All About that Discharge

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Case: 68 yr old female comes in with worsening dysuria, frequency, discharge and subjective fever.  

What is high on your differential? 

a)      Urinary Tract infection 

b)      Pyelonephritis 

c)       Sexually Transmitted Infections- ie chlamydia, gonorrhea, syphilis   

d)      All over the Above 

 Answer: 

e)      All of the above 

Wait Doc, she is 68 and STIs are HIGH on your differential?? 

YES! 

Did you know that the cases of chlamydia, gonorrhea and syphilis are rising and are actually rising FASTEST in the elderly population!  

While absolute rates are HIGHEST in the 15 – 29 yr olds, numbers are rising in the elderly.  

Between 2009 and 2019 There was a 114% relative increase of chlamydia in those 40 – 49 yo and 90.2% increase in those above 60 years old. 

But don’t ignore the other end of the spectrum! 

The young adolescents (15 – 19 yr olds) have the second highest absolute rates of STIs.  

So doc, what are you saying?  

STIs are on the rise in EVERYONE! So Test liberally! 

Especially, don’t discount those who are young (< 20 yo) and those older (>60 yo) , they are ALL sexually active!  

Ok, I understand gonorrhea and chlamydia, but Syphilis? Why are we worried about that? 

Syphilis has never gone away and its rates are also dramatically rising!  

Syphilis however is much more common in males (72%), and especially in the men who have sex with men (MSM) population, but rates are increasing in women. So look at the patient’s risk factors and presentation and do not hesitate to test.  

Ok Doc, if we are worried about STIs in women, can we just do Urine testing or do we need to do swabs? 

Urine testing is great for minimally symptomatic individuals and for asymptomatic patients.  

However, a recent study showed that vaginal swabs were more accurate than urine tests when detecting Chlamydia and gonorrhea

Also, you cannot test for bacterial vaginosis, candidiasis, and trichomonas* with urine testing.  

So for patients with any vaginal discharge, odour, vaginal pain etc, a swab would likely be more useful. 

*Note- at some institutions you can test for trichomonas in the urine 

So does that mean we HAVE to do a PELVIC / genital exam?  

If the patient is symptomatic or STI is suspected a physical exam is essential! 

There is a lot of useful information which can be gained by doing a pelvic exam.  

You can check for pain, other masses, lesions, ulcers (herpes), vaginal/ penile discharge etc which may increase your suspicion for empiric treatment for an STI in the equivocal patients or point to other diagnoses.  

Also, as previously mentioned, vaginal swabs are  the most accurate way to test for major STIs and also the only way to test for bacterial vaginosis, trichomonas (at SHN), candidiasis.  

So don’t ditch the pelvic exam! It is an essential part of our physical. 

Ok, so we suspect patient may have gonorrhoea or chlamydia. How do we treat? 

Chlamydia trachomatis (CT) Neisseria gonorrhoeae (NG) 
Doxycycline 100 mg PO bid for 7 days Ceftriaxone 500 mg IM/IV in a single dose  

You treat empirically for BOTH gonorrhoea AND Chlamydia, so give BOTH medications.  

Note- Ceftriaxone CAN be given IV (intravenous), so if patient ALREADY has an IV, don’t torture them with an IM! 

NOTE- in the US if gonorrhoea solely is identified, monotherapy with ceftriaxone 500mg IM for gonorrhoea is now recommended. However in Canada DUAL therapy (ceftriaxone AND doxycycline)  (to cover Chlamydia) is STILL recommended to increase efficacy and prevent resistance [iv]  

Practice Changes! 

Important updates:  

  • Ceftriaxone- Increased from 250mg to 500mg  
    •  WHY? – Increased multi drug resistance 
  • Azithromycin is NO longer First Line for chlamydia treatment! Doxycycline is 
    • WHY?
      • According to the CDC azithromycin had higher treatment failures in men and did not have good coverage for rectal infections.  Note- women can be asymptomatic carriers of rectal chlamydia.  
      • Doxycycline, on the other hand, appears effective for infections in urogenital, rectal, and oropharyngeal sites 
      • HOWEVER Azithromycin is STILL quite effective for urogenital infections in women and should be used in patients with high risk of non-compliance  and  pregnant  patients 

If the patient comes back POSITIVE for one of the tests, what do I do? 

  1. Treat for the positive result – as indicated above 
  2. Treat for OTHER STIs!! 

Patients with one STI are at HIGH risk for having OTHER STIs. So if a patient has tested positive for gonorrhoea or chlamydia, Make sure to test them for:  

  • Either Gonorrhoea or chlamydia (if BOTH weren’t originally tested for) 
  • Syphilis and  
  • HIV,  
    • As per the recommendations in the HIV Screening and Testing Guide 
    • Infection with chlamydia can increase the risk of acquiring  and transmitting  HIV 

If the patient is being treated for an STI what discharge instructions do you want to give? 

  • Abstain from any sexual activity until:
    • A) Treatment of the person is complete and ALL symptoms have resolved.
      • Ie at LEAST
        • 7 days for those on Doxycline and  
        • 7 days AFTER single dose of azithromycine/ Ceftriaxone. 
    • B) Treatment of ALL current partners is complete and all symptoms resolved 
      • Ask patient to inform ALL partners in the prior 60 days to get tested 

Future testing 

  • Advise patient that they MAY need to be retested in 4 weeks if:
    • Symptoms or signs persist post-therapy 
    • Compliance to the prescribed treatment is suboptimal 
    • Preferred treatment regimen is not used 
    • The person is prepubertal 
    • The person is pregnant 
  • ALL patients should be re-tested in 3 months
    • At 3 months if patient has symptoms it is NOT because of treatment failure, but actually because of re-infection
      • Ie failure of sex partners to receive treatment or initiation of sexual activity with a new infected partner 

Note: For those with EMRs, attached below is a discharge instruction template. Feel Free to copy/use/ adapt it for your practice 

But Doc, I never see these patients once they leave the ED. Doesn’t public health or their family doctor follow up? 

  • While public health usually follows up, many patients are LOST to follow up, OR do not KNOW that they need to follow up 
  • As their first line of contact it is useful to at least let them KNOW that they need follow up, so at the very least can seek it out themselves. 

Summary: 

  • STI rates are INCREASING – especially those young and old 
  • Rates are highest in those 15 – 29  
  • Don’t forget about the above 60 population.  
  • Syphilis is NOT gone, and is actually rising.
    • Prevalence is higher in MALES and MSM population, so test liberally. 
  • Urine test for gonorrhea and chlamydia is great for asymptomatic individuals 
  • Swabs are preferred for symptomatic females 
  • Physical exam/ Pelvic exam on all high risk patients 
  • Treatment is:
    • Doxycycline 100mg PO BID x 7 days 
    • Ceftriaxone 500mg IM/ IV x 1 
  • If patient is positive for ONE STI, make sure to test for HIV and Syphilis! 
  • Good discharge and follow up instructions are necessary 

Random tip: To increase the accuracy of urine tests: 

  1) The patient should not urinate for at least one hour prior to collecting the specimen. 

  2) Collect the first 15 – 20 ml of void­ed urine (ie FIRST void not midstream)  

References/ Further Reading

  1. Aaron, K. J., et al. (2023). Vaginal swab vs urine for detection of chlamydia trachomatis, neisseria gonorrhoea, and trichomonas vaginalis: a meta-analysis. The Annals of Family Medicine, 21(2), 172–179.
  2. Chlamydia and LGV guide: Key information and resources. (n.d.). The Government of Canada. Retrieved September 13, 2023
  3. Chlamydial infections – STI treatment guidelines 2021. (n.d.). Centers for Disease Control and Prevention. Retrieved September 13, 2023
  4. Gonococcal infections among adolescents and adults – STI treatment guidelines 2021. (n.d.). Centers for Disease Control and Prevention. Retrieved September 13, 2023
  5. Gonorrhea guide: Key information and resources. (n.d.). Government of Canada. Retrieved September 13, 2023
  6. Helman, A., & Jalali, H. (2023). STIs: Cervicitis, vulvovaginitis and urethritis. Emergency Medicine Cases
  7. Report on sexually transmitted infection surveillance in Canada, 2019. (n.d.). Government of Canada. Retrieved September 13, 2023

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