# OAML Guideline on the Investigation of Genital Tract Infections
The purpose of this guideline is to provide ordering clinicians with a clear and concise reference for the investigation of genital tract infections for community patients. For detailed information, clinicians are encouraged to consult:
The Canadian Guidelines for the Sexually Transmitted Infections (CGSTI) available at  and
The Public Health Ontario Guidelines for Testing and Treatment of Gonorrhea in Ontario available at .
OAML guidelines will not apply to every clinical situation, nor can they serve as a substitute for sound clinical judgment. In particular, this guideline does not apply to pre-menarchal and post-menopausal females, as specimens from these patients may require additional investigations and different interpretation of test results. Since a high proportion of individuals with gonorrhea are at risk of co-infection with Chlamydia trachomatis (CT), when testing for N. gonorrhoeae patients should be concurrently tested for CT.

# Clinical Investigation of Urethritis/Cervicitis, Vulvovaginitis, and Genital Lesions a) Urethritis/cervicitis caused by Chlamydia trachomatis and/or N. gonorrhoeae (CT/GC) i. Nucleic Acid Amplification Test (NAAT)
The NAAT is a superior test to culture and is the preferred test for detection of CT/GC. However, in women the urine NAAT for N. gonorrhoeae is less sensitive than the cervical NAAT for N. gonorrhoeae.
If clinical symptoms persist, a repeat specimen can be collected four weeks after the initial NAAT.

# Appropriate specimen types include:
- females -endocervical NAAT swabs, and vaginal NAAT swabs where available, or first void urine  males -urethral NAAT swabs or first void urine
- NAAT is not Health Canada approved for pharyngeal and rectal specimens, nor is it an acceptable test for medicolegal cases.  Conventional culture swabs are not suitable for the NAAT; Swabs designed for NAAT must be used.

# ii. Culture Method
The NAAT is superior to the culture method for detecting N. gonorrhoeae; however, in cases of treatment failure, the culture method must be used to obtain a antimicrobial susceptibility result. If the culture grows N. gonorrhoeae, then the isolate is sent to Public Health Ontario Laboratory (PHOL) for susceptibility testing.
For test of cure, regardless of the presence or absence of symptoms, the preferred testing method is culture. NAAT is an acceptable alternative test; however, it should only be performed 4 weeks after treatment and in situations where culture is not feasible.
Test of cure is recommended in a number of circumstances, such as pregnancy and when first-line antibiotic treatment of N. gonorrhoeae is not used. The other circumstances are outlined in the Public Health Ontario Guidelines for Testing and Treatment of Gonorrhea in Ontario.

# 2, p28
For patients who receive appropriate treatment and are asymptomatic routine testing of a post-treatment specimen as a "test-of-cure" is NOT indicated. Appropriate specimen types for culture of N. gonorrhoeae include:
- females -endocervical specimen using conventional swabs;  males -urethral specimen using conventional swabs and;  pharyngeal or rectal specimens using conventional swabs.

# b) Vulvovaginitis
Laboratories will investigate specimens for:

#  Trichomonas vaginalis (T. vaginalis)
- morphotypes associated with bacterial vaginosis  yeast

# i. Microscopy
Appropriate specimen type:  Conventional vaginal swab; swabs used for NAAT are not suitable for microscopic examinations.
A wet mount and a gram stain will be prepared from specimens labeled as vaginal swabs and examined microscopically. Laboratories that perform wet mount examination for T. vaginalis should receive the specimen within 2 hours of collection to allow the organism to be identified. Vaginal flora in pre-pubertal and post-menopausal females may be different than that of post-pubertal and pre-menopausal females and may impact the interpretation of results. Pre-pubertal and post-menopausal female patients will not be tested for bacterial vaginosis.

# 1, p.3
Pre-pubertal and post-menopausal female patients will be tested for yeast and trichomonas infections.
In pre-pubertal females, cultures for N. gonorrhoeae will also be set up routinely on vaginal swabs.
If a physician suspects toxic shock syndrome, this information should be clearly indicated on the requisition. Accordingly, the vaginal swab will be cultured for detection of Staphylococcus aureus.
Specimens for culture and microscopy should be maintained at room temperature and processed within a few hours of collection.

# ii NAAT
The NAAT is a more sensitive method than microscopy for the detection of T. vaginalis.
Acceptable female specimen types include vaginal and cervical swabs, and first void urine in the appropriate NAAT specimen collection/transport kit.
Check with your laboratory for availability of NAAT for T. vaginalis.

# c) Genital Lesions
Causative organisms include:  females -urethral specimen using conventional swabs  males -urethral specimen using conventional swabs Information on the appropriate testing method and collection/transport kit can be obtained by contacting your local laboratory.
Note: Testing for T. vaginalis is challenging in males, since wet mount microscopy is often negative in infected men. The NAAT is not currently licensed for detection of T. vaginalis in male patients.

# Herpes simplex virus and other agents
For other etiologies, such as Herpes simplex virus, the PHOL should be contacted for advice on the appropriate specimen collection/transport kit.
Specimen collection instructions and requisitions for these tests are available on the PHOL's website at /.

# Specimen Collection
Specimens for culture and NAAT should be maintained at room temperature and transported to the laboratory for testing as quickly as possible, and processed within 24 hours.
Laboratories that perform wet mount examination for T. vaginalis should receive the specimen within 2 hours of collection to allow the organism to be identified.

# Learning Points
- In females, urine, cervical or vaginal specimens can be tested simultaneously for CT/GC or CT/GC/T. vaginalis on the same specimen using the NAAT.
- In females, the urine NAAT for N. gonorrhea is less sensitive than the cervical NAAT; however, this specimen type has the advantage of being a less invasive than a cervical specimen.
- In males, urine or urethral specimens can be tested simultaneously for CT and GC on the same specimen using the NAAT. The urine specimen has the advantage of being less invasive.
- Culture for GC is recommended for test of cure and for medical/legal cases.
- The NAAT is not licensed for use in pre-pubertal patients or for pharyngeal or rectal sites.
- Conventional vaginal swabs will be used to diagnose bacterial vaginosis. Swabs will be routinely tested by microscopy for presence of T. vaginalis and yeast.
- Specimens for culture and NAAT should be maintained at room temperature and transported to the laboratory for testing as quickly as possible and processed within 24 hours.
- Laboratories that perform wet mount examination for T. vaginalis should receive the specimen within 2 hours of collection to allow the organism to be identified.
- Swabs used for NAAT are not suitable for culture or microscopic examinations.
The OAML gratefully acknowledges the contribution of the following experts:

# Additional References
- Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections. Available at . Accessed February 2015.

# Warning & Disclaimer
This Guideline was prepared to assist clinicians who order tests from community laboratories. Users must ensure that their own practices comply with all specific government policies and specific legislative and accreditation requirements that apply to their organizations. The Guideline is not meant to be construed as legal advice or be all inclusive on this topic. Given the complexity of legal requirements, users are reminded that whenever there is uncertainty regarding whether some aspect of a Guideline is appropriate for their practice or organization, further direction should be obtained from the Laboratory Director, their own professional association, college and/or legal counsel or appropriate government ministry.