|Sexually Transmitted Diseases (STD) Syndromic Management (AIDSCAP/FHI, 1997, 54 p.)|
|DESIGN OF STD FLOWCHARTS|
The symptoms of cervicitis and vaginitis overlap. Abnormal (in amount, color or odor) vaginal discharge is the symptom most commonly presented, but it is more predictive for vaginitis than for cervicitis.18,19 The sensitivity of the symptom vaginal discharge for cervicitis varies from 25 percent (prostitutes in Zaire) to 48 percent (STD patients in USA). Cervical mucopus and induced endocervical bleeding have a high specificity (83 to 99 percent) but a low sensitivity (1 to 43 percent) as clinical signs for cervicitis. Examples of flowcharts for vaginal discharge are shown in Figures 4 and 5.
Figure 4 is a flowchart for situations in which a speculum examination is not possible. The most probable cause of a woman complaining of vaginal discharge is vaginitis. Cervicitis is a less frequent cause of consultation for vaginal discharge, but the complications of untreated cervicitis are much more serious.
Figure 4 - Example of a Flowchart for the Management of Vaginal Discharge - HAITI (without speculum)
The accuracy and cost-effectiveness of syndromic diagnosis of vaginitis can be improved significantly in some settings by adding a risk assessment component to the case management protocols (for instance, determining whether an individual has had a new sexual partner or more than one sexual partner in the past three months). Using this approach, a woman with vaginal discharge and positive risk assessment for STDs would be treated for gonorrhea and chlamydia cervicitis as well as for vaginitis; a woman with no risk factors for STDs would be treated only for vaginitis, which requires a much less expensive treatment regimen. A recent analysis of data from pregnant women and sex workers in Zaire suggested that a simple case management protocol based on reported vaginal discharge and a risk assessment could be a useful tool for symptomatic women at high and low risk for STDs.20
In situations where a speculum examination is possible, the clinician can try to differentiate between various etiologies of vaginal discharge. The clinical sign mucopus, however, is not sensitive enough to be the only indication for cervicitis treatment. Figure 5 is an example of a flowchart utilizing a speculum exam and a risk assessment.
Figure 5 - Example of a Flowchart for the Management of Vaginal Discharge - JAMAICA (without speculum)
An alternative for differentiating etiologies for vaginitis can be offered by simple laboratory tests, if the infrastructure is available. Direct examination of a vaginal wet mount is useful for detecting trichomonads and yeast forms. Determination of the vaginal pH and amine odor with 10 percent potassium hydroxide solution can be helpful in the diagnosis of bacterial vaginosis. However, no simple laboratory test has been developed so far for detecting cervicitis. Adding Gram stain for the detection of intracellular gram-negative diplococci or leukocytes in the endocervix does not offer any advantage, as the sensitivity will drop dramatically. The leukocyte esterase dipstick, which has a good sensitivity for detecting male urethritis, had a sensitivity of only 47 percent for the detection of cervicitis.15