Table 1304 Management of Urethral Discharge in Men

Usual Causes

Usual Initial Evaluation

Chlamydia trachomatis

Demonstration of urethral discharge or pyuria

Neisseria gonorrhoeae

Exclusion of local or systemic complications

Mycoplasma genitalium

Urethral Gram's stain to confirm urethritis,

detect gram-negative diplococci

Ureaplasma urealyticum Trichomonas vaginalis

Test for N. gonorrhoeae, C. trachomatis
Herpes simplex virus
Initial Treatment for Patient and Partners
plus
Treat gonorrhea (unless
excluded):

Treat chlamydial infection:

Azithromycin, 1 g PO; or

Ceftriaxone, 250 mg IM;

or

Doxycycline, 100 mg bid PO for 7 days

Cefpodoxime, 400 mg
PO; or
Cefixime, 400 mg POa
Management of Recurrence
Confirm objective evidence of urethritis. If patient was reexposed to untreated or new partner,
repeat treatment of patient and partner.
If patient was not reexposed, consider infection with T. vaginalisb or doxycycline-resistant M.
genitalium or Ureaplasma, and consider treatment with metronidazole, azithromycin, or both.

Updates on the emergence of antimicrobial resistance in N. gonorrhoeae can be obtained from

the Centers for Disease Control and Prevention at http://www.cdc.gov/std.
b

In men, the diagnosis of T. vaginalis infection requires culture (or nucleic acid amplification
test, where available) of early-morning first-voided urine sediment or of a urethral swab
specimen obtained before voiding.

Table 1305 Diagnostic Features and Management of Vaginal Infection

Feature

Normal Vaginal
Examination

Vulvovaginal
Candidiasis

Trichomonal
Vaginitis

Bacterial
Vaginosis

Etiology

Uninfected;
lactobacilli
predominant

Candida albicans

Trichomonas
vaginalis

Associated with
Gardnerella
vaginalis, various
anaerobic and/or
noncultured
bacteria, and
mycoplasmas

Typical
symptoms

None

Vulvar itching
and/or irritation

Profuse purulent Malodorous,

discharge; vulvar slightly increased
itching
discharge

Amount

Variable; usually
scant

Scant

Often profuse

Moderate

Colora

Clear or
translucent

White

White or yellow

White or gray

Homogeneous

Homogeneous, low
viscosity;
uniformly coats
vaginal walls

Discharge

Consistency Nonhomogeneous, Clumped; adherent

floccular
plaques

Inflammation None
of vulvar or
vaginal
epithelium

Erythema of vaginal
epithelium,
introitus; vulvar
dermatitis, fissures
common

pH of vaginal Usually
fluidb

Usually

4.5

Erythema of
None
vaginal and
vulvar
epithelium;
colpitis macularis

4.5 Usually

Usually >4.5

Amine
None
("fishy") odor
with 10%
KOH

None

May be present

Present

Microscopyc

Leukocytes,
epithelial cells;

Leukocytes;
motile

Clue cells; few

leukocytes; no

Normal epithelial
cells; lactobacilli

Feature

Normal Vaginal
Examination

Vulvovaginal
Candidiasis

Trichomonal
Vaginitis

Bacterial
Vaginosis

predominant

mycelia or
pseudomycelia in
up to 80% of C.
albicansculturepositive persons
with typical
symptoms

trichomonads
seen in 8090%
of symptomatic
patients, less
often in the
absence of
symptoms

lactobacilli or only
a few outnumbered
by profuse mixed
microbiota, nearly
always including
G. vaginalisplus
anaerobic species
on Gram's stain
(Nugent's score
7)

Isolation of
Candida spp.

Isolation of T.
vaginalis or
positive NAATd

Azole cream, tablet,

or suppository
e.g., miconazole
(100-mg vaginal
suppository) or
clotrimazole (100mg vaginal tablet)
once daily for 7
days Fluconazole,
150 mg orally
(single dose)

Metronidazole or
tinidazole, 2 g
orally (single
dose)
Metronidazole,
500 mg PO bid
for 7 days

None; topical
treatment if
candidal dermatitis
of penis is detected

Examination for None

STD; treatment
with
metronidazole, 2
g PO (single
dose)

Other
laboratory
findings
Usual
treatment

Usual
management
of sexual
partner

None

None

Metronidazole, 500
mg PO bid for 7
days
Metronidazole gel,
0.75%, one
applicator (5 g)
intravaginally once
daily for 5 days
Clindamycin, 2%
cream, one full
applicator vaginally
each night for 7
days

Color of discharge is best determined by examination against the white background of a swab.

A pH determination is not useful if blood is present.

To detect fungal elements, vaginal fluid is digested with 10% KOH prior to microscopic
examination; to examine for other features, fluid is mixed (1:1) with physiologic saline. Gram's
stain is also excellent for detecting yeasts (less predictive of vulvovaginitis) and pseudomycelia
or mycelin (strongly predictive of vulvovaginitis) and for distinguishing normal flora from the
mixed flora seen in bacterial vaginosis, but it is less sensitive than the saline preparation for
detection of T. vaginalis.
d

NAAT, nucleic acid amplification test (where available).

Table 1307 Clinical Features of Genital Ulcers

Feature

Syphilis

Herpes

Chancroid

Lymphogranulom Donovanosis
a Venereum

Incubation period 990 days

27 days

114 days

3 days6 weeks

14 weeks
(up to 6
months)

Early primary
lesions

Papule

Vesicle

Pustule

Papule, pustule, or
vesicle

Papule

No. of lesions

Usually one Multiple

Usually
multiple,
may
coalesce

Usually one; often

not detected,
despite
lymphadenopathy

Variable

Diameter

515 mm

Variable

210 mm

Variable

Edges

Sharply
Erythematou Undermined Elevated, round, or Elevated,
demarcated, s
, ragged,
oval
irregular
elevated,
irregular
round, or
oval

Depth

Superficial Superficial
or deep

Base

Smooth,
Serous,
Purulent,
Variable,
nonpurulent erythematous bleeds easily nonvascular
, relatively , nonvascular
nonvascular

Red and
velvety,
bleeds readily

Induration

Firm

Firm

Pain

Uncommon Frequently
tender

Lymphadenopath Firm,

12 mm

None

Excavated

Soft

Superficial or deep Elevated

Occasionally firm

Usually very Variable

tender

Firm, tender, Tender, may Tender, may

Uncommon
None;

Feature

Syphilis

Herpes

Chancroid

Lymphogranulom Donovanosis
a Venereum

nontender,
bilateral

often
bilateral with
initial
episode

suppurate,
loculated,
usually
unilateral

suppurate,
loculated, usually
unilateral

pseudobuboe
s

Source: From RM Ballard, in KK Holmes et al (eds): Sexually Transmitted Diseases, 4th ed.
New York, McGraw-Hill, 2008.

Table 1308 Initial Management of Genital or Perianal Ulcer

Usual causes
Herpes simplex virus (HSV)
Treponema pallidum(primary syphilis)
Haemophilus ducreyi (chancroid)
Usual initial laboratory evaluation
Dark-field exam (if available), direct FA, or PCR for T. pallidum; RPR, VDRL, or EIA test for
syphilis (if negative but primary syphilis suspected, treat presumptively when indicated by
epidemiologic and sexual risk assessment; repeat in 1 week); culture, direct FA, ELISA, or PCR
for HSV; consider HSV-2-specific serology. In chancroid-endemic area: PCR or culture for H.
ducreyi
Initial Treatment
Herpes confirmed or suspected (history or sign of vesicles):
Treat for genital herpes with acyclovir, valacyclovir, or famciclovir
Syphilis confirmed (dark-field, FA, or PCR showing T. pallidum, or RPR reactive):
Benzathine penicillin [2.4 million units IM once to patient, recent (e.g., within 3 months)
seronegative partner(s), and all seropositive partners]
Chancroid confirmed or suspected (diagnostic test positive, or HSV and syphilis excluded,
and persistent lesion):
Ciprofloxacin (500 mg PO as single dose) or
Ceftriaxone (250 mg IM as single dose) or
Azithromycin (1 g PO as single dose)

Abbreviations: FA, fluorescent antibody; PCR, polymerase chain reaction; RPR, rapid plasma
reagin; EIA, enzyme immunoassay; ELISA, enzyme-linked immunosorbent assay; HSV, herpes
simplex virus; VDRL, Venereal Disease Research Laboratory.