A case of undertreatment of Sexual Disease associated with syndromic management

Case Study #1: Tina Intro: Day 1 (Clinic Visit): Meet Tina

Tina is a recently married 27-year-old woman who has dreams of having a large family and is actively trying to get pregnant. She presents to the local clinic with complaints of vaginal discharge and irritation. Could it be an STD, possibly trichomoniasis? Only a trichomoniasis Home Test will help us figure this out.

Case Update: Day 1 (Clinic Visit): Medical and Sexual History

In the exam room, the nurse collects medical and sexual history.

Tina reiterates her chief complaint as vaginal discharge and irritation, both of which started 1-2 weeks ago. She reports regular menstrual cycles and denies using any method of contraception because she has been trying to get pregnant for the last 12 months.

The nurse requests a urine sample to assess for signs of a urinary tract infection and an STD Test to determine pregnancy status.

Nurse-patient dialogue:

Nurse: When did the vaginal discharge and irritation start?

Tina: I noticed it toward the end of my last menstrual cycle about 2 weeks ago.

Nurse: How would you describe the vaginal discharge and irritation?

Tina: The discharge is more than usual and appears white or off-white. The irritation is focused around the vaginal opening. It seems like it might be trichomoniasis.

Nurse: How many sexual partners have you had in the past year?

Tina: I have not had any sexual partners in over 1.5 years beyond my husband. Although we’ve only been married for 3 months, we’ve been engaged and trying to get pregnant for about 1 year. We recently planned a consult with a reproductive endocrinologist (RE) since it’s been 12 months without a pregnancy.

Nurse: Do you or your husband have any history of STDs? If you used STI prevention methods (e.g., condoms), how often did you use them?

Tina: I’ve never had a diagnosis with an STI. My husband has never shared if he has, but I doubt he ever has. I have always used a condom with prior partners and with my husband before we started trying to get pregnant.

Day 1 (Clinic Visit): Physical and Pelvic Exams, Lab Assessments

Tina provides a urine sample for in-house processing. She prepares for the physical and pelvic exam while waiting for the physician and is still suspected to have been infected with trichomoniasis.

Examinations

– Physical Exam:

  • All vitals are within normal limits
  • The patient is alert, well-developed, and well-nourished

-Pelvic Exam:

External findings:

  • Noted presence of white/off-white discharge in and around the vaginal vestibule
  • Observed mild erythema around the vaginal introitus; patient confirms that is the area in which the irritation is the most notable

-Bimanual exam findings:

  • Patient feeling mild tenderness upon palpation of the uterus and adnexal regions, as well as mild cervical motion tenderness (CMT)
  • No adnexal masses or tubo-ovarian abscesses are present
  • The vaginal swab is collected for lab analysis.
  • Laboratory tests
  • External lab test
  • Human chorionic gonadotropin (hCG): not detected; negative
  • Visual test: clear, straw-coloured
  • Chemistry test: no protein, glucose, or blood detected

Case Updates: Day 1 (Clinic Visit): Treatment Plan

The physician reviews his case notes.

A definitive diagnosis from the lab test will likely be unavailable for several days, so the physician recommends empirical treatment or syndromic management for VVC.

 Syndromic management is a strategy used to identify and treat STIs based only on the specific presenting syndromes, including symptoms identified by the patient and clinically observed signs of infection.

It is used widely as a means to medically manage people with symptoms of STIs because untreated STIs can cause serious physical complications (e.g., pelvic inflammatory disease, infertility, ectopic pregnancy, miscarriage, and increased susceptibility to HIV and other STIs) and can also impact mental health and relationships with partners.

In most resource-limited settings, syndromic management is the standard of care because laboratory diagnosis is not feasible, and lab test results can take many days.

Case Update: Day 12-15

Day 12

The clinic receives the STI lab results, which the physician always reviews. The results confirm that Tina does not have VVC but that she does have chlamydia and trichomoniasis.

Day 15

After 3 days and 4 attempts at contacting Tina, the clinic nurse finally reached her and shared the lab results. The results showed she had 2 STIs, neither of which were VVC. Therefore, in retrospect, fluconazole was not necessary.

Tina expresses immediate concern that she got these STIs while being in a long-term, committed relationship. The clinic nurse tells her that STIs can often remain with no symptoms and, if left untreated, can persist for several years.

Tina is to pick up a new prescription for the identified STIs:

  • Azithromycin for chlamydia
  • Metronidazole for trichomoniasis

Duration of infections

-For chlamydia:

It is not known how long asymptomatic chlamydial infections with no treatment lasts.

Modelling studies suggest that although men are less likely to establish an infection, they are slower at resolving it. The mean duration of untreated symptomatic infections in males is ~2.84 years compared with ~1.35 years in females.

-For trichomoniasis:

In females, untreated trichomoniasis can persist for months or even years.

In males, infection generally lasts for <10 days.

Infertility and untreated infections

Recall that Tina noted during her medical history that she and her husband have been trying to get pregnant for over 12 months, which may meet the American Society for Reproductive Medicine guidelines for infertility.

With Tina’s diagnosis of chlamydia and the presence of cervical motion, uterine, and adnexal tenderness, the physician notes’ possible PID’ in Tina’s chart and supports her in discussing this with the RE who she is planning to visit.

Case update

What if STI Test Results Are Available During the Patient Visit?

Let’s revisit Tina’s story and see how it would play out differently if the clinic had a rapid, highly accurate POCT, such as the Visby Medical Sexual Health Test.

During her clinic visit, the nurse asks Tina to provide a vaginal swab and urine sample. Both samples are tested right away at the start of the visit.

30 minutes later…

Tina meets with the physician, who has both her urine analysis and the POCT results.

Key Takeaways

-Traditional PCR-based STD testing can take several days to return results. In this instance, the use of syndromic management can treat potential STDs.

-Syndromic management can lead to both under- and overtreatment

-Inappropriate use of antibiotics comes with risks

-Untreated or failure to treat STDs the correct way increases the risk of issues, especially in women (e.g., pelvic inflammatory disease, infertility, ectopic pregnancy, miscarriage)

-Point-of-care testing allows a patient to receive an exam, precise diagnosis, and appropriate treatment all in one clinic visit

-This helps to make the treatment quicker for both the patient and their sexual partner (or partners) and reduces community spread.

Most people don’t show any STD symptoms, said Dr. Melanie Taylor, author of the World Health Organization’s stats report.

People don’t realize that they have the infection.

“They don’t realize that they are at risk. When they don’t go in for testing and treatment, the opportunity to pass the infection is quite high,” she says. That doesn’t mean it’s without harm, though. In women who do show symptoms, it looks something like a yeast infection, with inflammation of the vaginal tissue. There may be a “yellowy or maybe creamy discharge” as well.

-Men can also get irritation of their penis and occasionally a discharge as well.

-Left with no treatment, trichomoniasis can be “very uncomfortable” for a woman and cause lower abdominal pain, Taylor said. “In addition, if the woman has an infection during pregnancy, it can cause adverse pregnancy outcomes, specifically premature delivery, premature rupture of membranes, and low birth weight due to that prematurity.”

-It’s important to treat both sexual partners, as they can easily keep passing the infection back and forth, he said.

-Using a condom and getting regular STD testing is the best way to prevent and detect the infection.