Genital symptoms, discharge and pelvic infection

A respectful symptom and exposure history

Ask about pain, discharge, bleeding, ulcers, urinary symptoms, pregnancy possibility, exposures and the anatomical sites involved. Use neutral language and obtain consent for examination and sampling. Sexual orientation alone does not define practices or infection risk. Offer an interpreter and a chaperone where appropriate, with privacy from accompanying partners for sensitive questions. Screen for coercion or violence when indicated. Severe pelvic pain, haemodynamic compromise, pregnancy with pain, testicular torsion, sepsis or inability to pass urine requires an emergency pathway rather than a routine STI visit.

Normal physiological vaginal discharge varies with the cycle and is a common explanation, but history, examination and tests distinguish disease. Itch and thick discharge suggest candidiasis; fishy odour/thin discharge suggests bacterial vaginosis; cervicitis can accompany chlamydia or gonorrhoea. These patterns overlap and cannot replace appropriate testing. Consider retained foreign body, dermatitis, atrophy, fistula and malignancy when relevant. BV is associated with sexual activity but is not simply classified as an STI; current treatment and partner recommendations should be checked as evidence evolves.

Sampling and treatment

NAAT sampling is selected by anatomy and exposure, including vaginal/first-catch urine, rectal and pharyngeal sites where indicated. A self-collected sample may improve access but does not replace an examination when PID, a lesion or another serious cause is suspected. Gonorrhoea culture can help susceptibility assessment where indicated. Offer HIV and syphilis testing and hepatitis assessment according to risks and vaccination. Test windows and recent exposures affect interpretation; a negative early test does not always exclude infection from that exposure.

Use the current Australian STI guideline for the syndrome and organism, including resistance-aware gonorrhoea and Mycoplasma genitalium treatment. Do not apply an old fixed antibiotic regimen to every discharge. Presumptive treatment may be appropriate before results based on symptoms and risk. Arrange partner notification/testing, abstinence advice and organism-specific follow-up, including test of cure where recommended. Explain confidentiality and how results will be communicated. Document a system to recall positive tests rather than relying on the patient to phone if concerned.

Pelvic inflammatory disease

PID is a clinical diagnosis that can have mild or nonspecific symptoms. Lower abdominal pain, cervical motion/adnexal tenderness and relevant risk support empirical treatment after considering pregnancy and surgical alternatives. A negative chlamydia test does not exclude PID, which can be polymicrobial. Exclude ectopic pregnancy and assess for tubo-ovarian abscess or sepsis. Pregnancy, severe illness, inability to tolerate oral treatment or uncertainty about a surgical emergency can require hospital care. Delayed treatment increases risks such as infertility and chronic pain.

Treat with the current broad PID regimen and arrange timely review of response. Provide pain control, partner management and return instructions for worsening pain, fever, vomiting or faintness. A normal ultrasound does not rule out uncomplicated PID; imaging is useful for a collection or alternative diagnosis. An IUD does not automatically require removal in every case; coordinate treatment and reassessment using the guideline. Do not allow a presumed PID diagnosis to obscure an evolving appendicitis, torsion or pregnancy complication.

Ulcers and male genital symptoms

Painful grouped vesicles/ulcers suggest herpes, while a painless ulcer can be syphilis, but appearance is not fully reliable. Sample/test appropriately and treat according to the suspected diagnosis and pregnancy context. Syphilis can have systemic manifestations and requires staging, contact management and public-health coordination. A genital ulcer is not proof of one organism or of recent infidelity. Discuss chronicity and transmission without stigma. HIV exposure may require urgent PEP assessment through a time-sensitive pathway; prevention planning also includes PrEP and vaccination where appropriate.

Urethral discharge/dysuria in a male patient suggests urethritis, while balanitis can be irritant, fungal or inflammatory. Persistent penile lesions merit examination and possible biopsy rather than repeated empiric antifungal treatment. Acute scrotal pain must first exclude torsion; epididymitis microbiology follows exposures and urinary risk rather than an age-thirty-five rule. Paraphimosis, where a retracted foreskin is trapped with swelling, needs urgent reduction assessment. Explain safe foreskin care; forced retraction in a child can cause injury.

Applied decisions and safety

A patient with lower abdominal pain and discharge needs pregnancy testing, examination and assessment for PID and alternative emergencies. A positive vaginal chlamydia NAAT requires treatment and partner/follow-up arrangements, not simply an electronic result label. A patient with severe unilateral scrotal pain of sudden onset needs urgent surgery consideration even if they report a new sexual partner. Exposure risk and anatomical urgency are separate dimensions. Ask about ongoing safety at home and allow private discussion before disclosing information to a companion.

Australian STI vaginal-discharge guidance and PID guidance.

Review checkpoints

• Pelvic inflammatory disease may need empirical treatment before results return.
• Collect STI samples from the anatomical sites relevant to exposure.
• Persistent or atypical genital lesions need assessment beyond repeated empirical infection treatment.