Dr. Devi Artami Susetiati, M.Sc.

, SpKK
Pendahuluan
Syndromic approach an inexpensive & effective method
for the treatment of symptomatic sexually transmitted
infections (STIs) & vaginal discharge in which no lab test
are required & the patient treated empirically on antibiotics.
Components are:
History taking
Examination
Correct Dx
Early & effective Tx
Advice on sexual behavior
Promotion &/or provision of condoms
Partner notification & Tx
Case reporting & clinical follow up
Disadvantages pasien asimtomatik & pengobatan
berlebihan
Sindrom Discar Uretra
Merupakan sindrom yang ditandai dengan adanya
discar uretra dan ditandai dengan meningkatnya
lekosit PMN dari apusan discar atau sedimen dari
fisrt-void urine
Sering disebut dengan uretritis : GU (gonorrheal
uretritis) atau NGU (nongonorrheal uretritis)
Vaginal Discharge Syndrome
is diagnosed when a woman complains of vaginal
discharge that is in excess of the usual or if it causes
itching or discomfort.
Women develop abnormal vaginal discharge if they have
either vaginitis (infection of the vagina) or cervicitis
(infection of the cervix), or both.
Unfortunately, it is not easy to distinguish between
cervicitis and vaginitis, especially when an internal
examination is not possible. Often, it may be useful to treat
the patient for both cervicitis and vaginitis if the diagnosis
cannot be established for certain
Discar
Patologis
Fisiologis
Vulva
Urethra
Vagina
Cervix
kandidiasis
trikomoniasis
Herpes
trauma (physical/chemical)
klamidia
GO
nonspesific infection
trikomoniasis
secondary to intra-urethral lesions
Secondary to upper urinary tract
lesions
kandidiasis
trikomoniasis
BV
Benda asing
klamidia
GO
nonspesific cervisitis
herpes
erosi/polip
Secondary to
supracervical lesions
AKDR
kehamilan
variasi siklus mens
Stimulasi seks
Penderita dg KU discar vagina atau gatal/rasa terbakar
(Pemeriksaan dg cara sindrom)
Ax riw penyakit, pasangan menderita ims, pemeriksaan palpasi
Px: Ada nyeri perut
bagian bwh?
Gunakan bagan alur nyeri perut bag bwh
Ada Fx risiko?
Obati sbg vaginitis: vaginosis bakterial
& kandidiasis
KIE
sediakan & anjurkan pemakaian
kondom
anjurkan konselling & tes STS & HIV
bila fasilitas tersedia
Obati sbg servisitis GO, klamidiosis,
& trikomoniasis
KIE
sediakan & anjurkan pemakaian
kondom
anjurkan konselling & tes STS & HIV
bila fasilitas tersedia
Ya
Ya
Tidak
Tidak
Hilangnya
keluhan pd
hr ke7?
rujuk
Hilangnya
keluhan pd
hr ke7?
Obati penderita sbg
servisitis GO,
klamidiosis, &
trikomoniasis
Hilangnya
keluhan pd
hr ke7?
Pengobatan selesai
rujuk
Risiko (+) bila memiliki 1/lbh Fx risiko dibwh ini:
1.suami/mitra seksual menderita IMS
2.Suami/mitra seksual/ penderita sndiri mpy pasangan >1 dlm 1 bl terakhir
3.Mpy pasangan baru dlm 3 bl terakhir
4.Malami 1/lbh episode IMS dlm 1 th terakhir
5.Pekj suami/mitra seksual berisiko tinggi
Tidak Tidak
Tidak
Ya Ya
Ya
Penderita dg KU discar vagina atau gatal/rasa terbakar
(Pemeriksaan gunakan spekulum)
Ax riw penyakit, pasangan menderita ims, pemeriksaan palpasi
Px: Ada nyeri perut
bagian bwh?
Gunakan bagan alur nyeri perut bag bwh
Spekulum: Ada
discar serviks atau
vaginal?
Ada discar serviks
mukopurulen?
Obati sbg vaginitis: vaginosis bakterial &
kandidiasis
KIE
sediakan & anjurkan pemakaian
kondom
anjurkan konselling & tes STS & HIV
bila fasilitas tersedia
KIE
sediakan & anjurkan pemakaian kondom
anjurkan konselling & tes STS & HIV bila
fasilitas tersedia
Ya
Ya
Ya
Tidak
Tidak
Obati sbg servisitis GO, klamidiosis,
& trikomoniasis
KIE
sediakan & anjurkan pemakaian
kondom
anjurkan konselling & tes STS & HIV
bila fasilitas tersedia
Hilangnya
keluhan pd
hr ke7?
Hilangnya
keluhan pd
hr ke7?
Obati penderita sbg
servisitis GO,
klamidiosis, &
trikomoniasis
rujuk
rujuk
Hilangnya
keluhan pd
hr ke7?
Pengobatan selesai
Tidak
Tidak
Tidak
Ya
Ya
Ya
Penderita dg KU discar vagina atau gatal/rasa terbakar
(Pemeriksaan dg spekulum & mikroskop)
Ax riw penyakit, pasangan menderita ims, pemeriksaan palpasi
Px: Ada nyeri perut
bagian bwh?
Gunakan bagan alur nyeri perut bag bwh
Spekulum: Ada
discar serviks atau
vaginal?
KIE
sediakan & anjurkan pemakaian
kondom
anjurkan konselling & tes STS & HIV
bila fasilitas tersedia
Buat sediaan basah dr cairan forniks post, sediaan Gram dr serviks & vagina
Ya
Ya
Tidak
Tidak
Leukosit >30 lpb
DGNI (+) pd px
gram
Ada gerakan
Trichomonas
vaginalis pd
sediaan basah
cairan forniks post
Cairan vagina yg homogen, putih
&keabu-abuan, melekat pd dinding
vagina
Ada clue cells pd px gram
Tes amin/whiff test bau amis
pH cairan vagina >4,5
Positif bila ditemukan 3 dr 4 gejala
diatas.
50% wanita asimtomatik
Ada sel ragi atau
pseudohifa pd px
Gram cairan
vagina?
Obati sbg kandidiasis
Obati sbg
servisitis GO
&
Klamidiosis
Obati sbg
trikomoniasis
Obati
sbg BV
KIE
sediakan & anjurkan pemakaian kondom
anjurkan konselling & tes STS & HIV bila fasilitas tersedia
konsul ulang bila perlu
Ya
Ya
Ya
Ya
Tidak
Tidak
Tidak
Tidak
Ya
Hilangnya
keluhan pd
hr ke7?
Hilangnya
keluhan pd
hr ke7?
Hilangnya
keluhan pd
hr ke7?
Obati sbg
servisitis GO &
Klamidiosis
rujuk
rujuk
Pengobatan selesai
Ya
Ya
Ya
Tidak
Tidak
Tidak
Nyeri Perut Bagian Bawah pd Wanita
Penderita dg keluhan NPB
Ax & Px fisik
Apakah ditemukan hal2 sbb?
terlambat haid, atau
Pasca partus/ abortus, atau
Nyeri lepas abdominal, atau
perdrhn vaginal yg abnormal,
atau
tdp massa abdomen, atau
Akseptor AKDR
Sbl dirujuk siapkan infus & O2 bila
memungkinkan
Rujuk penderita utk penilaian/ pertimbangan
tindk pembedahan atau ginekologis
suhu >38C, atau
pd px bimanual ada:
mukopus dr serviks
nyeri goyang pd serviks
obati sbg PRP
KIE
sediakan & anjurkan kondom
obati pasangan sexual
anjurkan konseling & tes HIV
bila tersedia
Tidak
Tidak
Ya
Ya
Kunjungan ulang
hr ke3 atau lbh
cepat bila perlu
perbaikan
Lanjutkan pengobatan &
amati smp nyeri hilang
rujuk
Tidak
Ya

Gonorrhea, Risk Factor
Multiple or new sex partners or inconsistent
condom use
Urban residence in areas with disease prevalence
Adolescents, females particularly
Lower socio-economic status
Use of drugs
Exchange of sex for drugs or money
Gonorrhea, Transmission
Efficiently transmitted by:
Male to female via semen
Female to male urethra
Rectal intercourse
Fellatio (pharyngeal infection)
Perinatal transmission (mother to infant)
Gonorrhea associated with increased transmission of
and susceptibility to HIV infection
Etiologic agent: Neisseria gonorrhoeae
Gram-negative intracellular diplococcus
Infects mucus-secreting epithelial cells
Gonorrhea, Etiology
Male Urethritis
Symptoms
Typically purulent or mucopurulent urethral
discharge
Often accompanied by dysuria
Discharge may be clear or cloudy
Asymptomatic in 10% of cases
Incubation period: usually 1-14 days for
symptomatic disease, but may be longer
26
Gonococcal Urethritis: Purulent Discharge
Source: Seattle STD/HIV Prevention Training Center at the University of Washington:
Connie Celum and Walter Stamm
27
Genital Infection in Women
Most infections are asymptomatic
Cervicitis inflammation of the cervix
Urethritis inflammation of the urethra

Cervicitis
Non-specific symptoms: abnormal vaginal
discharge, intermenstrual bleeding, dysuria,
lower abdominal pain, or dyspareunia
Clinical findings: mucopurulent or purulent
cervical discharge, easily induced cervical
bleeding
50% of women with clinical cervicitis have no
symptoms
Incubation period unclear, but symptoms may
occur within 10 days of infection
Gonococcal Cervicitis
Gonococcal Cervicitis, Complications
in Women
Accessory gland infection
Bartholins glands
Skenes glands
Pelvic Inflammatory Disease (PID)
Fitz-Hugh-Curtis Syndrome
Perihepatitis
Bartholins Abscess
32
Syndromes in Men and Women
Anorectal infection
Pharyngeal infection
Conjunctivitis
Disseminated gonococcal infection (DGI) an
arthritis-dermatitis syndrome. Joint or tendon pain
is the most common presenting complaint in the
early stage of infection. The 2
nd
stage of DGI is
characterized by septic arthritis. The knee is the
most common site of purulent gonococcal
arthritis
33
Disseminated Gonorrhea, skin Lesion
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
34
Gonorrhea Infection in Children
Perinatal: infections of the conjunctiva,
pharynx, respiratory tract

Older children (>1 year): considered possible
evidence of sexual abuse

35
Gonococcal Ophthalmia in Neonates
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
vaginal delivery from an untreated mother with a
gonococcal infection, symptoms of gonococcal
conjunctivitis include the following: Eye pain, Redness,
Purulent discharge
36
Gonorrhea, Diagnostic Methods
Culture tests
Non-culture tests
Amplified tests (NAATs)
Polymerase chain reaction (PCR) (Roche Amplicor)
Transcription-mediated amplification (TMA) (Gen-Probe
Aptima)
Strand displacement amplification (SDA) (Becton-Dickinson
BD ProbeTec ET)
Non-amplified tests
DNA probe (Gen-Probe PACE 2, Digene Hybrid Capture II)
Gram stain DGNI (+)
Diagnosis
37
Antimicrobial Susceptibility of N.
gonorrhoeae
Fluoroquinolones are no longer recommended
for therapy for gonorrhea acquired in Asia, the
Pacific Islands (including Hawaii), and
California.
CDC no longer recommends fluoroquinolones as
a first-line therapy for gonorrhea in MSM.
Management
Treatment of Gonorrhea
Tx alternatif
Kanamisin 2g im SD Tetrasiklin* 4x500mg po, 7 hari
Spektinomisin 2g im, SD Eritromisin 4x500mg po, 7 hari
Tiamfenikol* 3,5g po, SD
Levofloksasin* 250mg po, SD Doksisiklin* 2x100mg po, 7 hari
39
Special Considerations: Pregnancy
Pregnant women should NOT be treated
with quinolones or tetracyclines
Treat with alternate cephalosporin
If cephalosporin is not tolerated, treat with
spectinomycin 2 g IM once
Management
Chlamydiasis
Obligatory intracellular bacteria
Infect columnar epithelial cells
Survive by replication that results in the
death of the cell
Takes on two forms in its life cycle:
Elementary body (EB)
Reticulate body (RB)
41
Pathology
Source: California STD/HIV Prevention Training Center
42
Chlamydiaceae Family
(species that cause disease in
humans)
Pathology
Species (genus) Disease
C. trachomatis
2 biovars, non-LGV
LGV
Trachoma, NGU,
PID, conjunctivitis,
Infant pneumonia,
LGV
C. pneumoniae
Pharyngitis,
bronchitis,
pneumonia
C. psittaci Psittacosis
43
Clinical Syndromes Caused by C. trachomatis
Local Infection Complication Sequelae
Conjunctivitis
Urethritis
Prostatitis
Reiters syndrome
Epididymitis
Chronic arthritis
(rare)
Infertility (rare)
Conjunctivitis
Urethritis
Cervicitis
Proctitis
Endometritis
Salpingitis
Perihepatitis
Reiters syndrome
Infertility
Ectopic pregnancy
Chronic pelvic pain
Chronic arthritis
(rare)
Conjunctivitis
Pneumonitis
Pharyngitis
Rhinitis
Chronic lung
disease?
Rare, if any
Men
Women
Infants
44
C. trachomatis Infection in Men
UrethritisOne cause of non-gonococcal urethritis
(NGU)
Majority (>50%) asymptomatic
Symptoms/signs if present: mucoid or clear
urethral discharge, dysuria
Incubation period unknown (probably 5-10 days
in symptomatic infection)

Clinical Manifestations
45
Non-Gonococcal Urethritis: Mucoid
Discharge
Source: Seattle STD/HIV Prevention Training Center at the University of
Washington/UW HSCER Slide Bank
46
C. trachomatis Infections in Women
Cervicitis
Majority (70%-80%) are asymptomatic
Local signs of infection, when present, include:
Mucopurulent endocervical discharge
Edematous cervical ectopy with erythema and
friability
Urethritis
Usually asymptomatic
Signs/symptoms, when present, include dysuria,
frequency, pyuria
47
Normal Cervix
Source: STD/HIV Prevention Training Center at the University of
Washington/Claire E. Stevens
48
Chlamydial Cervicitis
Source: STD/HIV Prevention Training Center at the University of
Washington/Connie Celum and Walter Stamm
49
C. trachomatis Complications in
Women
Pelvic Inflammatory Disease (PID)
Salpingitis
Endometritis
Perihepatitis (Fitz-Hugh-Curtis Syndrome)
Reiters Syndrome
50
Chlamydiasis, Testing Technologies
Culture gold standard
Non-culture tests
Nucleic Acid Amplification Tests (NAATs)
Non-Nucleic Acid Amplification Tests (Non-
NAATs)
Serology
Diagnosis
51
Treatment of Uncomplicated Genital
Chlamydial Infections
CDC-recommended regimens
Azithromycin 1 g orally in a single dose, OR
Doxycycline 100 mg orally twice daily for 7 days
Alternative regimens
Erythromycin base 500 mg orally 4 times a day for 7 days,
OR
Erythromycin ethylsuccinate 800 mg orally 4 times a day for
7 days, OR
Ofloxacin 300 mg orally twice a day for 7 days, OR
Levofloxacin 500 mg orally once a day for 7 days
52
Treatment of Chlamydial Infection in
Pregnant Women
CDC-recommended regimens
Erythromycin base 500 mg orally 4 times a day for 7 days, OR
Amoxicillin 500 mg orally 3 times a day for 7 days
Alternative regimens
Erythromycin base 250 mg orally 4 times a day for 14 days, OR
Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7
days, OR
Erythromycin ethylsuccinate 400 mg orally 4 times a day for 14
days, OR
Azithromycin 1 g orally (single dose)
53
Treatment of Neonatal Conjunctivitis
and/or Pneumonia
CDC-recommended regimen
Erythromycin base or ethylsuccinate 50
mg/kg/day orally divided into 4 doses daily
for 14 days
54
Treatment of Chlamydial Infection in
Children
Children who weigh <45 kg:
Erythromycin base or ethylsuccinate 50 mg/kg/day orally
divided into 4 doses daily for 14 days

Children who weigh 45 kg, but are <8 years of age:
Azithromycin 1 g orally in a single dose

Children 8 years of age:
Azithromycin 1 g orally in a single dose, OR
Doxycycline 100 mg orally twice a day for 7 days
Management
Bacterial Vaginosis
a polymicrobial clinical syndrome resulting from
replacement of the normal hydrogen peroxide producing
Lactobacillus sp. in the vagina with high concentrations of
anaerobic bacteria (e.g., Prevotella sp. and Mobiluncus
sp.), G. vaginalis, Ureaplasma, Mycoplasma, & numerous
fastidious or uncultivated anaerobes
>> asimtomatik
having multiple male or female partners, a new sex partner,
douching, lack of condom use,& lack of vaginal lactobacilli
women who have never been sexually active can also be
affected
Kriteria Dx mnt Amsel:
Cairan vagina yg homogen, putih, & keabu2an, melekat pd
dinding vagina
pH vagina >4,5
Sekret vagina bau amis sebelum atau setelah penambahan
KOH 10% (Whiff test) bau amin yg menguap
Clue cells pd pemeriksaan mikroskop
Bacterial Vaginosis
cont
Bacterial Vaginosis
cont
Trichomoniasis
caused by the protozoan T. vaginalis.
Some who are infected with T. vaginalis might not
have symptoms; others have NGU
Some have symptoms characterized by a diffuse,
malodorous, yellow-green vaginal discharge with vulvar
irritation, dyspareunia, lower abdominal discomfort, or
dysuria
Diagnosis of vaginal trichomoniasis is usually
performed microscopy of vaginal secretions, but this
method has a sensitivity of only approximately 60%
70% and requires immediate (will die on sun exposed
or water) evaluation of wet preparation slide for optimal
results during 48 hours

Masa inkubasi 3-28 hari
organisme dpt diisolasi dr
vagina, urethra, cervix, kelenjar
bartolin, kelenjar skene.
Manifestasi klinis bervariasi mulai
dr asimtomatis smp inflammatory
vaginitis
Bayi baru lahir dpt terinfeksi mll
ibu yg terinfeksi TV
Colpitis macularis atau strawberry
cervix dinding vagina & cervix

Trichomoniasis
cont
Strawberry appearance of
cervix with punctate bleeding
erosions
Trichomonas vaginalis
Komplikasi:
kelahiran prematur
early rupture membrane pd ibu hamil
berat bayi lahir rendah
meningkatkan risiko transmisi HIV
Vulvovaginal Candidiasis
caused by C. albicans, but occasionally is caused by
other Candida sp. or yeasts
pruritus, vaginal soreness, dyspareunia, external dysuria,
and abnormal vaginal discharge none is specific for
VVC
estimated 75% of women will have at least one episode
of VVC, and 40%45% will have two or more episodes
within their lifetime
Approximately 10%20% of women will have
complicated VVC that necessitates diagnostic and
therapeutic considerations

Vulvovaginal Candidiasis
cont
On the basis of clinical presentation, microbiology, host factors,
& response to therapy, VVC can be classified as either
uncomplicated or complicated
C. albicans mrpk saprofit, komensal 20-25% mukosa
vagina sehat, 30% hamil
Jamur jarang dpt diisolasi dr kulit sehat mns kec. Pd
daerah lipatan.
Vulvovaginal Candidiasis
cont
Recurrent VVC 4 episode/ thn 5%
Perubahan hormonal (kehamilan) & fase luteal siklus
mens relapse VVC
Pguna pembersih vagina/ douche meningkatkan
kerentanan vagina thd C. albicans krn adanya reaksi
respon hipersensitivitas/ alergi recurrent kandidiasis
Frequent sexual intercourse recurrent VVC
abrasi vagina yg terus menerus & alergi semen
Vulvovaginal Candidiasis
cont
Saline, 40x KOH, 10x
Recurrent VVC (RVVC) - Usually defined as four or more episodes each year
7-14 days of topical therapy, or
100 mg,150 mg, 200 mg oral dose of fluconozole every third day for a total of 3
doses (day 1, 4, 7)
Maintenance regimens
Severe VVC 7-14 days of topical therapy, or
150 mg oral dose of fluconozole repeated in 72 hours
Non-albicans VVC Optimal treatment unknown
7-14 days non-fluconozole therapy, or
600 mg boric acid in gelatin capsule vaginally once a day for 14 days for
recurrences
Compromised host 7-14 days of topical therapy