STI-associated syndromes guide: Syndromic management

On this page:

• Introduction
  • Common STI-associated syndromes
• Management of symptomatic individuals
  • Clinical assessment
  • Empiric treatment
  • Follow-up
  • Reporting and partner notification
• References

Introduction

This guide provides an overview of the management of the following sexually transmitted infection (STI)-associated syndromes: anogenital ulcers, cervicitis, epididymitis, pelvic inflammatory disease (PID), proctitis, urethritis and vaginitis.

These syndromes may be caused by an STI, another infection or have a non-infectious cause. The probability that a syndrome is caused by an STI, a non-sexually transmitted infection or a non-infectious cause varies by syndrome and a person's risk.

Although STI may present as a syndrome, many STI are frequently asymptomatic. Screening for sexually transmitted and blood-borne infections (STBBI) permits early detection and treatment of asymptomatic infections, thereby preventing or limiting complications and lessening the potential for transmission. When an STI has been identified, refer to the etiology-specific guide(s) for guidance and information on:

• Common clinical presentations
• Screening and diagnostic testing
• Management and treatment
• Test of cure (TOC) and follow-up
• Reporting requirements
• Notification and treatment of partners

In this guide, syndromic management of STI refers to the management of an individual based on signs and symptoms, prior to laboratory confirmation of the etiologic agent(s). The recommended empiric treatments are based on the most common STI associated with each syndrome. In some situations, the empiric treatment may vary from that recommended in the etiology-specific guide because a longer regime of antibiotics or a different combination of antibiotics is needed to adequately treat complicated (e.g. those that are frequently polymicrobial) and deep-seated infections.

Consult Health Canada and product monographs for warnings, contraindications and side effects of treatments outlined in this guide.

Common STI-associated syndromes

Pathogen	Associated syndromes
Chlamydia trachomatis(CT)Footnote 1	Cervicitis Urethritis Epididymitis PID Proctitis Anogenital ulcers (CT serotype L1, L2 or L3, causing lymphogranuloma venereum)
Neisseria gonorrhoeae (GC)Footnote 2	Cervicitis Urethritis Epididymitis PID Proctitis
Herpes simplex virus type 1 or type 2 (HSV-1 or HSV-2)Footnote 3	Anogenital ulcers Cervicitis Urethritis Proctitis
Mycoplasma genitaliumFootnote 4	Cervicitis Urethritis PID Proctitis
Treponema pallidum, subspecies pallidum (Syphilis)	Anogenital ulcers Proctitis
Trichomonas vaginalis (TV)	Vaginitis Cervicitis Urethritis
Mpox virusFootnote 5	Anogenital ulcers Proctitis

Note: Many pathogens can also cause extra-genital manifestations (e.g., disseminated GC infections, CT or GC pharyngeal infections, HSV-1 or HSV-2 orolabial lesions, syphilis-related skin rash, alopecia, mucous patches, neurosyphilis).

Management of symptomatic individuals

Clinical assessment

Clinical assessment of symptomatic individuals should include:

• The identification of risk factors for STBBI
• A physical exam
• STBBI testing according to risk factors, signs, symptoms and sites of exposure

A syndrome may have more than one infectious cause. Transmission routes are similar for many STBBI and co-infection is common. Anyone suspected of having a specific STI should be screened for other STBBI. Depending on type of sexual activity, it may be necessary to screen for STBBI at multiple anatomical sites.

CT and GC are the most common bacterial STI in Canada and co-infection is common. Test people for both CT and GC if either is suspected^{Footnote 6}. Nucleic acid amplification tests (NAAT) can detect both GC and CT from a single specimen^{Footnote 6Footnote 7}. Validated NAAT for extra-genital specimens are available in many jurisdictions. Due to increasing rates of antimicrobial resistant GC (AMR-GC), there is a need for drug susceptibility information. If feasible, when GC is suspected, collect swabs for culture (in addition to samples for NAAT). Check with your local laboratory for information on available testing methods.

Where an etiology other than a sexually transmitted infection is suspected, the presentation is severe, or symptoms are persistent or recurrent, consider consulting an experienced colleague or relevant specialist.

Empiric treatment

The decision to treat empirically or to wait for test results should reflect the:

• Severity of the clinical condition
• Probability of infection
• Person's risk factors for an STBBI
• Person's willingness to abstain from sex and to return for test results or follow-up

Empiric treatment is useful to manage symptoms, to control transmission and to prevent complications. At the same time, different STI may have similar presentations or conversely, the same STI may present in different ways. Waiting for test results before treatment allows for the appropriate use of antibiotics, which can enhance health outcomes, reduce AMR and decrease unnecessary or inadequate treatment. Delaying treatment until test results are available may be preferable when the clinical condition is not severe, risk factors suggest that it's unlikely that an STI is the cause of symptoms and the person agrees to abstain from sex while waiting for test results.

If empiric treatment is provided for a suspected STI, advise the person to abstain from sexual activity until therapy is completed, symptoms have resolved, and sexual partners have been adequately treated. If abstinence is in doubt, recommend the use of barrier protection for oral, genital and anal sex. For suspected or confirmed cases of mpox, refer to your provincial, territorial or local public health authority's reporting requirements and recommendations for contacts.

Consider providing empiric treatment as a public health preventive measure, to prevent the development of infection in a sexual contact of a person with a confirmed STI. As a case in point, rates of infectious syphilis have increased in Canada in recent years and outbreaks have been declared in most provinces and territories since 2017. Therefore, empiric treatment of contacts of suspected cases of infectious syphilis may be appropriate.

Follow-up

A test of cure (TOC) may be recommended depending on the pathogen, site of infection and treatment regimen. For some pathogens, a TOC is always recommended while for others, it is recommended in specific situations only. In cases of syphilis, post-treatment serologic testing can assess treatment response. It should be done at recommended intervals according to stage of infection.

For up-to-date guidance on pre-exposure and post-exposure vaccination for mpox, refer to the Canadian Immunization Guide or provincial and territorial vaccination schedules and guidelines.

In the case of persistent or recurrent symptoms, consider the following causes or contributing factors:

• Barriers to adherence to treatment
• Use of alternate rather than preferred (first-line) treatment
• Possible reinfection
• Possible AMR
• Presence of other pathogens that were not part of initial testing
• Presence of non-infectious etiologies

Offer repeat screening for STBBI based on ongoing risk factors and continued potential for exposure. Repeat screening is generally recommended 3-6 months after treatment for an STI, due to the potential for reinfection.

Integrate STBBI prevention strategies such as counselling, vaccination and education on preventive practices into care. If clinically indicated:

• Discuss HIV testing as per the recommendations in the HIV screening and testing guide and risk reduction strategies including the use of HIV pre-exposure prophylaxis (HIV PrEP) and post-exposure prophylaxis (HIV PEP) in those at elevated risk of acquiring HIV.
• Offer vaccination for hepatitis A virus (HAV), hepatitis B virus (HBV), human papillomavirus (HPV) and mpox to people at risk of these infections, as per the Canadian immunization guide or provincial and territorial vaccination schedules and guidelines.

Reporting and partner notification

Case finding, partner notification and treatment are critical to reduce the spread of STBBI. Partner notification has public health benefits (e.g., infectious disease surveillance and control) and reduces the risk of reinfection.

STBBI reporting requirements vary by jurisdiction. Refer to provincial and territorial regulations for reporting requirements when a STBBI is identified.