Overview

The WHO global health sector strategy on sexually transmitted infections, 2016–2021, endorsed by the World Health Assembly in 2016, aims to eliminate STIs as a public health threat by 2030. In 2019, WHO published estimates of new cases of chlamydia, gonorrhoea, syphilis and trichomoniasis. Recent changes in the epidemiology of STIs and progress in prevention, diagnosis and treatment of STIs and HIV have necessitated changes in approaches to STI prevention and management. To address these STIs, the most widely used approach in clinical settings is the syndromic management of STIs. In most resource-limited settings, the syndromic management flow charts are still the standard of care where laboratory diagnosis is not available or is hard to access.

The objectives of these guidelines are to provide updated, evidence-informed clinical and practical recommendations on the case management of people with symptoms of STIs; and to support countries in updating their national guidelines for the case management of people with symptoms of STIs. These guidelines include the management of symptomatic infections related to urethral discharge syndrome, including persistent urethral discharge syndrome; vaginal discharge syndrome, including persistent vaginal discharge; anorectal infection; genital ulcer disease syndrome; and lower abdominal pain syndrome. These guidelines are intended for programme managers for STI prevention and control at the national level and the health-care providers at the frontline – primary, secondary and tertiary health care.

Contents

• ACKNOWLEDGEMENTS
• ABBREVIATIONS AND ACRONYMS
• EXECUTIVE SUMMARY
• 1. SUMMARY OF RECOMMENDATIONS
  • 1.1. Recommendations for the management of urethral discharge
  • 1.2. Recommendations for the management of vaginal discharge
  • 1.3. Recommendations for the management of lower abdominal pain among women
  • 1.4. Recommendations for the management of genital ulcer disease, including anorectal ulcers
  • 1.5. Recommendations for the management of anorectal discharge
• 2. INTRODUCTION AND OVERVIEW OF THE DEVELOPMENT OF WHO GUIDELINES FOR THE MANAGEMENT OF SYMPTOMATIC SEXUALLY TRANSMITTED INFECTIONS
  • 2.1. Epidemiology and global burden of sexually transmitted infections
  • 2.2. STIs and HIV
  • 2.3. Objectives and rationale for developing the guidelines
  • 2.4. Objectives of the guidelines
  • 2.5. Target audience
  • 2.6. Guiding principles
  • 2.7. Methods for developing the guidelines
  • 2.8. Reviews of the evidence
  • 2.9. Modelling outcomes
  • 2.10. Presentation of the evidence
  • 2.11. Making recommendations
  • 2.12. Managing conflicts of interest
• 3. CASE MANAGEMENT FOR PEOPLE WITH STIs
  • 3.1. Objectives of STI case management
  • 3.2. Requirements to achieve the objectives of STI case management
• 4. DIAGNOSTIC TESTS FOR ASYMPTOMATIC AND SYMPTOMATIC PEOPLE WITH STIs
  • 4.1. Role of microscopy in diagnosing STIs and other reproductive tract infections
  • 4.2. Quality-assured laboratory testing with a fully operational management system
• 5. RATIONALE FOR STANDARDIZED TREATMENT RECOMMENDATIONS
• 6. IMPLEMENTING THE SYNDROMIC APPROACH FOR THE MANAGEMENT OF STIs
• 7. URETHRAL DISCHARGE SYNDROME
  • 7.1. Clinical presentation – symptoms
  • 7.2. Examination findings – signs
  • 7.3. Laboratory diagnosis
  • 7.4. Recommendations for the management of urethral discharge
  • 7.5. Treatment recommendations for urethral discharge
• 8. VAGINAL DISCHARGE SYNDROME
  • 8.1. T. vaginalis
  • 8.2. Candidiasis
  • 8.3. Bacterial vaginosis
  • 8.4. Cervical infection – gonococcal and/or chlamydial cervicitis
  • 8.5. Recommendations for the management of vaginal discharge
  • 8.6. Treatment options for vaginal discharge
• 9. LOWER ABDOMINAL PAIN
  • 9.1. Recommendations for the management of lower abdominal pain among women
  • 9.2. Treatment for people presenting with lower abdominal pain
• 10. GENITAL ULCER DISEASE SYNDROME
  • 10.1. Herpes simplex virus
  • 10.2. Syphilis
  • 10.3. H. ducreyi (chancroid)
  • 10.4. Recommendations for the management of genital ulcer disease, including anorectal ulcers
  • 10.5. Treatment of genital ulcer disease, including anorectal ulcers
• 11. ANORECTAL DISCHARGE
  • 11.1. Anatomical sites of infection
  • 11.2. Sexual practices that may be associated with anorectal infections
  • 11.3. Examination
  • 11.4. Recommendations for the management of anorectal discharge
  • 11.5. Treatment recommendations for anorectal infections
• 12. DISSEMINATION AND IMPLEMENTATION OF THE GUIDELINES
  • 12.1. Dissemination
  • 12.2. Updating the STI guidelines and user feedback
  • 12.3. Implementation considerations
• 13. SURVEILLANCE AND RESEARCH NEEDS
  • 13.1. Challenges in STI surveillance and anticipated responses
  • 13.2. Research needs in STI case management
• REFERENCES
• ANNEX 1. STI GUIDELINE DEVELOPMENT GROUP
• ANNEX 2. DECLARATIONS OF CONFLICTS OF INTEREST
• ANNEX 3. EVIDENCE-TO-DECISION TABLE: URETHRAL DISCHARGE
• ANNEX 4. EVIDENCE-TO-DECISION TABLE: VAGINAL DISCHARGE
• ANNEX 5. EVIDENCE-TO-DECISION TABLE: LOWER ABDOMINAL PAIN
• ANNEX 6. EVIDENCE-TO-DECISION TABLE: GENITAL ULCER DISEASE
• ANNEX 7. EVIDENCE-TO-DECISION TABLE: ANORECTAL DISCHARGE
• ANNEX 8. SUPPLEMENTAL MATERIALS

Suggested citation:

Guidelines for the management of symptomatic sexually transmitted infections. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.

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