IM once only Disseminated Gonococcal infection Ceftriaxone 1 gm IM or intravenous once daily for 7 days Spectinomycin 2 gm IM twice daily for 7 days TREATMENT OF CHLAMYDIA Uncomplicated Anal/ Genital Infection Doxycycline 100 mg orally twice daily for 7 days OR Azithromycin 1 gm orally once only Alternative Regimens Amoxycillin 500 mg orally 3 times a day for 7 days Erythromycin 500 mg 4 times a day for 7 days Ofloxacin 400 mg orally twice a day for 7 days Tetracycline 500 mg orally 4 times a day for 7 days VAGINAL DISCHARGE Treat for Gonorrhoea and Chlamydia Patient complains of vaginal discharge, vulval itching or burning High NG/CT prevalence in community or high individual risk profile Yes No Lower abdominal pain No Yes Yes History, examination and Risk assessment* Use Lower Abdominal pain flowchart Treat for BV/ Trichomonas Abnormal discharge or vulval erythema *Risk factors assessed should include: Personal sexual history (including extramarital sex) High risk group membership Community factors such as STI prevalence in community. No Vulval edema/curd-like discharge, erythema, excoriations present Use Appropriate flowchart TREATMENT OF BACTERIAL VAGINOSIS Metronidazole 2 gm orally once (also treats Trichomonas) OR Clindamycin 2% vaginal cream, 5 gm intravaginally at bedtime for 7 days Metronidazole 0.75% gel, 5 gm intravaginally twice daily for 7 days Clindamycin 300 mg orally twice daily for 7 days Treatment during Pregnancy First Trimester (only if treatment is imperative): Metronidazole 2 gm orally once 2nd or 3rd trimesters: Metronidazole 200- 250 mg 3 times a day for 7 days Alternative regimen Metronidazole 2 gm orally once Yes No Yes Any other genital disease Reassure patient Provide analgesics if needed 4 Cs Treat for Candida No 4 Cs: Compliance Counseling Promote & provide Condoms Counseling for STI prevention, HIV testing; Educate and Reassure patient Partner (Contact) treatment TREATMENT OF CANDIDA Miconazole or clotrimazole 200 mg intarvaginally daily for 3 days OR Clotrimazole 500 mg intravaginallly once Fluconazole 150 mg orally once Alternate Regimen Nystatin 100,000 IU intarvaginally daily for 14 days

LOWER ABDOMINAL PAIN 4 Cs: OUTPATIENT TREATMENT OF LOWER ABDOMINAL PAIN Ceftriaxone 125 mg IM once only OR Spectinomycin 2 gm IM once only PLUS Doxycycline 100 mg orally twice daily for 7 days Tetracycline 500 mg orally 4 times a day for 7 days (both Doxycylcine and Tetracycline are contraindicated for pregnant women) Metronidazole 400 mg orally twice daily for 14 days LOWER ABDOMINAL PAIN Patient complains of lower abdominal pain Appropriate surgical or gynecological referral History and examination (including gynecological exam) Yes Any other illness found Cervical motion tenderness or lower abdominal tenderness and vaginal discharge Appropriate management No Any of the following present: Missed or overdue period Recent delivery/ abortion/ miscarriage Adnominal guarding and/or rebound tenderness Abnormal vaginal bleeding Abdominal mass intrauterine device Manage for PID 4 Cs Review in 5 days Refer or Specialist care No Yes ALL PATIENTS NOT IMPROVING WITH OUTPATIENT THERAPY MUST BE ADMITTED FOR FURTHER TREATMENT No Patient improved Yes 4 Cs: Compliance Counseling Promote & provide Condoms Counseling for STI prevention, HIV testing; Educate and Reassure patient Partner (Contact) treatment Continue until treatment completed Reassure patient Provide analgesics if needed 4 Cs Ask patient to return as needed

Treatment of Syphilis All patients being considered for STI management must be considered for syphilis testing: All those who test positive must be treated Early Syphilis (Primary, Secondary or Latent of less than 2 years duration) Benzathine Penicillin 2.4 million IU intramuscularly once (Due to large volume it is recommended that this dose be divided and given as 2 injections sites) Alternative Regimen Procaine Benzyl Penicillin 1.2 million IU intramuscularly once daily for 10 days Alternative Regimen (for Penicillin allergic patients and non-pregnant patients) Doxycycline 100 mg orally twice a day for 14 days OR Tetracycline 500 mg orally twice a day for 14 days Alternative Regimen (for Penicillin allergic patients and pregnant patients) Erythromycin 500 mg orally 4 times a day for 14 days Late Latent Syphilis (Infection of more than 2 years duration) Benzathine Penicillin 2.4 million IU intramuscularly once a week for 2 consecutive weeks (Due to large volume it is recommended that this dose be divided and given as 2 injections sites) Alternative Regimen Procaine Benzyl Penicillin 1.2 million IU intramuscularly once daily for 20 days Alternative Regimen (for Penicillin allergic patients and non-pregnant patients) Doxycycline 100 mg orally twice a day for 30 days OR Tetracycline 500 mg orally 4 times a day for 30 days Alternative Regimen (for Penicillin allergic patients and pregnant patients) Erythromycin 500 mg orally 4 times a day for 30 days