Focus on
Sexually Transmitted Diseases
(STDs)
(Relates to Chapter 53,
“Nursing Management:
Sexually Transmitted Diseases,”
in the textbook)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Sexually Transmitted Diseases
Infectious diseases most commonly
transmitted through sexual contact
 Can also be transmitted by

•Blood
•Blood products
•Autoinoculation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
2
Sexually Transmitted Diseases
Estimated 65 million Americans
infected with one or more STDs
 Additional 19 million newly infected
each year

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
3
Sexually Transmitted Diseases
Can be bacterial or viral
 Usually start as lesions on genitals
or mucous membranes and can
spread to other areas

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
4
Sexually Transmitted Diseases

Latent or subclinical phase present
with all STDs
•Leads to long-term persistent
infection
•Contributes to the transmission of
disease from asymptomatic (but
infected) person to another person
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
5
Sexually Transmitted Diseases

All cases of gonorrhea and syphilis
(and in most states chlamydia) must
be reported to state or local public
health authorities.
•Still underreported
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
6
Sexually Transmitted Diseases

Contributing factors to STD rates
•Earlier reproductive maturity
•Longer sexual life span
•Greater sexual freedom
•Media emphasis
•Lack of barrier methods during sexual
activity
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
7
Sexually Transmitted Diseases

Changes in methods of contraception
•Condom is best protection against
STDs but still is not used frequently in
general population.
•Oral contraceptive effects on acidity of
vaginal/cervical secretions promote
growth of certain organisms, causing
STDs.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
8
Gonorrhea
Second most frequently reported
STD in the United States
 Since 2006, infection rate has been
increasing.

•More than 700,000 new cases each
year
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
9
Gonorrhea

Highest incidence
•Adolescents
•African Americans
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
10
Gonorrhea
Etiology and Pathophysiology

Caused by Neisseria gonorrheae
•Gram-negative bacteria
•Direct physical contact with infected
host
•Mucosa with columnar epithelium is
susceptible.
•Present in genitalia, rectum, and
oropharynx
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
11
Gonorrhea
Etiology and Pathophysiology
Easily killed by drying, heating, or
washing with antiseptic
 Incubation period: 3 to 8 days
 Provides no immunity to
subsequent reinfection

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
12
Gonorrhea
Etiology and Pathophysiology

Elicits inflammatory process that
can lead to fibrous tissue and
adhesions
•Tubal pregnancy
•Chronic pelvic pain
•Infertility in women
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
13
Gonorrhea
Clinical Manifestations

Men
•Initial site infection is urethra.
•Symptoms
•Develop 2 to 5 days after infection
• Dysuria
• Profuse, purulent urethral discharge
•Unusual to be asymptomatic
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
14
Gonococcal Urethritis
Fig. 53-1. Profuse, purulent drainage in a patient with gonorrhea.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
15
Gonorrhea
Clinical Manifestations

Women
•Mostly asymptomatic or have minor
symptoms
•Vaginal discharge
•Dysuria
•Frequency of urination
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
16
Gonorrhea
Clinical Manifestations

Women (cont’d)
•After incubation
•Redness and swelling occur at site of
contact.
•Greenish, yellow purulent exudate often
develops.
• May develop abscess
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
17
Endocervical Gonorrhea
Fig. 53-2. Endocervical gonorrhea. Cervical redness and edema with discharge.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
18
Gonorrhea
Clinical Manifestations

Women (cont’d)
•Disease may remain local or may
spread by tissue extension to uterus,
fallopian tubes, and ovaries.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
19
Gonorrhea
Clinical Manifestations

Anorectal gonorrhea
•Usually from anal intercourse
•Few symptoms
•Include soreness, itching, and discharge
of anus
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
20
Gonorrhea
Clinical Manifestations

Orogenital
•Few symptoms
•Gonococcal pharyngitis can develop.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
21
Gonorrhea
Complications

Men
•Include prostatitis, urethral strictures,
and sterility
•Often seek treatment early, so less
likely to develop complications
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
22
Gonorrhea
Complications

Women
•Include pelvic inflammatory disease
(PID), Bartholin’s abscess, ectopic
pregnancy, and infertility
•Usually asymptomatic, so seldom
seek treatment
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
23
Gonorrhea
Complications

Women (cont’d)
•Small percentage develop
disseminated gonococcal infection
(DGI).
•Skin lesions, fever, arthralgia, arthritis,
or endocarditis
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
24
Disseminated Gonococcal Infection (DGI)
Fig. 53-3. Skin lesions with disseminated gonococcal infection. A, On the hand. B, On the fifth toe.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
25
Gonorrhea
Clinical Manifestations

Eye infections in newborns
•Instillations of prophylactic
erythromycin (0.5%) ophthalmic
ointment or silver nitrate (0.1%)
aqueous solution
•Untreated infants develop permanent
blindness.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
26
Gonorrhea
Diagnostic Studies
History and physical examination
 Laboratory tests

•Gram-stained smear to identify
organism
•Culture of discharge
•Nucleic acid amplification test
•Testing for other STDs
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
27
Gonorrhea
Diagnostic Studies

Women
•Smears and discharge do not establish
diagnosis.
•Female GU tract harbors organisms
resembling N. gonorrhea.
•Must have culture to confirm
diagnosis
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
28
Gonorrhea
Collaborative Care

Drug therapy
•Treatment generally instituted
without culture results
•Treatment in early stage is curative.
•Most common
•Oral dose of cefixime (Suprax)
•IM dose of ceftriaxone (Rocephin)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
29
Gonorrhea
Collaborative Care

Drug therapy (cont’d)
•Fluoroquinolones are no longer used.
•Patients with coexisting syphilis are
likely to be treated with azithromycin
(Zithromax) or doxycycline
(Vibramycin).
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
30
Gonorrhea
Collaborative Care
All sexual contacts of patients must
be evaluated and treated.
 Patient should be counseled to
abstain from sexual intercourse and
alcohol during treatment.
 Reexamine if symptoms persist
after treatment.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
31
Syphilis
About 11,500 cases annually
 Mainly due to men who have sex
with men

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
32
Syphilis
Etiology and Pathophysiology

Caused by Treponema pallidum
•Spirochete bacterium
•Enters the body through breaks in skin
or mucous membranes
•Facilitated by abrasions that occur during
sexual intercourse
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
33
Syphilis
Etiology and Pathophysiology
Complex disease in which many
organs and tissues can become
infected
 Causes production of antibodies
that react with normal tissues
 Not all exposures cause disease.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
34
Syphilis
Etiology and Pathophysiology
Destroyed by drying, heating, or
washing
 May also be spread through

•Contact with infectious lesions
•Sharing of needles among IV drug
users
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
35
Syphilis
Etiology and Pathophysiology
Incubation 10 to 90 days
 Spread in utero after 10th week of
pregnancy

•Infected mother has a greater risk of
stillbirth or of having a baby who dies
shortly after birth.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
36
Syphilis
Etiology and Pathophysiology
Association with HIV
 Syphilitic lesions on the genitals
enhance HIV transmission.
 Evaluation of all patients with
syphilis includes testing for HIV with
patient’s consent.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
37
Syphilis
Clinical Manifestations
Variety of signs/symptoms can
mimic another disease.
 Primary stage

•Chancres appear.
•Painless indurated lesions
•Occur 10 to 90 days after inoculation
•Lasting 3 to 6 weeks
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
38
Syphilis
Complications
Occur most often in late syphilis
 Gummas can produce irreparable
damage to bone, liver, or skin.
 Aneurysm may press on structures
such as intercostal nerves, causing
pain.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
39
Syphilis
Complications

Neurosyphilis causes degeneration
of brain with mental deterioration.
•Neurologic deficits possible

Tabes dorsalis causes nerve
involvement.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
40
Syphilis
Complications
Sudden attacks of pain
 Loss of vision and sense of position

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
41
Syphilis
Diagnostic Studies
History, including sexual history
 PE

•Examine lesions.
•Note signs/symptoms.
Dark-field microscopy
 Serologic testing
 Testing for other STDs

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
42
Syphilis
Collaborative Care

Drug therapy
•Benzathine penicillin G (Bicillin)
•Aqueous procaine penicillin G
•Recurring or persistent symptoms
after drug therapy are re-treated.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
43
Syphilis
Collaborative Care
Monitor neurosyphilis with periodic
serologic testing, clinical
evaluation, and repeat CSF exams.
 Confidential counseling and HIV
testing
 Surveillance

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
44
Chlamydial Infections
Most commonly reported STD in the
United States
 Incidence is 3 times higher in
women than in men.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
45
Chlamydial Infections

Major contributor to
•PID
•Ectopic pregnancy
•Infertility in women
•Nongonococcal urethritis in men
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
46
Chlamydial Infections
Etiology and Pathophysiology

Caused by Chlamydia trachomatis
•Gram-negative bacteria
Largely underreported because
infected persons are asymptomatic
 Transmitted during vaginal, anal, or
oral sex

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
47
Chlamydial Infections
Etiology and Pathophysiology
Closely associated with gonococcal
infections
 Incubation period: 1 to 3 weeks

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
48
Chlamydial Infections
Etiology and Pathophysiology

Risk factors
•Women and adolescents
•New or multiple sexual partners
•Sexual partners who have had
multiple partners
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
49
Chlamydial Infections
Etiology and Pathophysiology

Risk factors
•History of STDs and cervical ectopy
•Coexisting STDs
•Inconsistent or incorrect use of
condoms
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
50
Chlamydial Infections
Clinical Manifestations

“Silent disease”

Infection often is not diagnosed
until complications appear.
•Symptoms may be absent or minor.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
51
Chlamydial Infections
Clinical Manifestations

Men
•Urethritis
•Dysuria
•Urethral discharge
•Proctitis
•Rectal discharge
•Pain during defecation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
52
Chlamydial Infections
Clinical Manifestations

Men (cont’d)
•Epididymitis
•Unilateral scrotal pain
•Swelling
•Tenderness
•Fever
•Possible infertility and reactive arthritis
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
53
Chlamydial Infection
Fig. 53-7. Chlamydial epididymitis. Red, swollen scrotum.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
54
Chlamydial Infections
Clinical Manifestations

Women
•Cervicitis
•Mucopurulent discharge
•Hypertrophic ectopy
•Urethritis
•Dysuria
•Frequent urination
•Pyuria
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
55
Chlamydial Infections
Clinical Manifestations

Women (cont’d)
•Bartholinitis
•Purulent exudate
•Perihepatitis
•Fever, nausea, vomiting, right upper
quadrant pain
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
56
Chlamydial Infections
Clinical Manifestations

Women (cont’d)
•PID
•Abdominal pain, nausea, vomiting, fever,
malaise, abnormal vaginal bleeding,
menstrual abnormalities
•Can lead to chronic pain and infertility
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
57
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
58
Chlamydial Infections
Diagnostic Studies

Laboratory tests
•Nucleic acid amplification test (NAAT)
•Direct fluorescent antibody (DFA)
•Enzyme immunoassay (EIA)
•Testing for other STDs
•Culture for chlamydia
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
59
Chlamydial Infections
Diagnostic Studies

Cervical or urethral discharge less
purulent, watery, and painful in
chlamydia than in gonorrhea
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
60
Chlamydial Infections
Collaborative Care

Drug therapy
•Doxycycline (Vibramycin)
•100 mg bid for 7 days
•Azithromycin (Zithromax)
•1 g in single dose
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
61
Chlamydial Infections
Collaborative Care
Abstinence from sexual intercourse
for 7 days after treatment
 Follow-up care for persistent
symptoms
 Treatment of partners
 Encouraging use of condoms

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
62
Genital Herpes
Not a reportable disease in most
states
 True incidence difficult to determine
 More than 45 million infected in the
United States

•1 in 5 Americans
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
63
Genital Herpes
Etiology and Pathophysiology
Caused by herpes simplex virus
(HSV)
 Enters through mucous membranes
or breaks in the skin during contact
with infected persons
 HSV reproduces inside cell and
spreads to surrounding cells.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
64
Genital Herpes
Etiology and Pathophysiology
Virus enters peripheral or
autonomic nerve endings.
 Ascends to sensory or autonomic
nerve ganglion, where it is dormant

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
65
Genital Herpes
Etiology and Pathophysiology
Recurrence when virus descends to
initial site of infection
 Persists for life
 Virus sheds even in absence of
lesion.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
66
Genital Herpes
Etiology and Pathophysiology

Two different strains
•HSV-1
•Causes infection above the waist
•HSV-2
•Frequently infects genital tract and
perineum

Either strain can cause disease on
mouth or genitals.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
67
Genital Herpes
Clinical Manifestations

Primary (initial) episode
•Burning or tingling at site
•Small vesicular lesion appear on penis,
scrotum, vulva, perineum, perianal
areas, vagina, or cervix.
•Vesicles contain large quantities of
infectious virus particles.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
68
Unruptured Vesicles
Fig. 53-8. Unruptured vesicles of herpes simplex virus type 2 (HSV-2). A, Vulvar area. B, Perianal area.
C, Penile herpes simplex, ulcerative stage.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
69
Genital Herpes
Clinical Manifestations

Primary (initial) episode (cont’d)
•Lesions rupture and form ulcerations.
•Crusting and epithelialization occur.
•Tend to be associated with local
inflammation and pain with systemic
manifestations
•Including fever, headache, malaise,
myalgia, and regional lymphadenopathy
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
70
Genital Herpes
Clinical Manifestations

Primary (initial) episode (cont’d)
•Urination may be painful from urine
touching lesion.
•Purulent vaginal discharge may
develop.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
71
Genital Herpes
Clinical Manifestations

Primary (initial) episode (cont’d)
•Primary lesions present for 17 to 20
days
•New lesions sometimes continue to
develop for 6 weeks.
•Lesions heal spontaneously.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
72
Genital Herpes
Clinical Manifestations

Recurrent genital herpes
•Occurs in 50% to 80% in following year
•Triggers
•Stress
•Fatigue
•Sunburn
•Menses
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
73
Genital Herpes
Clinical Manifestations
Women with recurrent symptoms
shed virus up to 1% of the time,
even with no lesions present.
 Suppressive therapy reduces but
does not eradicate shredding.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
74
Genital Herpes
Clinical Manifestations
Condoms or abstinence
 With lesions, sexual activity should
be avoided.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
75
Genital Herpes
Complications
Aseptic meningitis
 Lower neuron damage

•Atonic bladder
•Impotence
•Constipation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
76
Genital Herpes
Complications

Autoinoculation to extragenital
sites
•Lips, breasts, and fingers

High risk of transmission in
pregnancy with episode near
delivery
•Active lesion is indication for cesarean
section.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
77
Autoinoculation of Herpes Simplex Virus
Fig. 53-9. Autoinoculation of herpes simplex virus (HSV) to the lips.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
78
Genital Herpes
Complications

Herpes simplex virus keratitis
•HSV infection of the eye
•Resolves within 1 to 2 weeks
•Can progress to ulcers
•Most common cause of corneal
ulceration and blindness in the United
States
•May result in scarring of the cornea
and vision impairment
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
79
Genital Herpes
Complications

Herpes simplex virus keratitis
(cont’d)
•Treatment
•Topical antiviral agents
•Systemic acyclovir
•Ulcer may need to be debrided.
•Corneal transplant may be needed.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
80
Genital Herpes
Diagnostic Studies
History and physical examination
 Viral isolation by tissue culture
 Antibody assay for specific HSV viral
type

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
81
Genital Herpes
Collaborative Care

Drug therapy
•Inhibit viral replication
•Suppress frequent recurrences
•Acyclovir (Zovirax)
•Valacyclovir (Valtrex)
•Famciclovir (Famvir)
•Not a cure, but shorten duration and
healing time and reduce outbreaks
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
82
Genital Herpes
Collaborative Care

Symptomatic care
•Genital hygiene
•Loose-fitting cotton underwear
•Lesions clean and dry
•Sitz baths
•Barrier methods during sexual activity
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
83
Genital Warts
Estimated 20 million Americans are
currently infected.
 Most common STD in the United
States

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
84
Genital Warts
Etiology and Pathophysiology

Caused by human papillomavirus
(HPV)
•Usually types 6 and 11
Highly contagious
 Frequently seen in young, sexually
active adults

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
85
Genital Warts
Etiology and Pathophysiology
Minor trauma causes abrasions for
HPV to enter and proliferate into
warts.
 Epithelial cells infected undergo
transformation and proliferation to
form a warty growth.
 Incubation period: 3 to 4 months

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
86
Genital Warts
Clinical Manifestations
Discrete single or multiple growths
 White to gray and pink-fleshed
colored
 May form large cauliflower-like
masses

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
87
Genital Warts
Fig. 53-10. Genital warts. A, Severe vulvular warts. B, Perineal wart. C, Multiple genital warts of the
glans penis.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
88
Genital Warts
Clinical Manifestations
Itching may occur with anogenital
warts.
 Bleeding on defecation may occur
with anal warts.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
89
Genital Warts
Clinical Manifestations
Rapid growth with pregnancy
 Transmitted to newborn
 Linked with cervical and vulvar
cancer in women

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
90
Genital Warts
Clinical Manifestations
Linked with anorectal and
squamous cell carcinoma of penis in
men
 More than 100 types identified

•Some harmless and self-limiting,
while others have oncogenic potential
•Two thirds of early lesions are
undetectable by visual examination.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
91
Genital Warts
Diagnostic Studies

Diagnosis on basis of appearance of
lesions
•May be confused with other diseases
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
92
Genital Warts
Diagnostic Studies

Serologic and cytologic tests
•HPV DNA test to determine if women
with abnormal Pap test results need
follow-up
•Identify women who are infected with
high-risk HPV strains
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
93
Genital Warts
Diagnostic Studies

Primary goal: removal of
symptomatic warts
•Removal may or may not decrease
infectivity.
•Difficult to treat
•Often require multiple office visits and
variety of treatment modalities
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
94
Genital Warts
Collaborative Care

Treatments
•Chemical
•Trichloroacetic acid (TCA)
•Bichloroacetic acid (BCA)
•Podophyllin resin
• For small external genital warts
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
95
Genital Warts
Collaborative Care

Treatments (cont’d)
•Patient managed
•Podofilox (Condylox/Condylox gel)
•Imiquimod (Aldara)
• Immune response modifier
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
96
Genital Warts
Collaborative Care

Treatments (cont’d)
•If warts do not regress with previously
mentioned therapies
•Cryotherapy with liquid nitrogen
•Electrocautery
•Laser therapy
•Use of α-interferon
•Surgical excision
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
97
Genital Warts
Collaborative Care
Recurrences and reinfection
possible
 Careful long-term follow-up advised
 Vaccine to prevent cervical cancer,
precancerous genital lesion, and
genital warts due to HPV

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
98
Nursing Management
Nursing Assessment

Subjective data
•Past medical history, including sexual
history
•Medication use
•IV drug use
•Nausea/vomiting
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
99
Nursing Management
Nursing Assessment

Subjective Data (cont’d)
•Dysuria
•Urethral discharge
•Burning lesions
•Vaginal discharge
•Presence of genital or perianal lesions
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
100
Nursing Management
Nursing Assessment

Objective data
•Fever
•Visual assessment of lesions, warts,
rash
•Purulent rectal discharge
•Proctitis
•Urethral and cervical discharge
•Laboratory findings
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
101
Nursing Management
Nursing Diagnoses
Risk for infection
 Anxiety
 Ineffective health maintenance

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
102
Nursing Management
Planning

Patient with STD will
•Demonstrate understanding of mode
of transmission and risks imposed
•Complete treatment and follow-up
•Notify or assist in notification of
sexual contacts
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
103
Nursing Management
Planning

Patient with STD will
•Abstain until infection is resolved
•Demonstrate knowledge of safer sex
practices
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
104
Nursing Management
Nursing Implementation
Discuss practices with all patients.
 Screen for cervical cancer.
 Teach to inspect partner’s genitals.
 Some protection if void
immediately after intercourse; wash
genitalia and adjacent areas with
soap and water

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
105
Nursing Management
Nursing Implementation
Proper use of condoms
 Avoiding sexual contact with
HIV-infected persons
 Establishing risk of contracting STD

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
106
Nursing Management
Nursing Implementation
Compassion and respect
 Screening programs
 Locating and examining all contacts
of person with STD for testing and
treatment

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
107
Nursing Management
Nursing Implementation
Education programs
 Counseling to verbalize feelings
 Explaining side effects, need for
treatment adherence, and
follow-ups

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
108
Nursing Management
Nursing Implementation
Emphasize hygiene (hand washing,
bathing).
 Avoid douching.
 Avoid synthetic materials in
undergarments.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
109
Nursing Management
Nursing Implementation
Abstinence during treatment
period, condoms afterward
 Avoid oral-genital contact.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
110
Nursing Management
Evaluation

Patient with STD will
•Demonstrate modes of transmission
•Use appropriate hygienic measures
•Experience no reinfection
•Demonstrate compliance with
follow-up protocol
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
111
Audience Response Question
When caring for a patient with a sexually transmitted
disease, it is important that the nurse teach the patient
to:
1. Advise all sexual partners of the need for treatment.
2. Use a condom for sexual intercourse during treatment.
3. Engage in monogamous relationships to prevent
reinfection.
4. Wash the genitalia before sexual intercourse to
prevent disease transmission.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
112
Audience Response Question
The nurse teaches the patient with genital
herpes about the use of:
1. Acyclovir ointment.
2. Oral acyclovir (Zovirax).
3. Human papillomavirus vaccine.
4. Podofilox (Condylox) topical gel.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
113
Case Study
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
114
Case Study

18-year-old woman and 20-year-old
man enter a college student clinic
for an STD screening.

They would like to begin to have
unprotected sex but are concerned
they might have an STD.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
115
Case Study
The man has some pain upon
urination that began 2 days ago.
 The woman has no symptoms.
 A blood test is performed on both,
and a culture is taken from the
man’s penis.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
116
Case Study

He is diagnosed with gonorrhea.

She is diagnosed with chlamydia.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
117
Case Study

The man is given a single
intramuscular injection dose of
ceftriaxone (Rocephin).

The woman is given a prescription
for azithromycin (Zithromax).
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
118
Discussion Questions
1.
They would like to know how long
to wait before they can have
protected or unprotected sex.
What can you tell them?
2.
What patient teaching should you
do with them?
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
119